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Based on observation, the facility failed to maintain the two hour building separation barrier as evidenced by unsealed barrier penetrations. This affected the Facility Oncology Suite and had the potential to allow the spread of smoke and fire.

Findings:

During the facility tour with Staff 1 on May 17, 2011, the facility two hour barrier was observed.

At 4:05 p.m., there was a section of the 2 hour barrier that separated the Facility Oncology Suite from the Surgi-Center in the Medical Arts Building that was not completed on both side. On the wall above the Treatment Room in the Oncology Suite there was an approximately five foot by ten foot section of wall that was not completed with drywall. Staff 1 confirmed the wall was not completed.

At 4:10 p.m., there were unsealed penetrations in the 2 hour barrier that separated the Facility Oncology Suite from the Surgi-Center in the Medical Arts Building. On the wall above the Conference Room in the Oncology Suite there were conduits that penetrated the wall with approximately one-half inch gaps around the conduits that were not sealed. Staff 1 confirmed there were unsealed penetrations in the wall.

Based on observation the facility failed to maintain the corridor walls as evidenced by damaged walls and an unsealed wall penetration. This affected 5 of 28 Smoke Compartments in the Main Hospital and had the potential to transmit smoke and causing harm to the patients.

Findings:

During the facility tour with Staff 1 between May 17 and 19, 2011, the facility corridor walls and ceilings were observed.

At 1:24 p.m. on May 18, 2011, in the Main Hospital Building above the drop ceiling over the corridor door in patient room 2232, there was an approximately one-half inch by eight inch unsealed wall penetration beneath a piece of drywall used to repair the wall. Staff 1 confirmed there was an unsealed penetration in the wall.

At 2:07 p.m. on May 18, 2011, in the Main Hospital Building corridor wall above the drop ceiling adjacent to Respiratory Room 1303, there was an approximately eight inch circular unsealed wall penetration with a wire through the unsealed opening. Staff 1 confirmed there was an unsealed penetration in the corridor wall.

At 2:24 p.m. on May 18, 2011, in the Main Hospital Building above the ceiling in the Central Service break room, there was an approximately three inch by eight inch unsealed wall penetration with conduits through the penetration and an approximately eight inch by twelve inch unsealed penetration adjacent to an air duct. The penetrations were in the wall separating the break room from the main corridor. Staff 1 confirmed there were unsealed penetrations in the wall.

At 10:35 a.m. on May 19, 2011, in the Emergency Paging and Telephone Equipment Closet in the Medical Records Room on the 1st floor of Main Hospital, there were 5 unsealed penetrations in the ceiling with conduits running through them. Staff 2 confirmed there were unsealed penetrations in the wall.

At 12:47 p.m. on May 19, 2011, in the Main Hospital Building corridor wall above the drop ceiling adjacent to Operating Room waiting room, there was an approximately twelve inch by thirty-six inch unsealed wall penetration. There were metal conduits and black pipes that went through the unsealed penetration. Staff 1 confirmed there was an unsealed penetration in the corridor wall.

Based on observation, the facility failed to protect the smoke/fire integrity of the doors as evidenced by penetrations in a door and room door that failed to latch. This affected 2 of 28 smoke compartments in the Main Hospital and had the potential for the spread of smoke and fire within the facility and the increased risk of injury to the patients and staff due to smoke and fire.

Findings:

During a tour of the facility with Staff 2 on May 18, 2011, the facility doors were observed.

At 10:55 a.m., the door to Room 436 on the 4th floor of Tower 2 in the Main Hospital failed to positively latch. Staff 2 confirmed the door failed to latch.

At 2:01 p.m., the door to the Intensive Care Unit Storage, room 307, on the 3rd floor of Tower 1 in the Main Hospital, had two, dime size unsealed penetrations in the door. Staff 2 confirmed the door had unsealed penetrations.

Based on observation, the facility failed to maintain smoke barriers as evidenced by unsealed penetrations in the smoke barriers. This affected 2 of 28 smoke compartments in the Main Hospital and had the potential to fail to contain smoke during a fire leading to potential harm of the patients.

Findings:

During the facility tour with Staff 1 and 2 on May 18, 2011, the facility smoke barriers were observed.

At 9:58 a.m., there was an approximately two inch circular unsealed penetration with a wire through the penetration in the smoke barrier above the clean work room at the DOU Nurse Station. Staff 1 confirmed there was an unsealed penetration in the smoke barrier.

At 2:15 p.m., there was an approximately four inch wide by three inch deep penetration above the exit door in the smoke barrier wall of the Mechanical Room in the Basement of Tower 1 in the Main Hospital. Staff 2 confirmed there was a penetration in the smoke barrier.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by a barrier door that failed to fully close and latch. This affected 2 of 28 smoke compartments in the Main Hospital and had the potential to fail to contain smoke during a fire and causing harm to residents.

Findings:

During the facility tour with Staff 2 on May 19, 2011, the facility smoke barriers were observed.

At 3:05 p.m., the barrier door in Treatment Room 2 of the Emergency Room on the 1st floor of the Main Hospital failed to fully close and latch. There was an approximately two inch gap between the leaves in the door. Staff 2 confirmed the smoke barrier door leaves failed to fully close and latch.

NFPA 101 (2000 Edition) 9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 72 (1999 Edition) 1-5.4.4 Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

NFPA 72 (1999 Edition) 1-5.4.7 Distinctive Signals. Audible alarm notification appliances for a fire alarm system shall produce signals that are distinctive from other similar appliances used for other purposes in the same area. The distinction among signals shall be as follows:
(a) Fire alarm signals shall be distinctive in sound from other signals. Their sound shall not be used for any other purpose. The requirements of 3-8.4.1.2.1 shall apply.
(b) *Supervisory signals shall be distinctive in sound from other signals. Their sound shall not be used for any other purpose.

Exception: A supervisory signal sound shall be permitted to be used to indicate a trouble condition. If the same sound is used for both supervisory signals and trouble signals, the distinction between signals shall be by other appropriate means such as visible annunciation.

(c) Fire alarm, supervisory, and trouble signals shall take precedence, in that respective order of priority, over all other signals.

Exception: Signals from hold-up alarms or other life-threatening signals shall be permitted to take precedence over supervisory and trouble signals if acceptable to the authority having jurisdiction.

Based on observation, the facility failed to maintain the required automatic fire sprinkler system as evidenced by the failure of the tamper alarm to activate when tested. This affected 6 of 28 smoke compartments in the Main Hospital and had the potential for failure of staff to identify tampering with the sprinkler system.

Findings:

During the facility tour with Staff 1 on May 19, 2011, the facility automatic sprinkler system was observed and tested by facility staff.

At 3:15 p.m., the tamper switch on the Post Indicator Valve (PIV) for Tower 1 Floors 2, 3, and 4 was tested and failed to activate a trouble signal at the fire alarm panel. Staff 1 confirmed the trouble signal failed to activate the panel when tested.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition) 5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

NFPA 13 (1999 Edition), 5-6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers). The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Exception: Where other standards specify greater minimums, they shall be followed.

NFPA 13 (1999 Edition) 5-15.2.3.4 Where a fire department connection services only a portion of a building, a sign shall be attached indicating the portions of the building served.

NFPA 25 Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems(1998 Edition) 1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

NFPA 25 (1998 Edition) 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25 (1998 Edition) 2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

NFPA 25 (1998 Edition) 2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

NFPA 25 (1998 Edition) 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Based on observation and document review, the facility failed to maintain the required automatic fire sprinkler system as evidenced by the failure to provide documentation for 3 of 4 quarterly sprinkler tests, failed to provide documentation of the annual sprinkler inspection and maintenance, sprinkler heads with foreign material on the sprinkler head, the failure to provide 18 inches of clearance below sprinkler heads and the failure to provide signs on Fire Department Connections (FDC) indicating the portion of the building served by the FDC. This affected 28 of 28 smoke compartments in the main hospital building and had the potential for failure of the sprinkler system to function properly leading to harm of the patients.

Findings:

During the document review and facility tour with Staff 1 and 2 between May 17 and 19, 2011, the fire sprinkler test and inspection reports were reviewed and the fire sprinkler system was observed.

At 10:15 a.m. on May 17, 2011, the facility failed to provide a record for 2 of 4 quarterly testing and maintenance of the sprinkler system for the Main Hospital Building. There were no quarterly reports for the Second quarter (April-June) of 2010 and third quarter (July-September) of 2010. Staff 1 confirmed there were no reports for the 2nd and 3rd quarters of 2010.

At 2:57 p.m. on May 17, 2011, sprinkler heads/deflectors in the Medical Director Office were covered with debris. Staff 2 confirmed there was debris paint on the deflector.

At 9:55 a.m. on May 18, 2011, there was paint on the sprinkler head/deflector in Public Restroom on the 6th floor, Tower 2 of the Main Hospital Building. Staff 2 confirmed there was paint on the deflectors.

At 10:25 a.m.on May 18, 2011, there was paint on the sprinkler deflector in bathroom of Room 530 on the 5th floor of Tower 2 in the Main Hospital Building. Staff 2 confirmed there was paint on the deflectors.

At 10:56 a.m. on May 18, 2011, there was debris on the sprinkler deflector in Room 438 on the 4th floor of Tower 2 in the Main Hospital Building. Staff 2 confirmed there was debris on the deflector.

At 10:59 a.m. on May 18, 2011, in the case management storage on the 3rd floor of Tower 2 in the Main Hospital Building, there were boxes stacked within 18 inches below the sprinkler head. Staff 2 confirmed there was storage within 18 inches of the sprinkler head.

At 11:01 a.m. on May 18, 2011, in the Orthopedic Storage Room on the 3rd floor of Tower 2 in the Main Hospital Building, there was an unsealed penetration approximately ? around the sprinkler base through the ceiling and debris on a sprinkler deflector. Staff 2 confirmed there was debris on the deflector and an unsealed penetration.

At 1:25 p.m. on May 18, 2011, in the Pediatric Storage Room on the 2nd floor of Tower 2 of the Main Hospital Building, there was debris on 4 of 4 sprinkler deflectors. Staff 2 confirmed there was debris on the deflectors.

At 11:01 a.m. on May 19, 2011, in the Kitchen on the 1st floor of the Main Hospital Building, there was debris on the sprinkler deflector. Staff 2 confirmed there was debris on the deflector.

At 2:55 p.m. on May 19, 2011, there were two FDC on the east side of Tower 1 of the Main Hospital Building. Staff 1 stated both FDC served Tower 1. Both FDC were not equipped with a sign identifying the location served by the FDC. Staff 1 confirmed both FDC did not have a sign indicating the portion of the building served by the FDC.

At 3:02 p.m. on May 19, 2011, the FDC outside the Lobby and Emergency Room of the Main Hospital Building, identified as M1-10, was not equipped with a sign identifying the location served by the FDC. Staff 1 confirmed the FDC did not have a sign indicating the portion of the building served by the FDC.

NFPA 90A (1999 Edition), 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

NFPA 90A (1999 Edition), 2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

NFPA 90A (1999 Edition), 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on observation, the facility failed to maintain the facility fire and smoke dampers as evidenced by the failure to identify service openings in air ducts indicating the fire protection device and the duct and the failure to provide documentation for the testing of fire dampers. This affected 22 of 28 smoke compartments in the main hospital and had the potential for damper failure leading to harm of the patients.

Findings:

During the document review and facility tour with Staff 1 between May 18 and 19, 2011, the facility dampers inspection and test records were reviewed and the dampers were observed.

At 9:40 a.m. on May 18, 2011, the duct access panel adjacent to the damper in the penthouse of the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 9:51 a.m. on May 18, 2011, 1 of 2 damper duct access panels adjacent to room 2651 in the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 1:08 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the 2nd floor corridor separating Tower 1 and Tower 2 was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 1:44 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the 2nd floor corridor smoke barrier of Tower 1 adjacent to Medical Records was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 2:01 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the 3rd floor corridor smoke barrier of Tower 1 adjacent to the Security Office was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 2:42 p.m. on May 18, 2011, 2 of 2 duct access panels adjacent to the dampers in the basement corridor smoke barrier of the Main Hospital Building adjacent to the Fire Alarm Panel/Information Systems Room were not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panels to note the presence of the damper.

At 2:55 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the basement corridor smoke barrier of the Main Hospital Building adjacent to the south lab corridor door was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 3:00 p.m. on May 18, 2011, the duct grill covering the damper in the basement corridor ceiling of the Main Hospital Building adjacent to the south lab corridor door was not identified indicating the damper number within the duct. Staff 1 confirmed there was no number on the grill over the damper. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm the damper had been inspected, tested and maintained.

At 3:00 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the basement chiller shop area of the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 3:05 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the basement chiller area above the door to the corridor of the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 10:10 a.m. on May 19, 2011, the duct grill covering the dampers in the Chapel ceiling in the Main Hospital Building were not identified indicating the damper number within the duct. Staff 1 confirmed there was no number on the grills over the dampers. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm the dampers had been inspected, tested and maintained.

At 10:18 a.m. on May 19, 2011, the duct grill covering the dampers in the Gift Shop ceiling in the Main Hospital Building were not identified indicating the damper number within the duct. Staff 1 confirmed there was no number on the grills over the dampers. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm the dampers had been inspected, tested and maintained.

At 10.25 a.m. on May 19, 2011, the duct access panel for the damper identified as FL-29 of the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 10.45 a.m. on May 19, 2011, the duct access panel for the damper identified as FL-32 of the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 10.58 a.m. on May 19, 2011, Staff 1 was unable to ascertain from the facility damper test from 2009 how many dampers were behind the ceiling access labeled FL-47 and how many were tested. The vendor report was worded as if one damper was tested. 3 dampers were observed above the ceiling access panel. 2 of 3 duct access panels were not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panels to note the presence of the damper.

At 11:07 a.m. on May 19, 2011, an air duct was observed to penetrated the smoke barrier above the drop ceiling in patient room 158. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm the dampers had been inspected, tested and maintained.

At 11:07 a.m. on May 19, 2011, an air duct was observed to penetrated the smoke barrier above the drop ceiling in patient room 158. The duct access panel for the damper was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 1:08 p.m. on May 19, 2011, an air duct was observed to penetrated the 2-hour above smoke barrier above the drop ceiling in the corridor adjacent to the door to the operating room. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm if there was a damper in the duct adjacent to the duct access panel that was not labeled. Staff 1 thought the access panel was for access for cleaning the ducts.

At 1:13 p.m. on May 19, 2011, an unlabeled air duct with a damper was observed to penetrate ceiling in the corridor between an air duct with a damper identified as FL-38 and an air duct with a damper identified as FL-39. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm the unlabeled damper had been inspected, tested and maintained.

Based on observation, the facility failed to maintain the means of egress as evidenced by items stored in the corridors. This affected 1 of 28 smoke compartments in the main building. This could result in the delay in the evacuation of the facility and the increased risk of injury to the patients and staff due to fire and smoke.

Findings:

During the facility tour with Staff 2 on May 19, 2011, the facility corridors were observed.

At 9:10 a.m., the corridor of Treatment Room 2 in the Emergency Room on the 1st floor of the Main Hospital was obstructed with two chairs. Staff 2 stated the chairs were placed in the corridor for patient use.

At 1:44 p.m., a bed obstructed the corridor in front of an exit door in the Day Surgery Center on the 1st floor of the Main Hospital. Staff 2 confirmed the bed obstructed the corridor and exit access.

Based on observation and interview, the facility failed to properly store soiled linen containers as evidenced by oversized soiled linen containers stored in the corridor. This affected 1 of 28 smoke compartments and had the potential to delay the evacuation of the facility and increase the risk of injury to the patients and staff due to fire.

Findings:

During the facility tour with Staff 2 on May 18, 2011, the facility corridors were observed.

At 1:58 p.m., 3 large soiled linen bins approximately 3 feet by 4 feet were stored in an open alcove of the corridor on 2nd floor of Tower 1 in the Main Hospital. The bins contained soiled housekeeping rags and soiled mop heads. In an interview with Staff 2 and Staff 3 at 2:01 p.m., they acknowledged that the bins were stored daily in the open alcove of the corridor. Staff 2 acknowledged the bins were greater than the 32 gallons capacity per NFPA guidelines.

NFPA 99 (1999 Edition) 4-3.1.2.3 Gas Shutoff Valves. i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Based on observation, the facility failed to maintain access to the medical gas shutoff valves as evidenced by access to a valve box that was obstructed. This affected 1 of 28 smoke compartments in the Main Hospital and had the potential for the delay in shutting off the oxygen in an emergency and causing potential harm to the patients.

Findings:

During the facility tour with Staff 2 on May 19, 2011, the facility medical gas system was observed.

At 1:44 p.m., access to the emergency oxygen shutoff valve in the Day Surgery Center on the 1st floor of the main hospital was blocked by a bed in front of the box. Staff 2 confirmed a bed obstructed the access to the shutoff valve.

DRAFT STOPS

NFPA 101 (2000 Edition) 3.3.47 Draft Stop. A continuous membrane used to subdivide a concealed space to restrict the passage of smoke, heat, and flames.

NFPA 101 (2000 Edition) 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation, the facility failed to maintain the Draft Stops as evidenced by unsealed penetrations in the Draft Stops. This affected the facility Oncology Suite and had the potential for the migration of smoke causing harm to residents.

Findings:

During the facility tour with Staff 1 on May 17, 2011, the facility draft stops were observed.

At 4:15 p.m., the Draft Stop above the Consultation Room in the Medical Arts Building Onocology Suite was observed to have to an unsealed one inch gap around an air duct, unsealed three-quarter inch gaps around conduits and and an unsealed eight inch by eight inch penetration in the Draft Stop. Staff 1 confirmed there were unsealed penetrations in the Draft Stop.

At 4:20 p.m., there was an approximately twelve inch by twelve inch unsealed penetration the draft stop above the west doctor's office in the Medical Arts Building Oncology Suite. Staff 1 confirmed there was an unsealed penetration in the Draft Stop.

Code of Federal Regulations ?483.25(h) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

NFPA 70 (1999 Edition), article 110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 70 (1999 Edition), 400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:

(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

NFPA 70 (1999 Edition) 400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

NFPA 70 (1999 Edition) 517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or by an isolated power system if such interruption cannot be tolerated.

Exception: Branch circuits supplying only listed, fixed, therapeutic and diagnostic equipment shall be permitted to be supplied from a normal grounded service, single- or 3-phase system provided that

(a) Wiring for grounded and isolated circuits does not occupy the same raceway, and

(b) All conductive surfaces of the equipment are grounded.

NFPA 99 (1999 Edition) 3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.

Based on observation, the facility failed to maintain the electrical wiring as evidenced by damaged electrical receptacles, missing cover plates on boxes, patient care equipment plugged into surge protectors and multi-plug adapters instead of directly into an electrical receptacle, the use of extension cords to extend power to equipment instead of providing fixed wired electrical receptacles, the failure of an electrical receptacle with with ground-fault circuit-interrupter (gfi) protection and the failure to provide documentation that electrical installation was in accordance with NFPA 70. This affected 7 of 28 smoke compartments in the Main Hospital and had the potential for electrical shock or fire leading to harm of the patients.

Findings:

During the facility tour with Staff 1 and 2 between May 17 and 19, 2011, the facility electrical wiring and equipment were observed.

At 10:39 a.m., on May 18, 2011, the four outlet electrical receptacle on the corridor wall adjacent to room 2519 in the Main Hospital Building was damaged around the ground port. Staff 1 confirmed the ground port was damaged.

At 10:53 a.m., on May 18, 2011, there was an open junction box when looking at the smoke barrier from the supply room adjacent to room 2424 in the Main Hospital Building. Staff 1 confirmed there was as open junction box.

At 10:54 a.m., on May 18, 2011, the electrical receptacle on the corridor wall adjacent to room 2433 in the Main Hospital Building was damaged around the ground port. Staff 1 confirmed the ground port was damaged.

At 10:56 a.m., on May 18, 2011, the outlet electrical receptacle on the corridor wall of the 2400 wing adjacent to elevators in the Main Hospital Building was damaged around the ground port. Staff 1 confirmed the ground port was damaged.

At 2:05 p.m. on May 18, 2011, in Room 3116 (Security Office) on the 3rd floor of Tower 1 in the Main Hospital Building, there was a small refrigerator plugged into an extension cord instead of directly into a fixed wired electrical receptacle. The extension cord was plugged into another extension cord. The extension cords were used to extend power to the refrigerator in place of providing fixed wired receptacles. Staff 2 confirmed there were extension cords in use.

At 9:45 a.m. on May 18, 2011, in the Cath Laboratory on the 1st floor of the Main Hospital, there was a six plug power strip plugged into the wall. Staff 2 stated the power strip was for patient equipment usage and was used daily. The power strip was used in place of providing additional fixed wired electrical receptacles.

At 10:35 a.m. on May 18, 2011, two multi-plug power strips were plugged into the wall in the Endo Treatment Room 3 on the 1st floor of the Main Hospital. One multi plug power strip had a patient heart monitor machine plugged into it. The Endo Technician stated that they do plug patient equipment into the power strips because it makes the machines more mobile during procedures.

At 10:55 a.m. on May 19, 2011, in the break room/copier room in Administration there was a microwave oven plugged into a multi plug power strip instead of a wall outlet. Staff 2 confirmed the microwave oven was plugged into a power strip.

Based on observation, the facility failed to maintain the Alcohol Based Hand Rub (ABHR) dispensers as evidenced ABHR dispensers mounted adjacent to ignition sources. This affected 2 of 28 smoke compartments in the Main Hospital Unit and had the potential for a fire resulting in the risk of injury to patients, visitors and staff in the event of a fire.

Findings:

During a tour of the facility with Staff 2 between May 17 and 19, 2011, the ABHR dispensers were observed:

At 9:05 a.m. on May 19, 2011, in Chart Room of Emergency Room on the 1st floor of the Main Hospital the ABHR dispenser was mounted over the wall outlet. Staff 2 confirmed the dispenser was mounted above the light switch.

At 1:42 p.m. on May 19, 2011, outside of Room 4 of Operating Suite on the wall on 1st floor the ABHR dispenser was mounted over light switch. Staff 2 confirmed the dispenser was mounted above the light switch.

At 1:43 p.m. on May 19, 2011, the office of the Operating Suite on 1st floor the ABHR dispenser was mounted over the light switch. Staff 2 confirmed the dispenser was mounted above the light switch.

Based on observation, the facility failed to maintain the two hour building separation barrier as evidenced by unsealed barrier penetrations. This affected the Facility Oncology Suite and had the potential to allow the spread of smoke and fire.

Findings:

During the facility tour with Staff 1 on May 17, 2011, the facility two hour barrier was observed.

At 4:05 p.m., there was a section of the 2 hour barrier that separated the Facility Oncology Suite from the Surgi-Center in the Medical Arts Building that was not completed on both side. On the wall above the Treatment Room in the Oncology Suite there was an approximately five foot by ten foot section of wall that was not completed with drywall. Staff 1 confirmed the wall was not completed.

At 4:10 p.m., there were unsealed penetrations in the 2 hour barrier that separated the Facility Oncology Suite from the Surgi-Center in the Medical Arts Building. On the wall above the Conference Room in the Oncology Suite there were conduits that penetrated the wall with approximately one-half inch gaps around the conduits that were not sealed. Staff 1 confirmed there were unsealed penetrations in the wall.

Based on observation the facility failed to maintain the corridor walls as evidenced by damaged walls and an unsealed wall penetration. This affected 5 of 28 Smoke Compartments in the Main Hospital and had the potential to transmit smoke and causing harm to the patients.

Findings:

During the facility tour with Staff 1 between May 17 and 19, 2011, the facility corridor walls and ceilings were observed.

At 1:24 p.m. on May 18, 2011, in the Main Hospital Building above the drop ceiling over the corridor door in patient room 2232, there was an approximately one-half inch by eight inch unsealed wall penetration beneath a piece of drywall used to repair the wall. Staff 1 confirmed there was an unsealed penetration in the wall.

At 2:07 p.m. on May 18, 2011, in the Main Hospital Building corridor wall above the drop ceiling adjacent to Respiratory Room 1303, there was an approximately eight inch circular unsealed wall penetration with a wire through the unsealed opening. Staff 1 confirmed there was an unsealed penetration in the corridor wall.

At 2:24 p.m. on May 18, 2011, in the Main Hospital Building above the ceiling in the Central Service break room, there was an approximately three inch by eight inch unsealed wall penetration with conduits through the penetration and an approximately eight inch by twelve inch unsealed penetration adjacent to an air duct. The penetrations were in the wall separating the break room from the main corridor. Staff 1 confirmed there were unsealed penetrations in the wall.

At 10:35 a.m. on May 19, 2011, in the Emergency Paging and Telephone Equipment Closet in the Medical Records Room on the 1st floor of Main Hospital, there were 5 unsealed penetrations in the ceiling with conduits running through them. Staff 2 confirmed there were unsealed penetrations in the wall.

At 12:47 p.m. on May 19, 2011, in the Main Hospital Building corridor wall above the drop ceiling adjacent to Operating Room waiting room, there was an approximately twelve inch by thirty-six inch unsealed wall penetration. There were metal conduits and black pipes that went through the unsealed penetration. Staff 1 confirmed there was an unsealed penetration in the corridor wall.

Based on observation, the facility failed to protect the smoke/fire integrity of the doors as evidenced by penetrations in a door and room door that failed to latch. This affected 2 of 28 smoke compartments in the Main Hospital and had the potential for the spread of smoke and fire within the facility and the increased risk of injury to the patients and staff due to smoke and fire.

Findings:

During a tour of the facility with Staff 2 on May 18, 2011, the facility doors were observed.

At 10:55 a.m., the door to Room 436 on the 4th floor of Tower 2 in the Main Hospital failed to positively latch. Staff 2 confirmed the door failed to latch.

At 2:01 p.m., the door to the Intensive Care Unit Storage, room 307, on the 3rd floor of Tower 1 in the Main Hospital, had two, dime size unsealed penetrations in the door. Staff 2 confirmed the door had unsealed penetrations.

Based on observation, the facility failed to maintain smoke barriers as evidenced by unsealed penetrations in the smoke barriers. This affected 2 of 28 smoke compartments in the Main Hospital and had the potential to fail to contain smoke during a fire leading to potential harm of the patients.

Findings:

During the facility tour with Staff 1 and 2 on May 18, 2011, the facility smoke barriers were observed.

At 9:58 a.m., there was an approximately two inch circular unsealed penetration with a wire through the penetration in the smoke barrier above the clean work room at the DOU Nurse Station. Staff 1 confirmed there was an unsealed penetration in the smoke barrier.

At 2:15 p.m., there was an approximately four inch wide by three inch deep penetration above the exit door in the smoke barrier wall of the Mechanical Room in the Basement of Tower 1 in the Main Hospital. Staff 2 confirmed there was a penetration in the smoke barrier.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by a barrier door that failed to fully close and latch. This affected 2 of 28 smoke compartments in the Main Hospital and had the potential to fail to contain smoke during a fire and causing harm to residents.

Findings:

During the facility tour with Staff 2 on May 19, 2011, the facility smoke barriers were observed.

At 3:05 p.m., the barrier door in Treatment Room 2 of the Emergency Room on the 1st floor of the Main Hospital failed to fully close and latch. There was an approximately two inch gap between the leaves in the door. Staff 2 confirmed the smoke barrier door leaves failed to fully close and latch.

NFPA 101 (2000 Edition) 9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 72 (1999 Edition) 1-5.4.4 Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

NFPA 72 (1999 Edition) 1-5.4.7 Distinctive Signals. Audible alarm notification appliances for a fire alarm system shall produce signals that are distinctive from other similar appliances used for other purposes in the same area. The distinction among signals shall be as follows:
(a) Fire alarm signals shall be distinctive in sound from other signals. Their sound shall not be used for any other purpose. The requirements of 3-8.4.1.2.1 shall apply.
(b) *Supervisory signals shall be distinctive in sound from other signals. Their sound shall not be used for any other purpose.

Exception: A supervisory signal sound shall be permitted to be used to indicate a trouble condition. If the same sound is used for both supervisory signals and trouble signals, the distinction between signals shall be by other appropriate means such as visible annunciation.

(c) Fire alarm, supervisory, and trouble signals shall take precedence, in that respective order of priority, over all other signals.

Exception: Signals from hold-up alarms or other life-threatening signals shall be permitted to take precedence over supervisory and trouble signals if acceptable to the authority having jurisdiction.

Based on observation, the facility failed to maintain the required automatic fire sprinkler system as evidenced by the failure of the tamper alarm to activate when tested. This affected 6 of 28 smoke compartments in the Main Hospital and had the potential for failure of staff to identify tampering with the sprinkler system.

Findings:

During the facility tour with Staff 1 on May 19, 2011, the facility automatic sprinkler system was observed and tested by facility staff.

At 3:15 p.m., the tamper switch on the Post Indicator Valve (PIV) for Tower 1 Floors 2, 3, and 4 was tested and failed to activate a trouble signal at the fire alarm panel. Staff 1 confirmed the trouble signal failed to activate the panel when tested.

NFPA 13 Standard for the Installation of Sprinkler Systems (1999 Edition) 5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

NFPA 13 (1999 Edition), 5-6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers). The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Exception: Where other standards specify greater minimums, they shall be followed.

NFPA 13 (1999 Edition) 5-15.2.3.4 Where a fire department connection services only a portion of a building, a sign shall be attached indicating the portions of the building served.

NFPA 25 Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems(1998 Edition) 1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

NFPA 25 (1998 Edition) 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25 (1998 Edition) 2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

NFPA 25 (1998 Edition) 2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

NFPA 25 (1998 Edition) 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Based on observation and document review, the facility failed to maintain the required automatic fire sprinkler system as evidenced by the failure to provide documentation for 3 of 4 quarterly sprinkler tests, failed to provide documentation of the annual sprinkler inspection and maintenance, sprinkler heads with foreign material on the sprinkler head, the failure to provide 18 inches of clearance below sprinkler heads and the failure to provide signs on Fire Department Connections (FDC) indicating the portion of the building served by the FDC. This affected 28 of 28 smoke compartments in the main hospital building and had the potential for failure of the sprinkler system to function properly leading to harm of the patients.

Findings:

During the document review and facility tour with Staff 1 and 2 between May 17 and 19, 2011, the fire sprinkler test and inspection reports were reviewed and the fire sprinkler system was observed.

At 10:15 a.m. on May 17, 2011, the facility failed to provide a record for 2 of 4 quarterly testing and maintenance of the sprinkler system for the Main Hospital Building. There were no quarterly reports for the Second quarter (April-June) of 2010 and third quarter (July-September) of 2010. Staff 1 confirmed there were no reports for the 2nd and 3rd quarters of 2010.

At 2:57 p.m. on May 17, 2011, sprinkler heads/deflectors in the Medical Director Office were covered with debris. Staff 2 confirmed there was debris paint on the deflector.

At 9:55 a.m. on May 18, 2011, there was paint on the sprinkler head/deflector in Public Restroom on the 6th floor, Tower 2 of the Main Hospital Building. Staff 2 confirmed there was paint on the deflectors.

At 10:25 a.m.on May 18, 2011, there was paint on the sprinkler deflector in bathroom of Room 530 on the 5th floor of Tower 2 in the Main Hospital Building. Staff 2 confirmed there was paint on the deflectors.

At 10:56 a.m. on May 18, 2011, there was debris on the sprinkler deflector in Room 438 on the 4th floor of Tower 2 in the Main Hospital Building. Staff 2 confirmed there was debris on the deflector.

At 10:59 a.m. on May 18, 2011, in the case management storage on the 3rd floor of Tower 2 in the Main Hospital Building, there were boxes stacked within 18 inches below the sprinkler head. Staff 2 confirmed there was storage within 18 inches of the sprinkler head.

At 11:01 a.m. on May 18, 2011, in the Orthopedic Storage Room on the 3rd floor of Tower 2 in the Main Hospital Building, there was an unsealed penetration approximately ? around the sprinkler base through the ceiling and debris on a sprinkler deflector. Staff 2 confirmed there was debris on the deflector and an unsealed penetration.

At 1:25 p.m. on May 18, 2011, in the Pediatric Storage Room on the 2nd floor of Tower 2 of the Main Hospital Building, there was debris on 4 of 4 sprinkler deflectors. Staff 2 confirmed there was debris on the deflectors.

At 11:01 a.m. on May 19, 2011, in the Kitchen on the 1st floor of the Main Hospital Building, there was debris on the sprinkler deflector. Staff 2 confirmed there was debris on the deflector.

At 2:55 p.m. on May 19, 2011, there were two FDC on the east side of Tower 1 of the Main Hospital Building. Staff 1 stated both FDC served Tower 1. Both FDC were not equipped with a sign identifying the location served by the FDC. Staff 1 confirmed both FDC did not have a sign indicating the portion of the building served by the FDC.

At 3:02 p.m. on May 19, 2011, the FDC outside the Lobby and Emergency Room of the Main Hospital Building, identified as M1-10, was not equipped with a sign identifying the location served by the FDC. Staff 1 confirmed the FDC did not have a sign indicating the portion of the building served by the FDC.

NFPA 90A (1999 Edition), 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

NFPA 90A (1999 Edition), 2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

NFPA 90A (1999 Edition), 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on observation, the facility failed to maintain the facility fire and smoke dampers as evidenced by the failure to identify service openings in air ducts indicating the fire protection device and the duct and the failure to provide documentation for the testing of fire dampers. This affected 22 of 28 smoke compartments in the main hospital and had the potential for damper failure leading to harm of the patients.

Findings:

During the document review and facility tour with Staff 1 between May 18 and 19, 2011, the facility dampers inspection and test records were reviewed and the dampers were observed.

At 9:40 a.m. on May 18, 2011, the duct access panel adjacent to the damper in the penthouse of the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 9:51 a.m. on May 18, 2011, 1 of 2 damper duct access panels adjacent to room 2651 in the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 1:08 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the 2nd floor corridor separating Tower 1 and Tower 2 was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 1:44 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the 2nd floor corridor smoke barrier of Tower 1 adjacent to Medical Records was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 2:01 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the 3rd floor corridor smoke barrier of Tower 1 adjacent to the Security Office was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 2:42 p.m. on May 18, 2011, 2 of 2 duct access panels adjacent to the dampers in the basement corridor smoke barrier of the Main Hospital Building adjacent to the Fire Alarm Panel/Information Systems Room were not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panels to note the presence of the damper.

At 2:55 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the basement corridor smoke barrier of the Main Hospital Building adjacent to the south lab corridor door was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 3:00 p.m. on May 18, 2011, the duct grill covering the damper in the basement corridor ceiling of the Main Hospital Building adjacent to the south lab corridor door was not identified indicating the damper number within the duct. Staff 1 confirmed there was no number on the grill over the damper. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm the damper had been inspected, tested and maintained.

At 3:00 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the basement chiller shop area of the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 3:05 p.m. on May 18, 2011, the duct access panel adjacent to the damper in the basement chiller area above the door to the corridor of the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 10:10 a.m. on May 19, 2011, the duct grill covering the dampers in the Chapel ceiling in the Main Hospital Building were not identified indicating the damper number within the duct. Staff 1 confirmed there was no number on the grills over the dampers. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm the dampers had been inspected, tested and maintained.

At 10:18 a.m. on May 19, 2011, the duct grill covering the dampers in the Gift Shop ceiling in the Main Hospital Building were not identified indicating the damper number within the duct. Staff 1 confirmed there was no number on the grills over the dampers. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm the dampers had been inspected, tested and maintained.

At 10.25 a.m. on May 19, 2011, the duct access panel for the damper identified as FL-29 of the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 10.45 a.m. on May 19, 2011, the duct access panel for the damper identified as FL-32 of the Main Hospital Building was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 10.58 a.m. on May 19, 2011, Staff 1 was unable to ascertain from the facility damper test from 2009 how many dampers were behind the ceiling access labeled FL-47 and how many were tested. The vendor report was worded as if one damper was tested. 3 dampers were observed above the ceiling access panel. 2 of 3 duct access panels were not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panels to note the presence of the damper.

At 11:07 a.m. on May 19, 2011, an air duct was observed to penetrated the smoke barrier above the drop ceiling in patient room 158. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm the dampers had been inspected, tested and maintained.

At 11:07 a.m. on May 19, 2011, an air duct was observed to penetrated the smoke barrier above the drop ceiling in patient room 158. The duct access panel for the damper was not identified indicating a damper within the duct. Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.

At 1:08 p.m. on May 19, 2011, an air duct was observed to penetrated the 2-hour above smoke barrier above the drop ceiling in the corridor adjacent to the door to the operating room. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm if there was a damper in the duct adjacent to the duct access panel that was not labeled. Staff 1 thought the access panel was for access for cleaning the ducts.

At 1:13 p.m. on May 19, 2011, an unlabeled air duct with a damper was observed to penetrate ceiling in the corridor between an air duct with a damper identified as FL-38 and an air duct with a damper identified as FL-39. Staff 1 reviewed the facility damper test from 2009 and was unable to confirm the unlabeled damper had been inspected, tested and maintained.

Based on observation, the facility failed to maintain the means of egress as evidenced by items stored in the corridors. This affected 1 of 28 smoke compartments in the main building. This could result in the delay in the evacuation of the facility and the increased risk of injury to the patients and staff due to fire and smoke.

Findings:

During the facility tour with Staff 2 on May 19, 2011, the facility corridors were observed.

At 9:10 a.m., the corridor of Treatment Room 2 in the Emergency Room on the 1st floor of the Main Hospital was obstructed with two chairs. Staff 2 stated the chairs were placed in the corridor for patient use.

At 1:44 p.m., a bed obstructed the corridor in front of an exit door in the Day Surgery Center on the 1st floor of the Main Hospital. Staff 2 confirmed the bed obstructed the corridor and exit access.

Based on observation and interview, the facility failed to properly store soiled linen containers as evidenced by oversized soiled linen containers stored in the corridor. This affected 1 of 28 smoke compartments and had the potential to delay the evacuation of the facility and increase the risk of injury to the patients and staff due to fire.

Findings:

During the facility tour with Staff 2 on May 18, 2011, the facility corridors were observed.

At 1:58 p.m., 3 large soiled linen bins approximately 3 feet by 4 feet were stored in an open alcove of the corridor on 2nd floor of Tower 1 in the Main Hospital. The bins contained soiled housekeeping rags and soiled mop heads. In an interview with Staff 2 and Staff 3 at 2:01 p.m., they acknowledged that the bins were stored daily in the open alcove of the corridor. Staff 2 acknowledged the bins were greater than the 32 gallons capacity per NFPA guidelines.

NFPA 99 (1999 Edition) 4-3.1.2.3 Gas Shutoff Valves. i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Based on observation, the facility failed to maintain access to the medical gas shutoff valves as evidenced by access to a valve box that was obstructed. This affected 1 of 28 smoke compartments in the Main Hospital and had the potential for the delay in shutting off the oxygen in an emergency and causing potential harm to the patients.

Findings:

During the facility tour with Staff 2 on May 19, 2011, the facility medical gas system was observed.

At 1:44 p.m., access to the emergency oxygen shutoff valve in the Day Surgery Center on the 1st floor of the main hospital was blocked by a bed in front of the box. Staff 2 confirmed a bed obstructed the access to the shutoff valve.

DRAFT STOPS

NFPA 101 (2000 Edition) 3.3.47 Draft Stop. A continuous membrane used to subdivide a concealed space to restrict the passage of smoke, heat, and flames.

NFPA 101 (2000 Edition) 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation, the facility failed to maintain the Draft Stops as evidenced by unsealed penetrations in the Draft Stops. This affected the facility Oncology Suite and had the potential for the migration of smoke causing harm to residents.

Findings:

During the facility tour with Staff 1 on May 17, 2011, the facility draft stops were observed.

At 4:15 p.m., the Draft Stop above the Consultation Room in the Medical Arts Building Onocology Suite was observed to have to an unsealed one inch gap around an air duct, unsealed three-quarter inch gaps around conduits and and an unsealed eight inch by eight inch penetration in the Draft Stop. Staff 1 confirmed there were unsealed penetrations in the Draft Stop.

At 4:20 p.m., there was an approximately twelve inch by twelve inch unsealed penetration the draft stop above the west doctor's office in the Medical Arts Building Oncology Suite. Staff 1 confirmed there was an unsealed penetration in the Draft Stop.

Code of Federal Regulations ?483.25(h) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

NFPA 70 (1999 Edition), article 110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 70 (1999 Edition), 400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:

(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

NFPA 70 (1999 Edition) 400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

NFPA 70 (1999 Edition) 517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or by an isolated power system if such interruption cannot be tolerated.

Exception: Branch circuits supplying only listed, fixed, therapeutic and diagnostic equipment shall be permitted to be supplied from a normal grounded service, single- or 3-phase system provided that

(a) Wiring for grounded and isolated circuits does not occupy the same raceway, and

(b) All conductive surfaces of the equipment are grounded.

NFPA 99 (1999 Edition) 3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.

Based on observation, the facility failed to maintain the electrical wiring as evidenced by damaged electrical receptacles, missing cover plates on boxes, patient care equipment plugged into surge protectors and multi-plug adapters instead of directly into an electrical receptacle, the use of extension cords to extend power to equipment instead of providing fixed wired electrical receptacles, the failure of an electrical receptacle with with ground-fault circuit-interrupter (gfi) protection and the failure to provide documentation that electrical installation was in accordance with NFPA 70. This affected 7 of 28 smoke compartments in the Main Hospital and had the potential for electrical shock or fire leading to harm of the patients.

Findings:

During the facility tour with Staff 1 and 2 between May 17 and 19, 2011, the facility electrical wiring and equipment were observed.

At 10:39 a.m., on May 18, 2011, the four outlet electrical receptacle on the corridor wall adjacent to room 2519 in the Main Hospital Building was damaged around the ground port. Staff 1 confirmed the ground port was damaged.

At 10:53 a.m., on May 18, 2011, there was an open junction box when looking at the smoke barrier from the supply room adjacent to room 2424 in the Main Hospital Building. Staff 1 confirmed there was as open junction box.

At 10:54 a.m., on May 18, 2011, the electrical receptacle on the corridor wall adjacent to room 2433 in the Main Hospital Building was damaged around the ground port. Staff 1 confirmed the ground port was damaged.

At 10:56 a.m., on May 18, 2011, the outlet electrical receptacle on the corridor wall of the 2400 wing adjacent to elevators in the Main Hospital Building was damaged around the ground port. Staff 1 confirmed the ground port was damaged.

At 2:05 p.m. on May 18, 2011, in Room 3116 (Security Office) on the 3rd floor of Tower 1 in the Main Hospital Building, there was a small refrigerator plugged into an extension cord instead of directly into a fixed wired electrical receptacle. The extension cord was plugged into another extension cord. The extension cords were used to extend power to the refrigerator in place of providing fixed wired receptacles. Staff 2 confirmed there were extension cords in use.

At 9:45 a.m. on May 18, 2011, in the Cath Laboratory on the 1st floor of the Main Hospital, there was a six plug power strip plugged into the wall. Staff 2 stated the power strip was for patient equipment usage and was used daily. The power strip was used in place of providing additional fixed wired electrical receptacles.

At 10:35 a.m. on May 18, 2011, two multi-plug power strips were plugged into the wall in the Endo Treatment Room 3 on the 1st floor of the Main Hospital. One multi plug power strip had a patient heart monitor machine plugged into it. The Endo Technician stated that they do plug patient equipment into the power strips because it makes the machines more mobile during procedures.

At 10:55 a.m. on May 19, 2011, in the break room/copier room in Administration there was a microwave oven plugged into a multi plug power strip instead of a wall outlet. Staff 2 confirmed the microwave oven was plugged into a power strip.