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Based on observation it was determined the facility failed to have a 15 second sign posted on an exterior exit gate by the C Pod IV Infusion unit on the East Campus Hospital.

Findings include:

NFPA 101 Life Safety Code, 2012 Chapter 19, Section 19.2 Means of Egress Requirements. Section 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and exit access shall be in accordance with Chapter 7, unless modified by 19.2.2 through 19.2.11. Section 7.2.1.6* Special Locking Arrangements. Section 7.2.1.6.1 Delayed Egress Locking Arrangements. Section 7.2.1.6.1.1 Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. Section 7.2.1.6.1.1 # (4) A readily visible durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located o the door leaf adjacent to the release device in the direction of egress: "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS".

On September 13, 2017, the surveyor accompanied by the East Campus Administrator, Security/Safety Supervisor, and Engineering Supervisor observed the exterior exit gate by the C Pod IV Infusion unit on the East Campus Hospital was missing the 15 second sign on the special locking exit gate.

During the exit conference on September 13, 2017, the above findings were again acknowledged by Director of Engineering, East Campus Administrator, Security/Safety Supervisor, and Engineering Supervisor of East Campus.

Failure to have the sign posted adjacent to the exit gate could cause a delay in an emergency and could cause harm to the patients in event of a fire.

Based observation it was determined the the facility failed to provide sprinkler protection in one broom closet in the corridor of the Infusion Therapy unit on the East Campus Hospital.

Findings include:

NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.3.5.1, " Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." unless otherwise permitted by 18.3.5.5. In Type 1 and Type 11 construction, alternative protection measures shall be permitted to be substituted for sprinkler protection without causing a building to be classified nonsprinklered in specified areas where the authority having jurisdiction has prohibited sprinklers."

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, " Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." unless otherwise permitted by 19.3.5.5. In Type 1 and Type 11 construction, alternative protection measures shall be permitted to be substituted for sprinkler protection without causing a building to be classified nonsprinklered in specified areas where the authority having jurisdiction has prohibited sprinklers. Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler systems." (1.) NFPA 13, Standard for the Installation of Sprinkler Systems" NFPA 13,
Installation Requirements Section 8.1 Basic Requirements. NFPA 13 requires that sprinklers be provided throughout the premises. However, certain provisions permit sprinklers to be omitted from certain spaces where the specific conditions are satisfied. These spaces include concealed spaces see (8.15.1.2.1 through 8.15.1.2.16) vertical shafts (see 8.15.2), bathrooms and clothes closets in dwelling units of hotels and motels(see 8.15.8.1 and 8.15.8.2), elevator shafts (see 8.15.5), and electrical rooms(see 8.15.10)."

On September 12, 2017, the surveyor, accompanied by the East Campus Administrator, Security/Safety Supervisor, and Engineering Supervisor observed the broom closet in the corridor of the Infusion Therapy unit had no sprinkler protection.

During the exit conference on September 13, 2017, the above findings were again acknowledged by Director of Engineering, East Campus Administrator, Security/Safety Supervisor and Engineering Supervisor of East Campus.

Failing to provide sprinkler protection throughout the facility will allow a fire to grow rapidly and cause more sprinkler heads to fuse than necessary. Smoke produced by a fire in a non sprinkled area could cause harm to the patients.

Based on observation it was determined the facility failed to maintain the fire pump from leaking excessively more than one drop per second. The fire pump was located on the East Campus Hospital.

Findings include:

1. NFPA 101, Life Safety Code, 2012 Edition, Chapter 4 General. "Section 4.5.8 "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, unless the code exempts such maintenance. NFPA 25, Standard for the inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Chapter 8, Section 8.2. Inspection. The purpose of inspection shall be to verify that the pump assembly appears to be in operating condition and is free from physical damage. Section 8.2.2 The pertinent visual observations specified in the following checklists shall be performed weekly: See Table A.8.2.2 (2) Check packing adjustment approximately one drop per second is necessary to keep packing lubricated."

On September 12, 2017, the surveyor accompanied by the East Campus Administrator, Security/Safety Supervisor, and Engineering Supervisor observed the East Campus fire pump. The packing gland of the fire pump had a steady flow of running water as seen in the drip pocket of the fire pump at the time of the survey. The normal amount of water should be one drop per second to keep the packing gland lubricated.

During the exit conference on September 13, 2017, the above findings were again acknowledged by Director of Engineering, East Campus Administrator, Security/Safety Supervisor, and Engineering Supervisor of East Campus.

Failing to maintain the fire pump during a fire may cause a failure in the automatic sprinkler system and cause harm to the patients, in time of a fire.

Based on observation it was determined the facility failed to have an Annual inspection on the ABC fire extinguishers on the West Campus Hospital on the second, third, fourth floor and Cath Lab.

Findings include:

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.6 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Chapter 7, Section 7.3.1 Frequency Section 7.3.1.1 All fire extinguishers, Section 7.3.1.1.1. Fire extinguishers shall be subject to maintenance at intervals of not more than one 1 year, at the time of hydrostatic test, or specifically indicated by a inspection or electronic notification.
Section 7.3.3 Maintenance and Record Keeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed, identifies the person performing the work, and identifies the name of the agency performing the work."

On September 11, and 12, 2017, the surveyor accompanied by the East Campus Administrator, Security/Safety Supervisor, and Engineering Supervisor observed on the second, third, fourth floor and the Cath lab approximately ten (10) ABC fire extinguishers that did not have the Annual inspection completed by Climatec in August of 2017.

The Annual tag by Climatec indicated it was done in August of 2016. There was no current tag on the fire extinguishers too indicate an Annual test had been completed.

During the exit conference on September 13, 2017, the above findings were again acknowledged by Director of Engineering, East Campus Administrator, Security/Safety Supervisor, and Engineering Supervisor.

Failing to have inspect and document on an Annual basis all the ABC fire extinguishers in case of a fire could result in harm to the patients.

Based on review of NFPA Life Safety Code and observation, it was determined the facility:

1. Did not allow access to one electrical equipment panel in the East Campus Hospital.

2. Did not allow access to one electrical equipment panel in the West Campus Hospital.

Findings include:

1 and 2. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1 Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction." NEC, 2011 ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions."

"(NO STORAGE ALLOWED IN THE WORKING SPACE)"

1. On September 12, 2017, the surveyor accompanied by the East Campus Administrator, Security/Safety Supervisor, and Engineering Supervisor observed the electrical panels in the (OB) Obstetrical nurses station area were blocked within three feet with work on wheels (WOW) computer equipment. The electrical panels were marked as Panels CW21A11 and CW21A12.

2. The West Campus Hospital electrical plant electrical room had contractor equipment carts being stored directly in front of the electrical panels in the room.

During the exit conference on September 13, 2017 the above findings were again acknowledged by Director of Engineering, East Campus Administrator, Security/Safety Supervisor, and Engineering Supervisor.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients could be harmed if a fire should start because of a delay.

Based on observation it was determined the facility failed to:

1. segregate empty and full oxygen E-type cylinders in the green rated storage cabinets which were observed at both the East and West Campus Hospitals during the survey.

2. secure oxygen bottles in a storage rack or stand.

Findings include:

1. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders."

On September 11, and 12, 2017, the surveyor accompanied by one or more of the following staff: The East Campus Administrator, Security/Safety Supervisor, and Engineering Supervisors, Engineering Tech and Maintenance Engineer, observed on both the East and West Campus hospitals green rated oxygen storage cabinets, with empty or full E-type oxygen cylinders not segregated in the green rated storage cabinets.

The following locations were observed during the survey on the West Campus:

CVICU medical equipment storage room and the Cath Lab had E type oxygen cylinders that had either full E type oxygen cylinder bottles with empty, or empty with full being stored in the green rated storage cabinets.

There were signs posted inside the green storage cabinets marked empty and full.

2. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

The following locations were observed during the survey on the East Campus Hospital where oxygen bottles were observed as unsecured.

1. E type oxygen cylinder was observed unsecured in the utility room in the breast cancer unit.
2. Mechanical room an Argon black compressed cylinder was observed unsecured in the room.
3. Helipad observed two D type and one E type oxygen cylinder were unsecured and not in a rack or stand.
4. Helipad five E type oxygen cylinders stored in a rack with one empty oxygen cylinder and not segregated.

During the exit conference on September 13, 2017, the above findings were again acknowledged by Director of Engineering, East Campus Administrator, Security/Safety Supervisor, and Engineering Supervisor.

Failing to segregate compressed gas medical cylinders could cause harm to the patients if a full bottle is needed in a hurry for the patients. Failing to secure compressed medical gas cylinders could cause harm to the patients and staff if the cylinders are not secured in a rack or stand.