HospitalInspections.org

Based on observation, interview, and document review, the facility failed to have interim life safety code procedures in place or when in place, not implemented in accordance with facility policy. The patient census at the beginning of the survey was 314.

Findings:

On 02/26/19 at 2:00 PM a tour was taken of the 12th floor with Staff LQ and LS. During the tour, the B area was observed to be closed for construction, and, with it, access to exit stair B.

On 02/27/19 at 8:40 AM a tour was taken of the 11th floor with Staff LQ and LS. During the tour, the B area was observed to be closed for construction, and, with it, access to exit stair B.

On 03/06/19 a review of the facility's "Interim Life Safety Measure (ISLM)" policy last reviewed 11/2014 was completed. The review revealed an "ISLM Project Kick-off Check sheet" is to be completed.

The review revealed an exit in an area under construction is to be inspected and documented on the ISLM Daily Inspection Log.

The review revealed contractors are to be informed of the facility's cutting and welding permit procedure.

A review of the facility's policy titled "Fire System Management" last revised on 05/2014 revealed, "Contractors will be instructed to complete the Hot Work Permit each day before work is started...".

A review of the ISLM for the 11th and 12th floor construction areas was completed on 03/06/19. The review revealed a blank "ISLM Project Kick-off Check sheet" and there was no ISLM Daily Inspection Log to review. The review revealed on 02/12/19, 02/14/19, 02/25/19, and 02/28/19 the cutting and welding permits were not completed, leaving blank areas that included fire watch/area monitoring and required precautions.

On 03/07/19 at 11:05 AM in an interview, Staff LX confirmed the documentation.

On 02/27/19 at 3:13 PM observation of the neonatal intensive care unit revealed a construction barrier running north to south at the west end of the unit. The observation revealed the barrier took away the C exit stair.

On 02/27/19 at 3:13 PM in an interview, Staff LQ said there were no interim life safety code interventions implemented.

Based on observation and interview, the facility failed to ensure a two hour barrier between the facility and other buildings were free of penetrations and had doors that self closed and latched. The patient census at the beginning of the survey was 314.

Findings:

Tower Building

1. On 02/27/19 at 9:49 a tour was taken of the 10th floor with Staff LQ and LS.

On 02/27/19 at 10:19 AM observation above the drop down ceiling of the two hour barrier between the tower building and the F and G building revealed two inch open conduits holding blue wires.

On 02/27/19 at 10:19 AM Staff LQ confirmed the finding.

2. On 02/28/19 at 9:50 AM a tour is taken of the 8th floor with Staff LQ and LS.

On 02/28/19 at 10:51 AM observation of the door between the Tower building and the F and G building (containing business spaces) revealed it to be rated at 20 minutes, and did not close and latch when tested. Observation above the drop down ceiling over the door revealed an open one inch flex conduit.

On 02/28/19 at 10:51 AM in an interview, Staff LQ confirmed the finding.

3. On 02/28/19 at 10:55 AM observation above the drop down ceiling of the two hour separation between the shower room next to the F and G business space revealed a penetration from an old half inch conduit.

On 02/28/19 at 10:55 AM in an interview, Staff LQ confirmed the finding.

4. On 02/28/19 at 11:37 AM a tour was taken of the 7th floor with Staff LQ and LS.

On 02/28/19 at 2:29 PM observation above the drop down ceiling of the two hour barrier between the Tower Building (C area) and the F and G building (housing business spaces) and over the double doors revealed three open two inch conduits. Observation of one of the double doors revealed they did not close and latch when tested.

On 02/28/19 at 2:29 PM in an interview, Staff LQ confirmed the findings.

5. On 02/28/19 at 4:20 PM a tour was taken of the 6th floor with Staff LV.

On 02/28/19 at 4:20 PM observation above the drop down ceiling of the barrier between the Tower Building and the Q building and over the double doors perpendicular to Stair A revealed over the east door an open conduit holding a white cable.

On 02/28/19 at 4:20 PM in an interview, Staff LV confirmed the finding.

6. On 02/28/19 at 4:27 PM observation above the drop down ceiling of the one hour barrier between a physician lounge (607) and room 609 revealed, as seen from within 607 toward the southern part of the barrier, a green, open corrugated conduit holding a blue cable.

On 02/28/19 at 4:27 PM in an interview, Staff LV confirmed the finding.

7. On 02/28/19 at 4:32 PM observation above the drop down ceiling of the one hour barrier over door 600.11, as seen from within the physician lounge (607) revealed a penetration of four one inch conduits.

On 02/28/19 at 4:32 PM in an interview, Staff LV confirmed the finding.

8. On 03/06/19 at 8:13 AM a tour was taken of the 4th floor with Staff LQ and LS.

On 03/06/19 at 8:29 AM observation above the drop down ceiling of the two hour building separation barrier between the tower building and the F and G building revealed, as seen from within room 469, two open half inch copper lines in the most southern part of the wall.

On 03/06/19 at 8:29 AM in an interview, Staff LQ confirmed the finding.

Based on observation, record review and staff interview the facility failed to provide occupancy separation in accordance with NFPA 101 - 2012 Edition, Section 21.1.3.1, 6.1.14.1.1, 6.1.14.4.1, 6.1.14.4.2, 8.3.1.2 and Table 6.1.14.4.1. This deficient practice has the potential to affect all patients in the building. The total facility census the day of the survey was 20.

Findings include:

Observation on 02/25/19 during facility tour between 3:00 P.M. and 4:15 P.M. revealed no occupancy separation dividing the emergency department from the business occupancy adjacent to it. An examination of the firewall that was to separate both occupancies revealed that it was not complete from outside wall to outside wall. There was approximately sixty feet of the one hour fire wall separation that had failed to be constructed.

Record review on 02/25/19 of the facility's blueprints revealed that the firewall that was to separate both occupancies was not complete from outside wall to outside wall and from the floor to the upper deck.

These findings were verified and acknowledged by staff AA and CC during an interview at the time of discovery on 02/25/19.

Based on observation during the tour and staff verification, it was determined the facility failed to ensure the egress was maintained according to the 2012 National Fire Protection Association (NFPA) 101 - 2012 Edition, Sections 19.2.7, 7.7.1, 7.1.6, and have exit stairway E comply with 7.7.3.4. This had the potential to affect all patients utilizing these areas of the facility. The census was 314 at the beginning of the survey.

Findings include:

1. On 03/06/19 at 3:16 PM a tour was taken of Stair E with Staff LQ. The tour revealed, at floor one, that occupants are to exit to reach an exit discharge. Observation of the stairway revealed it continued another flight to the floor below. Observation revealed a gate was in place and open without means to close it to prohibit further travel down the stairwell in the event of a fire alarm.

On 03/06/19 at 3:16 PM in an interview, Staff LQ confirmed the finding.

2. Observation on 03/06/19 during facility tour between 9:30 A.M. and 2:00 P.M. noted the egress discharge (sidewalk) for the Fifth Floor F-Stair was not complete to the public way. Further examination revealed that sidewalk leads into an area where cars are being parked and provided no separation for vehicles and a clear path that would lead to the public way. Additionally, the sidewalk had no transition for the elevation change for the concrete sidewalk and the adjoining asphalt road. With no transition for elevation, it would result in an abrupt change in elevation. This change in elevation difference measured three and a half inches.

Based on observation and interview, the facility failed to ensure all paths of egress were marked in accordance with 7.10, NFPA 101, 2012 edition. The patient census at the beginning of the survey was 314.

Findings:

Tower Building

1. On 02/26/19 at 2:00 PM a tour was taken of the 12th floor with Staff LS and LT. On 02/26/19 at 3:12 PM Staff LV joined the tour.

On 02/26/19 at 3:31 PM the path of egress was observed for the west side of the tower building. The south exit access stairway was cut off due to construction. Another exit sign was not apparent before the double doors leading to the north exit access stairway.

On 02/26/19 at 3:31 PM in an interview, Staff LV confirmed the finding.

2. On 02/27/19 at 8:10 AM a tour was taken of the 11th floor with Staff LQ and LS.

On 02/27/19 at 9:41 AM the path of egress was observed for the west side of the tower building. The south exit access stairway was cut off due to construction. Another exit sign was not apparent before the double doors leading to the north exit access stairway.

On 02/27/19 at 9:41 AM in an interview, Staff LQ confirmed the finding.

3. On 02/27/19 at 10:26 AM a tour was taken of the 9th floor with Staff LQ and LS.

On 02/27/19 at 2:45 PM a review of the evacuation route for the A neonatal intensive care unit was completed. The review revealed the plan had occupants traveling west to the western door.

On 02/27/19 at 2:45 PM observation of the A neonatal intensive care unit revealed the C stair was inaccessible due to construction. The observation did not reveal an exit sign leading to the western door and ultimate access to the B stair.

On 02/27/19 at 2:45 PM in an interview, Staff LQ confirmed the finding.

4. On 02/27/19 at 3:06 PM the evacuation plan for the west side of the 9th floor was reviewed. The review revealed two paths of egress. One has occupants traveling north in corridor 913, entering nursery A, then immediately turning right, then left, and then accessing exit stairway A. Observation of this path of egress did not reveal an exit sign directing occupants to turn right upon entering nursery A, and did not have a visible exit sign redirecting occupants to travel north to exit stair A.

The other path of egress has the occupants traveling south in corridor 913, turning left at the first doors they go through, then turning south at the first corner (rather than continuing straight). Observation of this path of egress did not reveal an exit sign directing occupants to turn south at that corner.

On 02/27/19 at 3:06 PM in an interview, Staff LQ confirmed the findings.

5. On 02/28/19 at 9:50 AM a tour is taken of the 8th floor with Staff LQ and LS.

On 02/28/19 at 10:18 AM the path of egress from the outpatient physical therapy area was reviewed. The review revealed a path traveling north from the area, turning left (west), then right (returning to north) and then right again to a corridor door perpendicular to and recessed from the path.

Observation of the path did not reveal an exit sign directing occupants to turn left (west) and then to turn right to a corridor door.

On 02/28/19 at 10:18 AM in an interview, Staff LQ confirmed the finding.

6. On 02/28/19 at 4:09 PM a tour was taken of the 6th floor with Staff LV and LS.

On 02/28/19 at 4:45 PM a review of the evacuation plan revealed a path of egress traveling immediately north from the pre-op holding room (637) and then turning east. Observation of the area did not reveal an exit sign directing occupants to the east.

On 02/28/19 at 4:46 PM in an interview, Staff LV confirmed the finding.

Q Building

A facility tour took place on 02/28/19 to 03/01/19 and again on 3/4/19 to 3/6/19 with staff AA and BB. During tour of the sixth floor within the labor and delivery area heading north in the corridor housing rooms 20-24, observation was made of an exit sign located on the wall of the cross corridor (east/west) having a chevron directing flow to the left or west. Once turning left and now within the east/west corridor heading west observation was made of another exit sign mounted on the left wall of the east/west corridor having a chevron directing flow to the east, or the opposite direction currently in route. It was also noted that there was an exit sign within the cross corridor (east/west) at the east end and not at the west end.

This finding was acknowledged by staff AA during the tour of the Labor and Delivery area.

Based on observation and interview, the facility failed to ensure construction protecting vertical openings was free of penetrations and the doors on vertical openings were rated and self closed. The patient census at the beginning of the survey was 314.

Findings:

Tower building

1. On 02/25/19 at 3:47 PM a tour was taken of the 15th floor with Staff LQ and LR. Observation above the drop down ceiling revealed, looking up toward the northwest corner, a chaise with an open access door. At 3:47 PM in an interview, LQ confirmed the observation.

2. On 02/26/19 at 11:17 AM a tour of the 13th floor was conducted with Staff LS and LT. At 11:35 AM the door to the trash chute was observed to be unrated. On 02/26/19 at 11:35 AM in an interview, Staff LT confirmed the finding.

3. On 02/26/19 at 2:00 PM a tour was taken of the 12th floor with Staff LS and LT. At 3:09 PM observation of the trash chute door revealed it to have an illegible rating. On 02/26/19 at 3:09 PM in an interview, Staff LT confirmed the finding.

4. On 02/27/19 at 8:10 AM a tour was taken of the 11th floor with Staff LQ and LS. At 9:08 AM observation of the trash chute door revealed the rating label was scratched off, making its rating indeterminable. On 02/27/19 at 9:08 AM in an interview, Staff LQ confirmed the finding.

5. On 02/27/19 at 10:26 AM a tour was taken of the 9th floor with Staff LQ and LS. At 10:34 AM observation above the drop down ceiling of the two hour barrier between a chaise and the clean room revealed an open junction box with an open conduit leading to the chaise. On 02/27/19 at 10:34 AM in an interview, Staff LQ confirmed the finding.

6. On 02/27/19 at 10:40 AM observation above the drop down ceiling of the two hour barrier between a chaise and the corridor revealed, above the words "of ordinary," an open junction box with an open conduit traveling to the barrier. On 02/27/19 at 10:40 AM in an interview, Staff LQ confirmed the finding.

7. On 02/27/19 at 10:41 AM observation of the trash chute door revealed it to be unrated. At 10:41 AM in an interview, Staff LQ confirmed the finding.

8. On 02/27/19 at 4:22 PM a tour was taken of the 8th floor with Staff LQ and LS. At 4:29 PM observation above the drop down ceiling of the two hour barrier between the chaise next to elevator 22 and the corridor revealed a three inch copper line with an annular space. On 02/27/19 at 4:29 PM in an interview, Staff LQ confirmed the finding.

9. On 02/27/19 at 4:30 PM observation above the drop down ceiling of the two hour barrier between a chaise and the corridor and near the sign that read Advanced Obstetrical Care revealed an open junction box with an open conduit traveling toward the barrier. On 02/27/19 at 4:30 PM in an interview, Staff LQ confirmed the finding.

10. On 02/28/19 at 9:50 AM a tour is taken of the 8th floor with Staff LQ and LS. At 11:12 AM observation above the drop down ceiling of the two hour barrier between B stair and the corridor revealed open half inch conduit holding white and orange wires. On 02/28/19 at 11:12 AM in an interview, Staff LQ confirmed the finding.

11. On 02/28/19 at 11:37 AM a tour was taken of the 7th floor with Staff LQ and LS. At 1:00 PM observation above the drop down ceiling of the two hour barrier between a chaise and the corridor near door 703.1 revealed a one inch conduit with an annular space. On 02/28/19 at 1:00 PM in an interview, Staff LQ confirmed the finding.

12. On 02/28/19 at 1:05 PM observation above the drop down ceiling of the two hour barrier surrounding the chaise in the clean supply room, as seen from the supply room, revealed an open flex conduit. On 02/28/19 at 1:05 PM in an interview, Staff LQ confirmed the finding.

13. On 02/28/19 at 1:08 PM observation of the door to the garbage chute in the chute room revealed the rating label was scratched and the rating was illegible. On 02/28/19 at 1:08 PM in an interview, Staff LQ confirmed the finding.

14. On 02/28/19 at 3:37 PM a tour was taken of the 6th floor with Staff LV. At 3:45 PM observation of the chute door revealed it was unrated. On 02/28/19 at 3:45 PM in an interview, Staff LV confirmed the finding.

15. On 03/05/19 at 3:58 PM a tour was taken of the 5th floor with Staff LS and LQ. At 4:25 PM observation of the garbage chute in the kitchen area (503) revealed the chute door to be unrated and the self closer unable to close and latch the door. On 03/05/19 at 4:25 PM in an interview, Staff LQ confirmed the finding.

16. On 03/06/19 at 8:13 AM a tour was taken of the 4th floor with Staff LQ and LS. At 8:54 AM observation of the door at the terminus of the trash chute was observed to be unable to close off the chute because garbage bags were stacking up from the landing area into the chute itself. On 03/06/19 at 8:54 AM in an interview, Staff LQ confirmed the finding.

17. On 03/06/19 at 9:42 AM a tour was taken of the 9th floor of the H/I building with Staff LQ and LS. At 10:18 AM observation above the drop down ceiling of the two hour barrier between stair I and the corridor, revealed an open half inch conduit holding an orange line. On 03/06/19 at 10:18 AM in an interview, Staff LQ confirmed the finding.

18. On 03/06/19 at 10:24 AM observation above the drop down ceiling of the two hour barrier between the H stair and the corridor revealed an orange cable running through a penetration. On 03/06/19 at 10:24 AM in an interview, Staff LQ confirmed the finding.

19. On 03/06/19 at 10:30 AM a tour was taken of the 8th floor of the H/I building with Staff LQ and LS. At 10:41 AM observation of the door to the laundry chute revealed it did not have a rating. On 03/06/19 at 10:41 AM in an interview, Staff LQ confirmed the finding.

20. On 03/06/19 at 10:49 AM observation of the garbage chute door revealed it was unable to self close and latch cleaning hoses in the path of travel. On 03/06/19 at 10:49 AM in an interview, Staff LQ confirmed the finding.

21. On 03/06/19 at 11:34 AM a tour was taken of the emergency department with Staff LS and LQ. At 1:08 PM observation of the trash chute door revealed it did not have a rating. On 03/06/19 at 1:08 PM in an interview, Staff LQ confirmed the finding.

22. On 03/06/19 at 3:25 PM a chaise access door was observed in the C stair, floor seven, to have an access panel. When tested, the access panel did not close and latch.
On 03/06/19 at 3:25 PM in an interview, Staff LQ confirmed the finding.

23. On 03/06/19 at 3:38 PM a chaise access door was observed in the C stair on the fourth floor. When tested, the access panel did not close and latch. On 03/06/19 at 3:38 PM in an interview, Staff LQ confirmed the finding.

24. On 03/06/19 at 3:13 PM Stair E was traced with Staff LQ. Observation of the door at its terminus revealed it had self closing and latching hardware that did not close and latch the door. On 03/06/19 at 3:13 PM in an interview, Staff LQ confirmed the finding.

25. On 03/06/19 at 3:13 PM observation of the door at the terminus of Stair D revealed it had self closing and latching hardware that did not close and latch the door. On 03/06/19 at 3:13 PM in an interview, Staff LQ confirmed the finding.

F & G Building

26. A facility tour took place on 03/04/19 to 03/06/19 with staff HH and PP. When touring the fourth floor of the F & G building, specifically in the rubbish and laundry discharge rooms, observation was made of the doors to each chute failing to close and shut properly when tested. The rubbish discharge chute door had debris collecting on the rails which prevented the chute door from closing properly. The laundry discharge chute door was opened and a large mobile container was placed in a position to catch the laundry as it discharged from the chute but it also prevented the chute door from closing and latching properly. This finding was verified by staff HH during tour of the rubbish and laundry chute discharge rooms.

Based on observation and interview, the facility failed to ensure hazardous areas were protected barriers free of penetrations and with doors that self closed. The patient census at the beginning of the survey was 314.

Findings:

Tower Building

1. On 02/26/19 at 11:17 AM a tour of the 13th floor was conducted with Staff LS and LT. Observation above the drop down ceiling of the one hour barrier between the soiled holding room and the trash chute room revealed, over the door, a duct with an annular space at the top. On 02/26/19 at 11:40 AM, in an interview Staff LT confirmed the finding.

2. On 02/27/19 at 8:10 AM a tour was taken of the 11th floor with Staff LQ and LS. At 8:58 AM observation above the drop down ceiling of the one hour barrier between the clean room (1100) and over the door between it and the corridor revealed, as seen from within the room, a one inch open conduit. On 02/27/19 at 8:58 AM in an interview, Staff LQ confirmed the finding.

3. On 02/27/19 at 9:06 AM observation of the door in the one hour barrier surrounding room 1101 revealed it did not self close and latch when tested. On 02/27/19 at 9:06 AM in an interview, Staff LQ confirmed the finding.

4. On 02/27/19 at 10:26 AM a tour was taken of the 9th floor with Staff LQ and LS. At 2:21 PM observation above the drop down ceiling of the one hour barrier around room bassinette 56 revealed a one foot by one foot penetration in the north wall. On 02/27/19 at 2:21 PM in an interview, Staff LQ confirmed the finding.

6. On 02/28/19 at 11:37 AM a tour was taken of the 7th floor with Staff LQ and LS. At 2:38 PM observation above the drop down ceiling of the one hour barrier around storage area 752.2 as observed from within near the midpoint of the southern wall revealed a 1.5 inch penetration with a half inch flex conduit running through it. On 02/28/19 at 2:38 PM in an interview, Staff LQ confirmed the finding.

On 02/28/19 at 2:29 PM observation above the drop down ceiling of the one hour barrier around storage area 752.2 as observed from within near the midpoint of the east wall revealed an open half inch conduit holding a blue wire.

On 02/28/19 at 2:29 PM in an interview, Staff LQ confirmed the findings.

7. On 02/28/19 at 3:19 PM observation above the drop down ceiling of the one hour barrier surrounding equipment room 770 revealed on the western side of the northern barrier a three quarter inch open line. On 02/28/19 at 3:19 PM in an interview, Staff LQ confirmed the finding.

8. On 02/28/19 at 3:37 PM a tour was taken of the 6th floor with staff LV. At 3:45 PM observation of the door to the chute room revealed it was in a one hour barrier with a self closer. The door was observed held open by a recycle bin and a caution slippery sign. On 02/28/19 at 3:45 PM in an interview, Staff LV confirmed the finding.

9. On 03/06/19 at 8:13 AM a tour was taken of the 4th floor with Staff LQ and LS. At 8:15 AM observation of the double doors in soiled room 401 revealed they were in a one hour barrier between the room and the corridor. Observation of the doors revealed they had self closing and latching hardware that did not close and latch the doors because the right leaf was blocked by walkers and the left leaf by intravenous poles. On 03/06/19 at 8:15 AM in an interview, Staff LQ confirmed the finding.

10. On 03/06/19 at 9:42 AM a tour was taken of the 9th floor of the H/I building with Staff LQ and LS. At 9:50 AM observation of the one hour barrier between the soiled utility room and the corridor revealed, as seen from the corridor and near the exit sign, two open half inch conduits, a half inch open copper line, and an open abandoned sprinkler line. On 03/06/19 at 9:50 AM in an interview, Staff LQ confirmed the finding.

11. On 03/06/19 at 11:34 AM a tour was taken of the emergency department with Staff LS and LQ. At 11:38 AM observation above the drop down ceiling of the one hour barrier around equipment room 679.05 revealed, as seen from corridor 679.03 and over the door, a one foot by two foot polygonal shaped missing layer of drywall.
On 03/06/19 at 11:38 AM in an interview, Staff LQ confirmed the finding.

12. On 03/06/19 at 11:44 AM observation above the drop down ceiling of the one hour barrier around equipment room 679.05 revealed, as seen from housekeeping room 679.04, that the drywall did not extend all the way to the deck. On 03/06/19 at 11:44 AM in an interview, Staff LQ confirmed the finding.

13. On 03/06/19 at 1:42 PM observation above the drop down ceiling of the one hour barrier around clean room 679.27 revealed, as seen from within smoke compartment 6.13 and perpendicular to room 679.28 and over the statue, spacing between an heating, ventilation, and cooling duct and the barrier. On 03/06/19 at 1:42 PM in an interview, Staff LQ confirmed the finding.

14. On 03/06/19 at 1:58 PM observation above the drop down ceiling of the one hour barrier between work area 682 and smoke compartment 6.09 revealed, as seen from smoke compartment 6.09 and near door 682, an open junction box. On 03/06/19 at 1:58 PM in an interview, Staff LQ confirmed the finding.

Based upon observation and staff interview the facility failed to ensure fire alarm initiation devices were installed in accordance with NFPA 101 - 2012 Edition, Sections 21.3.4.2 and 9.6.2.3. This deficient practice has the potential to affect all patients in the building. The total facility census the day of the survey was 20.

Findings include:

Observation on 02/25/19 during facility tour between 3:00 P.M. and 4:15 P.M. noted no manual pull stations were provided at the exits. Further examination of each exit provided for the emergency department revealed no manual pull stations at or near the exits.

These findings were verified and acknowledged by staff AA and CC during an interview in the afternoon of 02/25/19.

Based on observation, document review, and interview, the facility failed to ensure its fire alarm system complied with NFPA 72, 2010 edition. The patient census at the beginning of the survey was 314.

Findings

On 03/07/19 a review of the facility's life safety code documentation was completed. The review revealed the fire alarm system was inspected on 12/07/18.

On 03/04/19 at 4:03 PM a horn/strobe device was observed in room 846 (lactation room) and a strobe and a horn/strobe device was observed in room 7148 (the medical surgical intensive care unit conference room).

The review of the fire alarm inspection report did not reveal where these devices had been inspected.

On 03/07/19 at 10:14 AM in an interview, Staff LP explained the facility had switched from one alarm company to another and not all devices had been brought under inspection.

The review of the fire alarm inspection report revealed one set of batteries failed a load test while three were expired.

Review of the facility's life safety code documentation revealed all sets of batteries had been replaced by facility staff, but none had been retested.

On 03/07/19 at 10:44 AM in an interview, Staff LP confirmed there was not any evidence the batteries had been retested.

Review of the facility's sprinkler system alarm reports revealed the last inspection of the sprinkler system's supervisory tamper switches was completed on 01/28/19. The review revealed three tamper switches had failed.

On 03/07/19 at 10:55 AM in an interview, Staff LQ confirmed the tamper switches were not yet fixed.

Based on observation during facility tour and staff verification it was determined the facility failed to ensure the proper instillation of the sprinkler system according to the National Fire Protection Association (NFPA) 101 - 2012 Edition, Section 19.3.5 and 9.7 and NFPA 13 - 2010 Edition, Section 8.1 and 8.15. This had the potential to affect all those utilizing these areas of this facility. The patient census at the beginning of the survey was 314.

Findings:

Facility tour took place on 3/4/19 to 3/6/19 with staff HH and PP. Observations were made of missing required sprinkler installation for proper coverage of building. The missing sprinklers were noted in the following areas:
Fourth Floor - The morgue identified as 0476.1, observation was made of a closet and bathroom that lacked any sprinkler coverage.
Fifth Floor - No sprinkler coverage within the electric closet 0549.30
Sixth Floor - No sprinkler coverage within both electric closets numbered 0674.76 and 0674.26
Seventh Floor - No sprinkler coverage within the closet number 2510.
Eighth floor - No sprinkler coverage within two electrical closets identified as 0864.28 and 0865.18.
Ninth floor - No sprinkler coverage within the telecommunications and electric closet in the south corridor of F & G Building.

These findings were verified by staff HH and PP during tour of the F & G building.

Based on document review, observation and interview, the facility failed to ensure sprinkler heads were kept clean and free of debris, had equal to or more than 18 inches of clearance from objects that would obstruct discharge development in accordance with 19.3.5.1 and therefore 9.7.1 of NFPA 101, 2012 edition and therefore 8.5.5.2 of NFPA 13, 2010 edition, and failed to ensure gauges were inspected monthly in accordance with NFPA 25, 2011 edition, 5.2.4.1 and table 5.1.1.2 and control valves were inspected monthly in accordance with 13.3.2.1.1 and table 13.3.2.1.1. The patient census at the beginning of the survey was 314.

Findings

Tower building

1. On 02/26/19 at 9:00 AM a tour of the 14th floor was conducted with Staff LS and LT. At 9:28 AM observation of the clean equipment storage room between two banks of elevators revealed supply carts with paraphernalia stacked to less than 18 inches of the sprinkler heads. On 02/26/19 at 9:28 AM in an interview, Staff LT confirmed the observation.

2. On 02/26/19 at 2:00 PM a tour was taken of the 12th floor with Staff LS and LT. At 2:20 PM observation of the supply carts in room 1256 revealed paraphernalia stacked to less than 18 inches of the sprinkler heads. On 02/26/19 at 2:20 PM in an interview, Staff LT confirmed the finding.

3. On 02/28/19 at 11:37 AM a tour was taken of the 7th floor with Staff LQ and LS. At 2:21 PM observation of the point of care office storage areas revealed 12.5 inch clearance between four traveling shelves in the middle of the room and the sprinkler heads above them. On 02/28/19 at 2:21 PM in an interview, Staff LQ confirmed the finding.

4. On 02/28/19 at 3:24 PM observation of the sprinkler head in office space/room 768 revealed it had string wrapped the head and dangled for one foot below it. On 02/28/19 at 3:24 PM in an interview, Staff LQ confirmed the finding.

5. On 03/06/19 at 8:13 AM a tour was taken of the 4th floor with Staff LQ and LS. At 8:15 AM observation of the sprinkler heads in room 401 revealed they were tarnished green. On 03/06/19 at 8:15 AM in an interview, Staff LQ confirmed the finding.

6. On 03/06/19 at 9:42 AM a tour was taken of the 9th floor of the H/I building with Staff LQ and LS. At 10:16 AM observation of the trash chute revealed it had a sprinkler head with bits of plastic (from plastic trash bags) stuck to it.
On 03/06/19 at 10:16 AM in an interview, Staff LQ confirmed the finding.

7. On 03/06/19 at 11:04 AM a tour was taken of the 7th floor of the H/I building with Staff LQ and LS. At 11:04 AM observation of the sprinkler within the trash chute revealed it had a sprinkler head with bits of plastic (from plastic trash bags) stuck to it. On 03/06/19 at 11:04 AM in an interview, Staff LQ confirmed the finding.

8. A review of the facility's life safety code documentation was completed on 03/07/19. The review did not reveal where the sprinkler system's gauges and locked controlled valves were inspected monthly. On 03/07/19 at 10:58 AM in an interview, Staff LP confirmed the gauges and controlled valves were not inspected monthly.

9. The review revealed the sprinkler system inspection of 01/28/19 revealed system lacked a hydraulic name plate. On 03/07/19 at 2:30 PM in an interview, Staff LS confirmed the nameplate had not yet been made.

10. Facility tour took place on 03/04/19 to 03/06/19 with staff HH and PP.
When touring the fourth floor of the F & G building specifically within the laundry chute discharge room, observation was made of a sprinkler head having plastic hanging from the deflector.

11. When touring the fifth floor of the F & G building specifically within the rubbish chute room identified as 0548.40, observation was made of a sprinkler head within the chute having plastic and other debris hanging from the deflector.

12. When touring the seventh floor of the F & G building and specifically within a storage room identified as 0774.18, observation was made of a thick coating of dust and debris covering the sprinkler head and glass bulb.

These findings were verified by staff HH during tour of the F & G building.

Based on observation during tour and staff verification it was determined the facility failed to ensure the proper identification of the locations of portable fire extinguishers for quick access in the event of an emergency. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 314.

Findings:

F & G Building

1. Facility tour took place on 03/04/19 to 03/06/19 with staff HH and PP. When touring the fourth floor corridor of the F & G building near room 0476.8 observation was made of a fire extinguisher located in a recessed cabinet that had a door which did not enable the viewer to see the portable fire extinguisher inside. A small flat sign was fixed to the door which read fire hose and fire extinguisher but was not visible if the viewer was a few feet away on the same side of the corridor of the recessed cabinet.

2. When touring the sixth floor and near stairwell 6F observation was made of a portable fire extinguisher that lacked a location identification tag.

3. When touring the seventh floor near room 774.22 observation was made of a fire extinguisher located in a recessed cabinet that had a door which did not enable the viewer to see the portable fire extinguisher inside. A small flat sign was fixed to the door which read fire hose and fire extinguisher but was not visible if the viewer was a few feet away on the same side of the corridor of the recessed cabinet.

O Building

5. When touring the sixth floor of the O building and across from OR #19 observation was made of a portable fire extinguisher that lacked a location identification tag.

These findings were verified by staff HH and PP during tour of the F & G and O buildings.

Based on observation and interview, the facility failed to ensure each waiting area that was open on a corridor and the total area of which was not visible from the nursing station had a smoke detector in accordance with 19.3.6.1 (2), NFPA 101, 2012 edition. The patient census at the beginning of the survey was 314.

Findings

Tower Building

1. On 02/26/19 at 9:00 AM a tour of the 14th floor was conducted with Staff LS and LT. At 9:00 AM the waiting area opposite the banks of elevators was observed to be without a smoke detector. The waiting area was observed to be without doors to the corridor. The waiting area was observed to be otherwise closed from the corridor, so that its space could not be observed from the nursing stations. On 02/26/19 at 9:00 AM in an interview, Staff LT confirmed the observation.

2. On 02/26/19 at 2:00 PM a tour was taken of the 12th floor with Staff LS and LT. At 2:33 PM observation of the waiting area opposite the bank of elevators revealed it to be without a smoke detector and doors to the corridor. On 02/26/19 at 2:33 PM in an interview, Staff LT confirmed the finding.

Based on observation and interview, the facility failed to ensure that doors with self closing and latching hardware that opened on a corridor self closed and latched. The patient census at the beginning of the survey was 314.

Findings:

1. On 02/26/19 at 3:41 PM a tour was taken of the 11th floor with Staff LS and LV. At 4:31 PM the door to patient room 1168 was observed to open on the corridor and have self closing and latching hardware that did not close and latch the door when tested. On 02/26/19 at 4:31 PM in an interview, Staff LV confirmed the finding.

2. On 02/28/19 at 3:37 PM a tour was taken of the 6th floor with Staff LV. At 3:57 PM the door to a housekeeping closet (652) was observed to have self closing and latching hardware that did not close and latch the door. On 02/28/19 at 3:57 PM in an interview, Staff LV confirmed the finding.

3. On 03/06/19 at 9:42 AM a tour was taken of the 9th floor of the H/I building with Staff LQ and LS. At 10:15 AM room 992.09 was observed to have a door that opened to the corridor that had self closing and latching hardware that did not close and latch the door. On 03/06/19 at 10:15 AM in an interview, Staff LQ confirmed the finding.

Based on observation during tour and staff verification, it was determined the facility failed to ensure corridor doors were constructed and maintained according to the 2012 National Fire Protection Association (NFPA) 101, Chapter 19, 3.6.4. This had the potential to affect all patients utilizing these areas of the facility. The census was 314 at the beginning of the survey.

Findings:

Facility tour on the sixth floor of the F and G building took place on 03/04/19 to 03/06/19 with staff PP and found two corridor doors that were unable to resist the passage of smoke due to transfer grilles installed on the doors. The following doors with the transfer grill installed were door #0674.76 (electric closet) and door # 0674.26 (electric closet). These observations were verified by the attending staff.

Based on observation and interview, the facility failed to ensure its smoke barriers were free of penetrations. The patient census at the beginning of the survey was 314.

Findings:

Tower Building

1. On 02/26/19 at 8:30 AM a tour of the 15th floor was conducted with Staff LS and LT. At 8:48 AM observation above the drop down ceiling of the one hour barrier between A and B areas, as seen at the nurses station, revealed a one inch corrugated conduit open to air with blue and gray wires running out of it. On 02/26/19 at 8:48 AM in an interview, Staff LT confirmed the observation.

2. On 02/26/19 at 9:00 AM a tour of the 14th floor was conducted with Staff LS and LT. At 9:35 AM observation above the drop down ceiling of the smoke barrier between B area and E area revealed, as seen from within the E area, revealed over crease between the doors a blue wire traveling through an unsealed penetration. On 02/26/19 at 9:35 AM in an interview, Staff LT confirmed the observation.

3. On 02/26/19 at 9:48 AM observation above the drop down ceiling of the smoke barrier between the charge nurse office and area A, as seen from the charge office, revealed an open corrugated conduit with a blue wire traveling out of it. On 02/26/19 at 9:48 AM in an interview, Staff LT confirmed the finding.

4. On 02/26/19 at 9:56 AM observation above the drop down ceiling of the one hour barrier between the nursing station and A area revealed, as seen from the nursing station, an open one inch flex conduit with a blue wire running out of it. On 02/26/19 at 9:56 AM in an interview, Staff LT confirmed the finding.

5. On 02/26/19 at 10:37 AM observation above the drop down ceiling of the one hour barrier between the charge nurse office and C area, as seen from within the charge nurse office, revealed an open junction box with a conduit leading to the barrier. On 02/26/19 at 10:37 AM in an interview, Staff LT confirmed the finding.

6. On 02/26/19 at 10:44 AM observation above the drop down ceiling of the one hour barrier between the nursing station and area D revealed, as seen from the nursing station (over the monitors) an open flex conduit with a blue wire running out of it. On 02/26/19 at 10:44 AM in an interview, Staff LT confirmed the finding.

7. On 02/26/19 at 11:17 AM a tour of the 13th floor was conducted with Staff LS and LT. At 12:54 PM observation above the drop down ceiling of the one hour barrier over the double doors between area A and B, as seen from the A side, revealed a bundle of blue wires with an annular space. On 02/26/19 at 12:54 PM in an interview, Staff LT confirmed the finding.

8. On 02/26/19 at 12:56 PM observation above the drop down ceiling of the one hour barrier between workroom 1316 and the nursery revealed an open junction box with a conduit leading to the barrier. On 02/26/19 at 12:56 PM in an interview, Staff LT confirmed the finding.

9. On 02/26/19 at 1:23 PM observation above the drop down ceiling of the one hour barrier over the double doors between area C and E revealed, as seen from area C and over the right door, an open conduit with yellow and purple wiring running out of it. On 02/26/19 at 1:23 PM in an interview, Staff LT confirmed the finding.

10. On 02/26/19 at 1:30 PM observation above the drop down ceiling of the one hour barrier over the double doors between the D and C areas revealed, as seen from the D area on the right side, a one inch open conduit with blue wiring running through it. On 02/26/19 at 1:30 PM in an interview, Staff LT confirmed the finding.

11. On 02/26/19 at 2:00 PM a tour was taken of the 12th floor with Staff LS and LT. At 2:30 PM observation above the drop down ceiling of the one hour barrier over the double doors between C and D areas, as seen from the C area and over the left door, revealed a one inch open conduit with blue wires traveling out of it. On 02/26/19 at 2:30 PM in an interview, Staff LT confirmed the finding.

12. On 02/26/19 at 2:31 PM observation above the drop down ceiling of the one hour barrier over the monitors and between the nursing station and area D revealed an open junction box with an open conduit traveling through the barrier. On 02/26/19 at 2:31 PM in an interview, Staff LT confirmed the finding.

13. On 02/26/19 at 3:12 PM Staff LV joins the tour. On 02/26/19 at 3:20 PM observation above the drop down ceiling of the one hour barrier over the monitors and between the nursing station and area A revealed an open flex conduit with blue and grey wires running out of it. On 02/26/19 at 3:20 PM in an interview, Staff LV confirmed the finding.

14. On 02/27/19 at 8:10 AM a tour was taken of the 11th floor with Staff LQ and LS. At 9:15 AM observation above the drop down ceiling of the one hour barrier between the nursing station and area A and over the nursing monitors revealed two flex conduits open with blue wires traveling out of them. On 02/27/19 at 9:15 AM in an interview, Staff LQ confirmed the finding.

15. On 02/27/19 at 9:29 AM observation of the one hour barrier between area A and B and over the double doors revealed, as seen from area A, a one inch conduit with blue wires with an annular space around it. On 02/27/19 at 9:29 AM in an interview, Staff LQ confirmed the finding.

16. On 02/27/19 at 10:26 AM a tour was taken of the 9th floor with Staff LQ and LS. At 10:27 AM observation above the drop down ceiling of the one hour barrier perpendicular to elevators 21 and 22 and over the double doors revealed, as seen from the E area, two open conduits holding blue wires. On 02/27/19 at 10:27 AM in an interview, Staff LQ confirmed the finding.

17. On 02/27/19 at 10:45 AM observation above the drop down ceiling of the one hour barrier over door 925 and perpendicular to room 911 revealed, as seen from the north side, a six inch by six inch open junction box with open conduits traveling through the barrier. On 02/27/19 at 10:45 AM in an interview, Staff LQ confirmed the finding.

18. On 02/27/19 at 3:28 PM observation above the drop down ceiling of the one hour barrier between the tower building and the Q building and over the double doors perpendicular to stair A (902.11), revealed an open conduit holding blue wires and an open corrugated conduit holding a gray wire. On 02/27/19 at 3:28 PM in an interview, Staff LQ confirmed the finding.

19. On 02/27/19 at 3:36 PM observation above the drop down ceiling of the one hour barrier in the area opposite Stair E revealed a junction box with a missing knock out holding a blue wire with open conduits traveling to the barrier. On 02/27/19 at 3:36 PM in an interview, Staff LQ confirmed the finding.

20. On 02/27/19 at 3:38 PM observation above the drop down ceiling of the one hour barrier over the single door opposite Stair E revealed a blue wire traveling through a penetration and three conduits with annular spaces. On 02/27/19 at 3:38 PM in an interview, Staff LQ confirmed the finding.

21. On 02/27/19 at 4:00 PM observation above the drop down ceiling of the one hour barrier at the back of the pregnancy triage area and over the fax and copier machine revealed an annular space around a corrugated conduit holding a blue line, and annular spaces around two plumb lines. On 02/27/19 at 4:00 PM in an interview, Staff LQ confirmed the finding.

22. On 02/27/19 at 4:05 PM observation above the drop down ceiling of the one hour barrier over door 959a revealed an annular space around a green flex conduit.
On 02/27/19 at 4:05 PM in an interview, Staff LQ confirmed the finding.

23. On 02/28/19 at 9:50 AM a tour is taken of the 8th floor with Staff LQ and LS. At 9:55 AM observation above the drop down ceiling of the one hour barrier between the C area and the E area and over double door 8100.1A revealed a two inch open flex conduit holding cables of many colors. On 02/28/19 at 9:55 AM in an interview, Staff LQ confirmed the finding.

24. On 02/28/19 at 9:56 AM observation above the drop down ceiling of the one hour barrier in room 8154 revealed at the corner two open one inch pipes. On 02/28/19 at 9:56 AM in an interview, Staff LQ confirmed the finding.

25. On 02/28/19 at 10:26 AM observation above the drop down ceiling of the one hour barrier between smoke compartment 8.07 and 8.08 and over the double doors perpendicular to the staff bathroom revealed a three inch open conduit, over the staff bathroom door three penetrations, and over the door to the conference room one elbow conduit with an open conduit holding a grey wire that traveled to the double doors. On 02/28/19 at 10:26 AM in an interview, Staff LQ confirmed the finding.

26. On 02/28/19 at 10:30 AM observation above the drop down ceiling of the one hour barrier between smoke compartment 8.07 and 8.06 as seen from 8.07 and between conference room 844.1 and door 845.1a revealed to the left of the door a bundle of blue cables unsleeved and with an annular space. On 02/28/19 at 10:30 AM in an interview, Staff LQ confirmed the finding.

27. On 02/28/19 at 10:36 AM observation of one hour smoke barrier between smoke compartment 8.07 and the room 846 revealed, as seen from room 846, a heating, ventilation, and cooling duct with a top annular space. On 02/28/19 at 10:36 AM in an interview, Staff LQ confirmed the finding.

28. On 02/28/19 at 10:45 am observation above the drop down ceiling of the one hour barrier between smoke compartment 8.07 and resident room shower revealed, as seen from the shower, a one inch open conduit next to the letters "1 hour smoke barrier." On 02/28/19 at 10:45 AM in an interview, Staff LQ confirmed the finding.

29. On 02/28/19 at 11:16 AM observation above the drop down ceiling of the one hour barrier between the B area and the E area and over door 800.1 revealed a penetration left by a half inch conduit. On 02/28/19 at 11:16 AM in an interview, Staff LQ confirmed the finding.

30. On 02/28/19 at 11:22 AM observation of the west one hour barrier in the soiled holding room, as seen from the soiled room, revealed a six inch by one foot penetration. On 02/28/19 at 11:22 AM in an interview, Staff LQ confirmed the finding.

31. On 02/28/19 at 11:25 AM observation above the drop down ceiling of the one hour barrier between the A and B areas and over the double doors revealed, as seen from the A area, a one inch open conduit holding black cords and an empty half inch open conduit. On 02/28/19 at 11:25 AM in an interview, Staff LQ confirmed the finding.

32. On 02/28/19 at 11:32 AM observation above the drop down ceiling of the one hour barrier between the Tower Building and the Q building revealed over the double doors perpendicular to room 809 three open flex conduits. On 02/28/19 at 11:32 AM in an interview, Staff LQ confirmed the finding.

33. On 02/28/19 at 11:37 AM a tour was taken of the 7th floor with Staff LQ and LS. At 11:55 AM observation above the drop down ceiling of the one hour barrier between the lab and area B, as seen from within the lab near the tube station area, revealed a two foot by four foot square penetration. On 02/28/19 at 11:55 AM in an interview, Staff LQ confirmed the finding.

34. On 02/28/19 at 1:39 PM observation above the drop down ceiling of the one hour barrier between the A area and the B area and over the double doors revealed an open conduit holding a green wire. On 02/28/19 at 1:39 PM in an interview, Staff LQ confirmed the finding.

35. On 02/28/19 at 2:09 PM observation above the drop down ceiling of the one hour barrier between the lab and the corridor, as seen from the corridor near and north of door 746.2, revealed two two inch conduits in a tray and open. On 02/28/19 at 2:09 PM in an interview, Staff LQ confirmed the finding.

36. On 02/28/19 at 3:06 PM observation of the 1 hour barrier between smoke compartment 7.07 and 7.06 as seen from within the dialysis unit (762) and between two stations revealed two open half inch corrugated conduits holding green cables, two open half inch conduits holding blue wires and a four inch penetration in the wall. On 02/28/19 at 3:06 PM in an interview, Staff LQ confirmed the finding.

37. On 02/28/19 at 3:37 PM a tour was taken of the 6th floor with Staff LV. At 3:45 PM observation above the drop down ceiling of the one hour barrier between equipment room 624 and the corridor, as seen from the corridor, revealed a two inch pipe traveling through a four by four inch penetration to the left of the door. On 02/28/19 at 3:45 PM in an interview, Staff LV confirmed the finding.

38. On 02/28/19 at 3:53 PM observation above the drop down ceiling of the one hour barrier near the sign "bed OR 7" revealed a half inch conduit traveling through a one inch by one inch penetration. On 02/28/19 at 3:53 PM in an interview, Staff LV confirmed the finding.

39. On 02/28/19 at 4:09 PM a tour was taken of the 6th floor with Staff LV and LS. At 4:09 PM observation above the drop down ceiling of the one hour smoke barrier between room 637 and cath lab #2, as seen within 637 and near the ice machine, revealed an open junction box with a conduit traveling to the barrier. On 02/28/19 at 4:09 PM in an interview, Staff LV confirmed the finding.

40. On 03/06/19 at 9:42 AM a tour was taken of the 9th floor of the H/I building with Staff LQ and LS. At 9:45 AM observation of the one hour barrier between the H/I building and F/G building revealed, as seen from within the H/I building, an open one inch conduit over the exit sign at the double doors perpendicular to room 991. On 03/06/19 at 9:45 AM in an interview, Staff LQ confirmed the finding.

41. On 03/06/19 at 9:46 AM observation of the one hour barrier between the H/I building and F/G building revealed, as seen from room 991, revealed an open one inch flex conduit and an open half inch conduit holding an orange cable. On 03/06/19 at 9:46 AM in an interview, Staff LQ confirmed the finding.

42. On 03/06/19 at 10:30 AM a tour was taken of the 8th floor of the H/I building with Staff LQ and LS. At 10:36 AM observation above the drop down ceiling of the one hour barrier over double doors 899.4, as seen from within smoke compartment 8.04, revealed an open junction box with open conduit traveling to the barrier. On 03/06/19 at 10:36 AM in an interview, Staff LQ confirmed the finding.

43. On 03/06/19 at 10:48 AM observation above the drop down ceiling of the one hour barrier between the H area and the I area and over the double doors, revealed, as seen from the H area, a fist sized penetration with a flex conduit traveling through it. On 03/06/19 at 10:48 AM in an interview, Staff LQ confirmed the finding.

44. On 03/06/19 at 11:34 AM a tour was taken of the emergency department with Staff LS and LQ. At 11:34 AM observation above the drop down ceiling of the one hour barrier between smoke compartment 6.12 and 6.10, as seen from smoke compartment 6.10 and at door 679.74 revealed an open two inch and one inch conduit, and an open junction box with conduits traveling to the barrier. On 03/06/19 at 11:34 AM in an interview, Staff LQ confirmed the finding.

45. On 03/06/19 at 11:48 AM observation above the drop down ceiling of the one hour barrier between smoke compartment 6.10 and 6.11 revealed, as seen above door 677, a two foot by two foot polygonal shaped penetration through which a sewer pipe and tube system pipe traveled through. On 03/06/19 at 11:48 AM in an interview, Staff LQ confirmed the finding.

46. On 03/06/19 at 1:21 PM observation of the one hour barrier perpendicular to room 675.14, and seen from within smoke compartment 6.12 revealed annular spaces around two insulated copper lines. On 03/06/19 at 1:21 PM in an interview, Staff LQ confirmed the finding.

47. On 03/06/19 at 2:16 PM observation above the drop down ceiling of the one hour barrier between smoke compartment 6.07 and 6.10, as seen from within office 680.2, revealed a half inch open conduit. On 03/06/19 at 2:16 PM in an interview, Staff LQ confirmed the finding.

48. On 03/06/19 at 2:35 PM observation above the drop down ceiling of the one hour barrier between smoke compartment 6.10 and 6.12 as seen from within room 679.75, revealed a six inch by six inch square with an old water line running through it. On 03/06/19 at 2:35 PM in an interview, Staff LQ confirmed the finding.

49. On 03/06/19 at 2:48 PM a tour was taken of the 5th floor/smoke compartment 5.3 with Staff LS and LQ. At 2:49 PM observation of the one hour barrier perpendicular to room 553.4 revealed, as seen from within smoke compartment 5.3, a three inch penetration. On 03/06/19 at 2:49 PM in an interview, Staff LQ confirmed the finding.

50. Facility tour took place on 02/28/19 to 03/01/19 and again on 03/04/19 to 03/06/19 with staff AA and BB. Penetrations were observed in the one-hour smoke barrier above the ceiling tiles and verified by the attending staff in the following areas:
Q Building
First Floor:
A four-inch junction box with a missing cover plate and an open-end silver curved conduit located above the fire panels in room 01107.
Above double doors 01185 observation was made of an open-end conduit with blue and grey wires passing through.

Second Floor:
Within room 0211.29 IT Bulk Storage. An unsealed steel beam passing through the smoke barrier.
Within 02130 conference room two open end conduits with orange tips of which one had two blue wires passing through.

Fourth Floor:
Above door 04400 of the electrical closet observation was made of an open-end silver conduit with two grey wires and pink insulation was noted to be wedged in between a row of silver conduits.
Above double doors 04200 two flex and a silver conduit was observed to be passing through an approximate four-inch circular hole.
Along the smoke barrier wall outside of rooms 04205 and 04206 observation was made of multiple penetrations consisting of unsealed conduits, open end conduits and a hole in the wall.
Within room 04220 observation was made of three open end conduits which were also not sealed around the annular space.
Within conference room 04110 at the back-smoke barrier wall, observation was made of a silver two inch open end conduit and a silver one inch open end conduit.
Within the adjacent conference room number 04110.1 three conduits were observed to have pink insulation stuffed within the end and a two-inch silver conduit was open at the end.

Fifth Floor:
Within procedure room #2 noted as 05370, observation was made of an unsealed two-inch sprinkler line around the annular space.
Within room # 05375, observation was made of two, three inch penetrations in the above ceiling space on the south wall.

Sixth Floor:
Above door 06185 observation was made of a one-inch unsealed silver conduit.
Above door 605 observation was made of a four inch junction box that did not have a cover and a silver one-inch open conduit.
Above door 06180 observation was made of an unsealed green and silver flex conduit, a curved open-end conduit, an approximate two inch by four inch opening and a half inch unsealed silver conduit.
Inside staff break room identified as 06425 observation was made of an approximate 14 inch by 10 inch opening in the smoke barrier with a one-and-a-half-inch copper pipe passing through.
Within the Surgicare waiting room near the back of the smoke barrier, observation was made of two small circular holes.

Ninth Floor:
At the east stairwell door 0959A within the labor and delivery area, observation was made of four unsealed flex conduits and pipes.
Within the nurse's station (0958.1) above the area where the printer was located observation was made of eight penetrations around flex conduits, open end conduits, wires and insulated pipes.
Within the nurse's station (0958.1) above and to the right side of the smoke barrier door, observation was made of a sprinkler pipe not sealed around the annular space.

F & G Building

Sixth Floor:
Above and next to the double doors identified as 0537.1A observation was made of a half dollar size hole and a small area of insulated lines which had an opening around the annular space.
Above double doors 0673 observation was made of an unsealed eight-inch flex duct, conduits and blue wires.
Within room 673.14 (staff lounge), two three-inch lines were observed not to be sealed around the annular space.
Within the cath lab at bay number 3 observation was made of a half dollar size hole in the smoke barrier.
Within the cath lab at bay number 4 observation was made of an open-end flex conduit.
Above doors 674.6 pneumatic tube system not sealed around the annular space.
Above doors 0673 observation was made of an eight-inch flex duct, conduits and blue wires not sealed around the annular space.

Seventh Floor:

Above double doors identified as 0774 observation was made of three junction boxes that lacked a cover plate and a three-inch unsealed drain line.
Above double doors identified as 0799.3 observation was made of a wire cable tray missing a small section of fire stop at the top right corner.
Within room 0774.1 observation was made of the north smoke barrier three unsealed conduits around the annular space.

Ninth Floor:
Above the double doors identified as 0992.3 observation was made of a small open area between two silver conduits.

Based on observation and interview, the facility failed to ensure doors in smoke barriers with self closing and latching hardware closed and latched the doors and where there were double doors, the doors did not have a large gap (greater than one-eighth inch) between leaves. The patient census at the beginning of the survey was 314.

Findings

Tower Building

1. On 02/26/19 at 8:30 AM a tour of the 15th floor was conducted with Staff LS and LT. At 8:55 AM observation of the double doors in the one hour smoke barrier between A and B units revealed, when tested, the self closing and latching hardware did not self close and latch the doors. On 02/26/19 at 8:55 AM in an interview, Staff Lt confirmed the observation.

2. On 02/26/19 at 11:17 AM a tour of the 13th floor was conducted with Staff LS and LT. At 11:55 AM observation of the double doors (1316.1) in the one hour barrier between A and B areas revealed the self closing and latching hardware did not close and latch the doors. On 02/26/19 at 11:55 AM in an interview, Staff LT confirmed the finding.

3. On 02/26/19 at 1:36 PM observation of the single door in the one hour barrier between workroom 1360 and the nursery revealed it was unrated, had a window within, and its self closing hardware was unable to self close the door because of a laundry cart blocking its path of travel. On 02/26/19 at 1:36 PM in an interview, Staff LT confirmed the finding.

4. On 02/26/19 at 2:00 PM a tour was taken of the 12th floor with Staff LS and LT. At 3:12 PM Staff LV joins the tour. On 02/26/19 at 3:12 PM the double doors in the one hour barrier between area A and B revealed the self closing and latching hardware did not self close and latch the doors. On 02/26/19 at 3:12 PM in an interview, Staff LV confirmed the finding.

5. On 02/27/19 at 10:26 AM a tour was taken of the 9th floor with Staff LQ and LS. At 10:27 AM observation of the double door in the one hour barrier perpendicular to elevators 21 and 22 revealed the self closing and latching hardware did not close and latch the doors. On 02/27/19 at 10:27 AM in an interview, Staff LQ confirmed the finding.

6. On 02/27/19 at 3:52 PM observation of the double doors in the one hour barrier between D area and the Q building revealed between the leaves there was a three quarter inch gap. On 02/27/19 at 3:52 PM in an interview, Staff LQ confirmed the finding.

7. On 02/28/19 at 9:50 AM a tour is taken of the 8th floor with Staff LQ and LS. At 9:58 AM observation of double doors 8100.1A in a one hour smoke barrier revealed the door furthest from the elevator had latching and self closing hardware that did not close and latch the door. On 02/28/19 at 9:58 AM in an interview, Staff LQ confirmed the finding.

8. On 02/28/19 at 11:37 AM a tour was taken of the 7th floor with Staff LQ and LS. At 2:14 PM observation of double doors 746.2 in the one hour barrier between the lab and the corridor revealed the doors' closing and latching hardware did not close and latch the doors. On 02/28/19 at 2:14 PM in an interview, Staff LQ confirmed the finding.

9. On 02/28/19 at 4:45 PM a tour was taken of the 6th floor with Staff LV and LS. At 4:45 PM observation of the double doors in the one hour barrier perpendicular to elevators 21 and 22 as well as clean room (600) revealed they had self closing and latching hardware that did not close and latch the doors. On 02/28/19 at 4:45 PM in an interview, Staff LV confirmed the finding.

10. On 03/06/19 at 9:42 AM a tour was taken of the 9th floor of the H/I building with Staff LQ and LS. At 9:50 AM observation of double doors 992.6 in the one hour barrier revealed them to have a half inch gap between the leaves. On 03/06/19 at 9:50 AM in an interview, Staff LQ confirmed the finding.

11. On 03/06/19 at 10:30 AM a tour was taken of the 8th floor of the H/I building with Staff LQ and LS. At 10:35 AM observation of double doors 899.4 in the one hour barrier revealed they had self closing and latching hardware that did not close and latch the doors. On 03/06/19 at 10:35 AM in an interview, Staff LQ confirmed the finding.

12. On 03/06/19 at 11:34 AM a tour was taken of the emergency department with Staff LS and LQ. At 11:53 AM observation of door 677.04 in a lounge in a one hour barrier revealed it had self closing and latching hardware that did not close and latch the door because coverall bibs were hanging from its edge and a box was blocking its path of travel from the front. On 03/06/19 at 11:53 AM in an interview, Staff LQ confirmed the finding.

13. Facility tour took place on 02/28/19 to 03/01/19 and again on 03/04/19 to 03/06/19 with staff AA and BB. Smoke barrier doors were observed to not either shut properly or had gaps greater that one-eighth inch between the door leaves while in the closed position, and/or lacked an automatic closing device. These findings were verified by the attending staff during tour of the facility in the following areas:

Q Building

Second Floor:
The door to conference room identified as 02130 lacked an automatic closing device.

Fourth Floor:
The double doors identified as 04389 was observed to be equipped with a latching device which failed when tested.

Sixth Floor:
The double doors identified as 06185 was observed to be equipped with a latching device which failed when tested.

The double doors identified as 06320.1 was observed to be equipped with a latching device which failed when tested. Additionally, a gap greater than one-eighth inch was observed between the door leaves when in the closed position.

Eighth Floor:
The double doors leading into Q building located by the exit door identified as 0855.2 was observed to have a gap greater than one-eighth inch between the door leaves when in the closed position.

F & G Building
Fifth Floor:
Double doors identified as 550.34 was equipped with a latching device but failed to latch when tested. Additionally, a gap greater that one-eighth inch was observed near the bottom of the doors between the door leaves when in the closed position.

Sixth Floor:
The double doors identified as 0674.34 was observed to be equipped with a latching device which failed when tested.

Ninth Floor:
At the double doors identified as 0992.3 observation was made of a gap greater than one-eighth inch between the door leaves when in the closed position.

Tenth Floor:
The double doors identified as 1027.6 was observed to have a gap greater than one-eighth inch between the door leaves when in the closed position.

The double doors identified as 1029 was observed to have a gap greater than one-eighth inch between the door leaves when in the closed position.

Based on observation and staff interview the facility failed to provide emergency lighting in accordance with NFPA 101 - 2012 Edition, Section 21.5.1.1, 9.1.3, 9.1.3.1, and NFPA 110 - 2010 Edition, Section 7.3. This deficient practice had the potential to affect all patients in the building. The total facility census the day of the survey was 20.

Findings include:

During observation on 02/25/19 during facility tour between 3:00 P.M. and 4:15 P.M. it was noted no battery back-up emergency lights were provided for the generator transfer switch gear area. The absence of this light has a potential to affect patient care if there was a malfunction issue in the transferring to emergency power in the event of a power outage.

These findings were verified and acknowledged by staff AA and CC during an interview at the time of discovery on 02/25/19.

Based on observation, document review, and interview, the facility failed to inspect (and repair where necessary) the function of the smoke dampers within the Heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition, and therefore 5.4.8.2 of 90A, 2012 edition and therefore 6.5.2 in NFPA 105, 2010 edition and failed to inspect (and repair where necessary) the function of the fire dampers within the Heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition, and therefore 5.4.8 of 90A, 2012 edition and therefore 19.4.1.1 in NFPA 80. The patient census at the beginning of the survey was 314.

Findings:

On 03/05/19 a review of the facility's life safety code documentation was completed. The review revealed not all smoke damper for fan 14 and 15 were inspected (and repaired if necessary).

The review of the dampers for fan 14 revealed 18 fire dampers passed inspection, with the remainder inaccessible. The review revealed 98 smoke dampers passed inspection although they were inaccessible.

The review of the dampers for fan 15 revealed 17 fire dampers passed inspection and 17 smoke detectors passed inspection, with another 12 passing although they could not be accessed.

Fan 15 had a total of 95 smoke and fire dampers altogether.

On 03/05/19 at 2:30 PM Staff LP confirmed that not all dampers had been inspected because they were inaccessible.

Based on interview and document review the facility failed to perform fire drills at unexpected times under varying condition. The patient census at the beginning of the survey was 314.

Findings

On 03/07/19 a review of the facility's fire drills' documentation was completed. The review revealed the drills were held the first month of every quarter and the drills for all three shifts were held within at most 10 days to as little as six days within each other.

The review revealed for fourth quarter 2018, there was a 79 percent participation rate, and for first quarter 2019 there was 90 percent participation rate in the fire drills.

On 03/06/19 at 9:15 AM in an interview, Staff LY confirmed the findings.

Based on record review and staff interview, the facility failed to ensure fire drills were conducted on each shift and that transmission times of the fire alarm signal was documented in accordance with NFPA 101 - 2012 Edition, Section 21.7.1.4 and 21.7.1.6. This deficient practice had the potential to affect all patients in the building. The total facility census the day of the survey was 20.

Findings include:

Record review on 02/25/19 of the facility's testing documentation noted missing documentation for the required quarterly fire drills and the transmission of the fire alarm signal. Further inspection of the documentation noted no record of a second, third and fourth quarter fire drill and alarm transmission test for 2018. The quarters missing for 2018 are as follows: Second quarter (April, May, June); Third quarter (July, August, September); Fourth quarter (October, November, December).

These findings were verified and acknowledged by staff AA and CC during an interview the afternoon of 02/25/19.

Based on observation and interview, the facility failed to keep a portable space heater away from a patient care area. The patient census at the beginning of the survey was 314.

Findings

On 03/04/19 at 10:15 AM a space heater was observed among paper and on the desk of the unit clerk at the A/B nursing station.

On 03/06/19 at 10:15 AM in an interview, LT confirmed the observation.

Based on observation during the facility tour and staff verification, it was determined the facility failed to ensure the gas and vacuum systems were maintained according to the 2012 National Fire Protection Association (NFPA) 99, Chapter 5, 1.5.16 and 1.5.16.1. This had the potential to affect all patients utilizing these areas of the facility. The census was 314 at the beginning of the survey.

Findings include:

Facility tour took place on 02/28/19 with staff AA and BB. While observing the Operating Room #2 in Labor and Delivery department on the Ninth Floor, in Building Q the color-coded gas and vacuum lines that were connected to the Anesthesia machine were not being utilized properly. Examination of the gas and vacuum lines found that the purple Waste Anesthetic Gas Disposal (WAGD) line was plugged into a white vacuum port on the gas and vacuum header. Further examination revealed that each air and vacuum line uses a non-interchangeable male and female adapter and utilizes color coordination of ports and lines to prevent accidental line to port hook up. When inspecting the WAGD male adapter, it was found to be an un-crimped male vacuum adapter.

This finding was verified and acknowledged by all staff present during the tour of OR #2 in the Labor and Delivery area.

Based on document review and interview, the facility failed to maintain its medical gas system, specifically the vacuum inlets, gas outlets, gas gauges/indicators in accordance with NFPA 99, 2012 edition, 5.1.14. The patient census at the beginning of the survey was 314.

Findings

On 03/07/19 a review of the facility's medical gas inspection report dated 10/15/18 to 10/17/18 was completed. The review revealed 47 vacuum inlets had less than the minimum standard flow and 35 medical gas outlets leaked.

On 03/07/19 at 2:50 PM in an interview, Staff LT confirmed not all vacuum inlets and medical gas outlets were fixed. On 03/06/19 a tour was taken of the 9th floor of the H/I area with Staff LQ and LS at 9:42 AM.

On 03/06/09 at 9:50 AM medical gas shut off valves were observed to be labeled "SCOB unit 1," but an area with that label could not be located. On 03/06/19 at 9:50 AM in an interview neither Staff LS or LW knew what area the shut off valves served.

On 03/06/19 at 9:50 AM observation of the medical gas shutoff valves opposite room 980 did not reveal labeling. On 03/06/19 at 9:50 AM in an interview, Staff LQ confirmed the finding.

Based on observation during tour and staff verification it was determined the facility failed to ensure the proper instillation of electrical outlets according to the National Fire Protection Association (NFPA) 101 Chapter 19.1 and NFPA 70 and NFPA 99. This had the potential to affect all those utilizing these areas of the facility. The patient census was 314 at the beginning of the survey.

Findings include:

F & G Building
Facility tour took place on 03/04/19 to 03/06/19 with staff HH and PP.

Seventh Floor:
An observation was made of three rooms that had a water source with electrical outlets installed without ground faults. These rooms were identified as 0774.5, 0774.14, 0774.16, 0774.20 (chute room), 0775.1, and 0775.14.
Eighth Floor:

An observation was made of the Female locker room and Room # 0864.19 and was found to have had a water source with electrical outlets installed without ground faults less than six feet away.

Ninth Floor:
An observation was made of Patient Room One through Twenty and Suite 0974.61 was found to have had a water source with electrical outlets installed without ground faults less than six feet away.

Tenth Floor:
An observation was made of Patient Room #1029. This room was found to have a tamper resistant electrical outlet with a foreign material covering the outlet faceplate and receptacle outlet.
These findings were verified by staff HH and PP during facility tour.

Q Building
Facility tour took place on 2/28/19 to 3/1/19 and again on 3/4/19 with staff AA and HH.
During tour of the seventh-floor of Q building it was noted the integrity of the ground fault interrupter in Patient Room #07102. Further examination of the outlet revealed that it failed to de-energize when it tested.

These findings were verified by staff HH during facility tour.

Based on observation during the facility tour and staff verification, it was determined the facility failed to ensure the use of multiple plug adapters, extension cords, and power strips were being adhered in accordance with National Fire Protection Association (NFPA) 99 - 2012 Edition, Section 10.2.3.6, 10.2.4, and 10.3 and in accordance with NFPA 70, 2011, section 400. This had the potential to affect all those utilizing these areas of the facility. The patient census was 314 at the beginning of the survey.

Findings

Tower Building
On 02/27/19 at 8:10 AM a tour was taken of the 11th floor with Staff LQ and LS. At 8:40 AM office space 1140.1 was observed to have a power strip with a microwave and refrigerator plugged into it. That power strip was observed to plug into another power strip that was plugged into an extension cord that was plugged into the wall. A coffee maker was also observed plugged into this daisy chain. On 02/27/19 at 8:40 AM in an interview, Staff LS confirmed the observation.

On 02/27/19 at 9:22 AM observation within the team coordinator room (1102) revealed a daisy chain of extension cords starting with an 8 power cube plugged into an extension cord that was plugged into the wall. The cube had four receptacles in use plus two USB ports in use. On 02/27/19 at 9:22 AM in an interview, Staff LS confirmed the observation.

F & G Building
Facility tour took place on 3/4/19 to 3/6/19 with staff HH and PP.
During the tour of the facility, the use of unapproved items plugged into a power strip, the use of multiplug adapters, and the use of extension cords were observed in the following areas:

Fifth Floor:
Room number 0548.32 - toaster, coffee maker, and microwave plugged into a power strip.

Seventh Floor:
Room number 0775.23 - coffee maker plugged into a multiplug adapter that was plugged into an extension cord and then was plugged into a power strip.
Room number 0774.29 - use of a multiplug adapter for computer equipment.
Eighth floor:
Room number 0864-2 - coffee maker and toaster plugged into a power strip.
Room number 0864.16 - coffee maker plugged in a power strip.
Ninth floor
Room number 097461 - refrigerator and microwave plugged into a power strip.

Based on observation during facility tour and staff verification it was determined the facility failed to ensure all rooms that had medical gas storage were constructed as required and identified with the required signage posted on the door according to the National Fire Protection Association (NFPA) 99 Chapter 11. This had the potential to affect all those who utilized this area f the facility. The patient census at the beginning of the survey was 314.

Findings include:

Q Building
Facility tour took place on 02/28/19 to 03/01/19 and again on 03/04/19 to 03/06/19 with staff AA and BB. During tour of the Labor and Delivery area located on the sixth-floor observation was made of the medical gas storage room identified as 06335 not having a self-closing or automatic closing device mounted on the door. This finding was verified by both staff members during tour of this area.

F & G Building
Facility tour took place on 3/4/19 to 3/6/19 with staff HH and PP. During tour of the lab area and specifically at room 0775.10 observation was made of eleven E-tanks of oxygen stored within the room and the door to the room lacked any signage indicating oxygen was stored within the room. This finding was verified by both staff present during the tour.

Based upon observation and staff interview the facility failed to ensure the safe storage of oxygen cylinders in accordance with NFPA 99 - 2012 Edition, Sections 11.3.4 and 11.5.3.2. This deficient practice has the potential to affect all patients in the building. The total facility census the day of the survey was 20.

Findings include:

Observation on 02/25/19 during facility tour between 3:00 P.M. and 4:15 P.M. noted oxygen storage taking place in room 161. Further examination of outside the room revealed no precautionary signs for oxygen stored within. The facility had a sign posted at the main entrance which read "No Smoking on Premises or In Building."

These findings were verified and acknowledged by staff AA and CC during an interview the afternoon of 02/25/19.