HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure structural steel beams had adequate fire rated protection in 1 of 3 penthouses. The findings were:

Observation of the chiller penthouse above the electro physiology lab on 1/10/13 at 10:50 AM showed the roof was constructed with steel I beam supports. Further observation showed the fire retardant coating was removed from three beams so electrical conduits could be attached to the beams. The exposed section measured 6 inches square on each beam. The removal of the fire retardant spray reduced the construction type from 2-hour rating to 0-hour rating. At the time of the observation the director of facilities and construction could not explain why this issue was not noticed and repaired with the original construction in 2010.

Reference NFPA 101, 2000 Edition;
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations

Construction Type Stories
1 2 3 4 or More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas on 2 of 6 floors. The findings were:

1. Observation of the operating room house keeping closet #30105 on 1/10/13 at 7:32 AM showed two, 55 gallon barrels storing mop supplies were being stored in this room. Further observation showed a wall was not complete from the floor to ceiling above. The wall was missing the top 24 inches of sheetrock for a length of 14 feet. At the time of the observation the engineering manager could not explain why the missing section of wall was not noticed and installed during the annual inspection of the area.

2. Observation of the intensive care unit, medication room #6046 on 1/10/13 at 10:02 AM showed a 1 inch by 4 inch gap around a pipe. At the time of the observation the director of facilities and construction could not explain why this gap had not been noticed and repaired during the annual inspection.

3. Observation of the labor and delivery Pyxis supply room on 1/10/13 at 1:38 PM showed the door was equipped with a self-closing device. Further observation showed the door was impeded in the open position by boxes. At the time of the observation the director of facilities and construction could not explain why staff members were not following facilities policies.

4. Observation of soiled utility #5055 on 1/10/13 at 2:06 PM showed three 32 gallon collection bins were being stored in this room. Further observation showed the wall terminated above the ceiling tile and was not continuous to the underside of the floor above. At the time of the observation the engineering manager could not explain why the missing section of wall was not noticed and replaced during the annual inspection of the area.

5. Observation of patient room #5101 on 1/10/13 at 2:50 PM showed 4 beds and 1 upholstered chair were being stored in the room. Further observation showed the corridor door was not equipped with a self-closing device as required on general storerooms. At the time of the observation registered nurse #1 confirmed this was the usual storage location for all unused beds and furniture. She was unaware storerooms required a self-closing device.

6. Observation of telecom room #2015 on 1/14/13 at 11:40 AM showed a 3 inch gap around three electrical conduit pipes. At the time of the observation the director of facilities and construction could not explain why the hole was not noticed and repaired during the annual inspection.

7. Observation of the endoscopy biohazard room on 1/14/13 at 3:01 PM showed four collection bins were stored in the room. Further observation showed the wall terminated above the ceiling tile and were not continuous to the underside of the floor above. At the time of the observation the engineering manager could not explain why the missing section of wall was not noticed and replaced during the annual inspection of the area.

Based on observation, plan review and staff interview, the facility failed to ensure suites were not oversized on 2 of 6 floors. The findings were:

1. Observation of the intensive care unit suite on 1/9/13 at 11:05 AM showed it had patient sleeping rooms and was greater than 5,000 square feet. Plan review at the time of the observation showed the suite was 6,919 square feet. At the time of the observation the director of facilities and construction confirmed the aforementioned square footage.

2. Observation of the operating suite on 1/10/13 at 6:43 AM showed it had non-sleeping rooms and was greater than 10,000 square feet. Plan review at the time of the observation showed the suite was 19,226 square feet. At the time of the observation the director of facilities and construction confirmed the aforementioned square footage.

3. Observation of the operating room on 1/10/13 at 6:45 AM showed two sub sterile rooms had more than 50 feet of travel distance through two intervening rooms. At the time of the observation the director of facilities and construction confirmed the travel distance was greater than 50 feet.

4. Observation of the ultrasound hallway on 1/14/13 at 3:26 PM showed the hallway had a dead-end travel distance of 37 feet. At the time of the observation the director of facilities and construction was aware dead-end corridors could not exceed 30 feet. He could not explain why the dead-end distance was not addressed during the 2010 modification of the area.

Deficiencies #1, #2, and #3 can be obviated by the Fire Safety and Evaluation System (FSES). If the facility agrees to the conditions of the FSES they can write and "F" in the providers Plan of Correction column and Complete Date column to accept the FSES. If the facility wants to fix the deficiency they can fill in the Providers Plan of Correction column with the appropriate information and dates.
Deficiency #4 was not addressed in the accepted FSES and will need a Plan of Correction.

Reference NFPA 101, 2000 Edition;
19.2.5.6 Suites of sleeping rooms shall not exceed 5000 ft2 (460 m2).
19.2.5.7 Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 ft2 (930 m2).
19.2.5.8 Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 ft (30 m) and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 ft (15 m).

Based on observation and staff interview, the facility failed to ensure 1 of 3 emergency generators was equipped with a remote emergency stop button. The findings were:

Observation of the corridor lights showed they were supplied with power from the emergency generator. Observation of the 750 kilowatt emergency generator on 1/15/13 at 10:15 AM showed it was not equipped with an emergency stop button outside of the weather proof enclosure. At the time of the observation the director of facilities and construction could not explain why the emergency stop button was not provided.

Reference, NFPA 101, 2000 Edition, 19.2.9.1, 7.9.2.3, NFPA 110, 1999 Edition;
3-5.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to the break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

Based on observation and staff interview, the facility failed to ensure staff were familiar with emergency procedures on 1 of 3 shifts. The findings were:

Observation of the fire drill on 1/15/13 at 1:41 PM showed two isolation carts were left in the corridor throughout the drill. At the time of the observation the nurse manager for this floor could not explain why the carts were not removed. She also reported that the staff were only involved in 1 fire drill a year on their floor, the rest of the drills occurred on different floors.

Based on observation and staff interview, the facility failed to ensure sprinkler heads were maintained on 2 of 6 floors. The findings were:

1. Observation of the sprinkler system on 1/10/13 between 2 PM and 3 PM showed a gap greater than ¼ inch between the ceiling and the escutcheon ring in patent room #5054 and #5061. On 1/10/13 at 2:03 PM the director of facilities and construction could not explain why the escutcheon rings were not noticed and repaired during the annual inspection.

2. Observation of patient room #3107 on 1/14/13 at 10:36 AM showed the sprinkler head was painted. At the time of the observation the director of facilities and construction could not explain why the sprinkler head was not observed and replaced during the annual inspection by an outside contractor.

3. Observation of the old switch gear vault on 1/14/13 at 3:44 PM showed four high-temperature (212 degree) sprinkler heads were installed. Observation of the room showed the switch gear had been removed from the room and the room was now used as general storage. At the time of the observation the director of facilities and construction could not explain why the sprinkler heads were not replaced with standard-temperature heads.

NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
3-2.7.2 Escutcheon plates used with a recessed or flush type sprinkler shall be part of a listed sprinkler assembly.
5-3.1.4 Temperature Ratings.
5-3.1.4.2 The following practices shall be observed to provide sprinklers of other than ordinary temperature classification unless other temperatures are determined or unless high-temperature sprinklers are used throughout ...
(1) Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification.
5-3.1.4.3 In case of occupancy change involving temperature change, the sprinklers shall be changed accordingly.
5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.
Reference NFPA 101, 2000 Edition, 19.3.5.1, 9.7.5, NFPA 25, 1999 Edition;
2-2.1.1* Sprinklers shall be visually inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged or loaded, or in the improper orientation.

Based on observation and staff interview, the facility failed to ensure portable fire extinguishers were placed at appropriate hazards on 1 of 6 floors. The findings were:

Observation of the cesarean section corridor on 1/10/13 at 1:41 PM showed a " K " type fire was located outside the cesarean room. At the time of the observation the director of facilities and construction could not explain why the fire extinguisher contractor had placed a cooking media fire extinguisher in this location.

Reference NFPA 101, 2000 Edition, 19.3.5.6, 9.7.4.1, NFPA 10, 1998 Edition;
3-7.1 Fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats).

Based on observation and staff interview, the facility failed to ensure portable fire extinguishers were properly maintained on 1 of 9 floors. The findings were:

Observation of physical therapy #6-1 on 1/10/13 at 9:26 AM showed the portable fire extinguisher near the North exit stair was manufactured in 2006. Further observation showed the 6 year maintenance was not performed in 2012. At the time of the observation the director of facilities and construction reported all fire extinguishers were maintained by an outside contractor. He could not explain why the fire extinguisher contractor failed to performed the 6 year maintenance on the aforementioned extinguisher.

Reference NFPA 101, 2000 Edition, 19.3.5.6, 9.7.4.1, NFPA 10, 1998 Edition;
4-4.3* Six-Year Maintenance. Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures ....

Based on observation and staff interview, the facility failed to ensure oxygen cylinders were separated from combustibles on 1 of 6 floors. The findings were:

1. Observation of the operating room biohazard room on 10/10/13 at 7:30 AM showed 16 " E " sized oxygen cylinders were stored less than one foot from a soiled linen cart. At the time of the observation the director of facilities and construction confirmed he was aware the storage of more than 12 " E " cylinders (300 cubic feet) required a separation of combustible material of 5 feet. He could not explain why more than 12 cylinders were stored in this location.

2. Observation of the emergency room clean utility room on 1/14/13 at 4:11 PM showed an oxygen cylinder storage rack with a capacity of 24 spaces was stored in the room. At the time of the observation the director of facilities and construction confirmed he was aware oxygen storage room with more than 12 " E " cylinders (300 cubic feet) were required to have the corridor door posted with OXYGEN IN USE, NO SMOKING SIGNS and 5 foot separation to combustible material. He could not explain why the increased capacity rack was in this location.

Reference NFPA 101, 2000 Edition, 19.3.2.3, NFPA 99, 1999 Edition;
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3.
1. A minimum of distance of 20 ft., or
2. A minimum distance of 5 ft if the entire storage location is protected by an automatic sprinkler system designed in accordance with NPA 13, standard for the installation of sprinkler systems, ...

Based on observation and staff interview, the facility failed to ensure electrical adapters were an integral permanent part of equipment tower in 2 of 9 operating rooms, failed to ensure temporary electrical adapters did not replace permanent fixed wiring, and failed to ensure junctions boxes were maintained with covers on 2 of 6 floors. The findings were:

1. Observation of operating room #9 on 1/10/13 at 6:46 AM showed the anesthetizing tower, ventilator, and defibrillator were all plugged into a surge protector lying on the floor. Further observation showed two IV poles were equipped with surge protectors attached to them. Multiple pieces of electrical equipment were plugged into each surge protector with the capacity of 6 items each. Interview with the cardiac coordinator on 1/10/13 at 7:06 AM revealed the anesthetizing tower, ventilator, and defibrillator were plugged into the single surge protector to limit the trip hazard from electrical cords as the only electrical receptacles were located on exterior walls. He also reported the IV poles were equipped with surge protectors because patients arrived in the operating room with multiple IV pumps and they needed to be plugged into said surge protectors to limit the number of cords running to receptacles.

2. Observation of operating room #8 on 1/10/13 at 7:11 AM showed an anesthetizing tower and ventilator were plugged into a surge protector lying on the floor.

3. Observation of multi-purpose room #6101 on 1/10/13 at 9:47 AM showed a lamp was plugged into two surge protectors in-line. At the time of the observation the engineering manager reported staff members were in-serviced too not connected surge protectors. He could not explain why the adapters had not been noticed and removed during the annual electrical inspection.

4. Observation of the 1968 elevator penthouse on 1/10/13 at 11:12 AM showed a junction box was missing the cover plate. At the time of the observation the director of facilities and construction could not explain why the cover was not replaced after the contractor completed the project.

5. Observation of the Otis C&D elevator room on 1/10/13 at 11:42 AM showed two lamps were plugged into extensions cords. At the time of the observation the director of facilities and construction could not explain why the extensions cords had not been noticed and removed during the annual inspection.

Reference NFPA 101, 2000 Edition, 19.3.2.3, NFPA 99, 1999 Edition;
7-5.1.2.5 Line Voltage Equipment-Anesthetizing Locations. Flexible cord for portable lamps or portable electrical appliances operating at more than 12 V between conductors, intended for use in anesthetizing locations, shall be continuous and without switches from the appliance to the attachment plug and of a type designated for extra-hard usage in accordance with Article 501-11 of NFPA 70 ...
Exception No.2. Two or more power receptacles supplied by a flexible card are permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, or pedestal-mounted provided:
(a) The receptacles are an integral part of the equipment assembly, permanently attached; and
(b) The sum of the ampacity of all appliances connected to the receptacles shall not exceed 75 percent of the ampacity of the flexible cord supplying the receptacles; and
(c) The ampacity of the flexible cord is suitable and in accordance with the current edition of NFPA 70; and
(d) The electrical and mechanical integrity of the assembly is regularly verified and documented through an ongoing maintenance program.
Reference NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls ...
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Based on observation and staff interview, the facility failed to ensure structural steel beams had adequate fire rated protection in 1 of 3 penthouses. The findings were:

Observation of the chiller penthouse above the electro physiology lab on 1/10/13 at 10:50 AM showed the roof was constructed with steel I beam supports. Further observation showed the fire retardant coating was removed from three beams so electrical conduits could be attached to the beams. The exposed section measured 6 inches square on each beam. The removal of the fire retardant spray reduced the construction type from 2-hour rating to 0-hour rating. At the time of the observation the director of facilities and construction could not explain why this issue was not noticed and repaired with the original construction in 2010.

Reference NFPA 101, 2000 Edition;
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations

Construction Type Stories
1 2 3 4 or More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas on 2 of 6 floors. The findings were:

1. Observation of the operating room house keeping closet #30105 on 1/10/13 at 7:32 AM showed two, 55 gallon barrels storing mop supplies were being stored in this room. Further observation showed a wall was not complete from the floor to ceiling above. The wall was missing the top 24 inches of sheetrock for a length of 14 feet. At the time of the observation the engineering manager could not explain why the missing section of wall was not noticed and installed during the annual inspection of the area.

2. Observation of the intensive care unit, medication room #6046 on 1/10/13 at 10:02 AM showed a 1 inch by 4 inch gap around a pipe. At the time of the observation the director of facilities and construction could not explain why this gap had not been noticed and repaired during the annual inspection.

3. Observation of the labor and delivery Pyxis supply room on 1/10/13 at 1:38 PM showed the door was equipped with a self-closing device. Further observation showed the door was impeded in the open position by boxes. At the time of the observation the director of facilities and construction could not explain why staff members were not following facilities policies.

4. Observation of soiled utility #5055 on 1/10/13 at 2:06 PM showed three 32 gallon collection bins were being stored in this room. Further observation showed the wall terminated above the ceiling tile and was not continuous to the underside of the floor above. At the time of the observation the engineering manager could not explain why the missing section of wall was not noticed and replaced during the annual inspection of the area.

5. Observation of patient room #5101 on 1/10/13 at 2:50 PM showed 4 beds and 1 upholstered chair were being stored in the room. Further observation showed the corridor door was not equipped with a self-closing device as required on general storerooms. At the time of the observation registered nurse #1 confirmed this was the usual storage location for all unused beds and furniture. She was unaware storerooms required a self-closing device.

6. Observation of telecom room #2015 on 1/14/13 at 11:40 AM showed a 3 inch gap around three electrical conduit pipes. At the time of the observation the director of facilities and construction could not explain why the hole was not noticed and repaired during the annual inspection.

7. Observation of the endoscopy biohazard room on 1/14/13 at 3:01 PM showed four collection bins were stored in the room. Further observation showed the wall terminated above the ceiling tile and were not continuous to the underside of the floor above. At the time of the observation the engineering manager could not explain why the missing section of wall was not noticed and replaced during the annual inspection of the area.

Based on observation, plan review and staff interview, the facility failed to ensure suites were not oversized on 2 of 6 floors. The findings were:

1. Observation of the intensive care unit suite on 1/9/13 at 11:05 AM showed it had patient sleeping rooms and was greater than 5,000 square feet. Plan review at the time of the observation showed the suite was 6,919 square feet. At the time of the observation the director of facilities and construction confirmed the aforementioned square footage.

2. Observation of the operating suite on 1/10/13 at 6:43 AM showed it had non-sleeping rooms and was greater than 10,000 square feet. Plan review at the time of the observation showed the suite was 19,226 square feet. At the time of the observation the director of facilities and construction confirmed the aforementioned square footage.

3. Observation of the operating room on 1/10/13 at 6:45 AM showed two sub sterile rooms had more than 50 feet of travel distance through two intervening rooms. At the time of the observation the director of facilities and construction confirmed the travel distance was greater than 50 feet.

4. Observation of the ultrasound hallway on 1/14/13 at 3:26 PM showed the hallway had a dead-end travel distance of 37 feet. At the time of the observation the director of facilities and construction was aware dead-end corridors could not exceed 30 feet. He could not explain why the dead-end distance was not addressed during the 2010 modification of the area.

Deficiencies #1, #2, and #3 can be obviated by the Fire Safety and Evaluation System (FSES). If the facility agrees to the conditions of the FSES they can write and "F" in the providers Plan of Correction column and Complete Date column to accept the FSES. If the facility wants to fix the deficiency they can fill in the Providers Plan of Correction column with the appropriate information and dates.
Deficiency #4 was not addressed in the accepted FSES and will need a Plan of Correction.

Reference NFPA 101, 2000 Edition;
19.2.5.6 Suites of sleeping rooms shall not exceed 5000 ft2 (460 m2).
19.2.5.7 Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 ft2 (930 m2).
19.2.5.8 Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 ft (30 m) and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 ft (15 m).

Based on observation and staff interview, the facility failed to ensure 1 of 3 emergency generators was equipped with a remote emergency stop button. The findings were:

Observation of the corridor lights showed they were supplied with power from the emergency generator. Observation of the 750 kilowatt emergency generator on 1/15/13 at 10:15 AM showed it was not equipped with an emergency stop button outside of the weather proof enclosure. At the time of the observation the director of facilities and construction could not explain why the emergency stop button was not provided.

Reference, NFPA 101, 2000 Edition, 19.2.9.1, 7.9.2.3, NFPA 110, 1999 Edition;
3-5.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to the break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

Based on observation and staff interview, the facility failed to ensure staff were familiar with emergency procedures on 1 of 3 shifts. The findings were:

Observation of the fire drill on 1/15/13 at 1:41 PM showed two isolation carts were left in the corridor throughout the drill. At the time of the observation the nurse manager for this floor could not explain why the carts were not removed. She also reported that the staff were only involved in 1 fire drill a year on their floor, the rest of the drills occurred on different floors.

Based on observation and staff interview, the facility failed to ensure sprinkler heads were maintained on 2 of 6 floors. The findings were:

1. Observation of the sprinkler system on 1/10/13 between 2 PM and 3 PM showed a gap greater than ¼ inch between the ceiling and the escutcheon ring in patent room #5054 and #5061. On 1/10/13 at 2:03 PM the director of facilities and construction could not explain why the escutcheon rings were not noticed and repaired during the annual inspection.

2. Observation of patient room #3107 on 1/14/13 at 10:36 AM showed the sprinkler head was painted. At the time of the observation the director of facilities and construction could not explain why the sprinkler head was not observed and replaced during the annual inspection by an outside contractor.

3. Observation of the old switch gear vault on 1/14/13 at 3:44 PM showed four high-temperature (212 degree) sprinkler heads were installed. Observation of the room showed the switch gear had been removed from the room and the room was now used as general storage. At the time of the observation the director of facilities and construction could not explain why the sprinkler heads were not replaced with standard-temperature heads.

NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
3-2.7.2 Escutcheon plates used with a recessed or flush type sprinkler shall be part of a listed sprinkler assembly.
5-3.1.4 Temperature Ratings.
5-3.1.4.2 The following practices shall be observed to provide sprinklers of other than ordinary temperature classification unless other temperatures are determined or unless high-temperature sprinklers are used throughout ...
(1) Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification.
5-3.1.4.3 In case of occupancy change involving temperature change, the sprinklers shall be changed accordingly.
5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.
Reference NFPA 101, 2000 Edition, 19.3.5.1, 9.7.5, NFPA 25, 1999 Edition;
2-2.1.1* Sprinklers shall be visually inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged or loaded, or in the improper orientation.

Based on observation and staff interview, the facility failed to ensure portable fire extinguishers were placed at appropriate hazards on 1 of 6 floors. The findings were:

Observation of the cesarean section corridor on 1/10/13 at 1:41 PM showed a " K " type fire was located outside the cesarean room. At the time of the observation the director of facilities and construction could not explain why the fire extinguisher contractor had placed a cooking media fire extinguisher in this location.

Reference NFPA 101, 2000 Edition, 19.3.5.6, 9.7.4.1, NFPA 10, 1998 Edition;
3-7.1 Fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats).

Based on observation and staff interview, the facility failed to ensure portable fire extinguishers were properly maintained on 1 of 9 floors. The findings were:

Observation of physical therapy #6-1 on 1/10/13 at 9:26 AM showed the portable fire extinguisher near the North exit stair was manufactured in 2006. Further observation showed the 6 year maintenance was not performed in 2012. At the time of the observation the director of facilities and construction reported all fire extinguishers were maintained by an outside contractor. He could not explain why the fire extinguisher contractor failed to performed the 6 year maintenance on the aforementioned extinguisher.

Reference NFPA 101, 2000 Edition, 19.3.5.6, 9.7.4.1, NFPA 10, 1998 Edition;
4-4.3* Six-Year Maintenance. Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures ....

Based on observation and staff interview, the facility failed to ensure oxygen cylinders were separated from combustibles on 1 of 6 floors. The findings were:

1. Observation of the operating room biohazard room on 10/10/13 at 7:30 AM showed 16 " E " sized oxygen cylinders were stored less than one foot from a soiled linen cart. At the time of the observation the director of facilities and construction confirmed he was aware the storage of more than 12 " E " cylinders (300 cubic feet) required a separation of combustible material of 5 feet. He could not explain why more than 12 cylinders were stored in this location.

2. Observation of the emergency room clean utility room on 1/14/13 at 4:11 PM showed an oxygen cylinder storage rack with a capacity of 24 spaces was stored in the room. At the time of the observation the director of facilities and construction confirmed he was aware oxygen storage room with more than 12 " E " cylinders (300 cubic feet) were required to have the corridor door posted with OXYGEN IN USE, NO SMOKING SIGNS and 5 foot separation to combustible material. He could not explain why the increased capacity rack was in this location.

Reference NFPA 101, 2000 Edition, 19.3.2.3, NFPA 99, 1999 Edition;
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3.
1. A minimum of distance of 20 ft., or
2. A minimum distance of 5 ft if the entire storage location is protected by an automatic sprinkler system designed in accordance with NPA 13, standard for the installation of sprinkler systems, ...

Based on observation and staff interview, the facility failed to ensure electrical adapters were an integral permanent part of equipment tower in 2 of 9 operating rooms, failed to ensure temporary electrical adapters did not replace permanent fixed wiring, and failed to ensure junctions boxes were maintained with covers on 2 of 6 floors. The findings were:

1. Observation of operating room #9 on 1/10/13 at 6:46 AM showed the anesthetizing tower, ventilator, and defibrillator were all plugged into a surge protector lying on the floor. Further observation showed two IV poles were equipped with surge protectors attached to them. Multiple pieces of electrical equipment were plugged into each surge protector with the capacity of 6 items each. Interview with the cardiac coordinator on 1/10/13 at 7:06 AM revealed the anesthetizing tower, ventilator, and defibrillator were plugged into the single surge protector to limit the trip hazard from electrical cords as the only electrical receptacles were located on exterior walls. He also reported the IV poles were equipped with surge protectors because patients arrived in the operating room with multiple IV pumps and they needed to be plugged into said surge protectors to limit the number of cords running to receptacles.

2. Observation of operating room #8 on 1/10/13 at 7:11 AM showed an anesthetizing tower and ventilator were plugged into a surge protector lying on the floor.

3. Observation of multi-purpose room #6101 on 1/10/13 at 9:47 AM showed a lamp was plugged into two surge protectors in-line. At the time of the observation the engineering manager reported staff members were in-serviced too not connected surge protectors. He could not explain why the adapters had not been noticed and removed during the annual electrical inspection.

4. Observation of the 1968 elevator penthouse on 1/10/13 at 11:12 AM showed a junction box was missing the cover plate. At the time of the observation the director of facilities and construction could not explain why the cover was not replaced after the contractor completed the project.

5. Observation of the Otis C&D elevator room on 1/10/13 at 11:42 AM showed two lamps were plugged into extensions cords. At the time of the observation the director of facilities and construction could not explain why the extensions cords had not been noticed and removed during the annual inspection.

Reference NFPA 101, 2000 Edition, 19.3.2.3, NFPA 99, 1999 Edition;
7-5.1.2.5 Line Voltage Equipment-Anesthetizing Locations. Flexible cord for portable lamps or portable electrical appliances operating at more than 12 V between conductors, intended for use in anesthetizing locations, shall be continuous and without switches from the appliance to the attachment plug and of a type designated for extra-hard usage in accordance with Article 501-11 of NFPA 70 ...
Exception No.2. Two or more power receptacles supplied by a flexible card are permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, or pedestal-mounted provided:
(a) The receptacles are an integral part of the equipment assembly, permanently attached; and
(b) The sum of the ampacity of all appliances connected to the receptacles shall not exceed 75 percent of the ampacity of the flexible cord supplying the receptacles; and
(c) The ampacity of the flexible cord is suitable and in accordance with the current edition of NFPA 70; and
(d) The electrical and mechanical integrity of the assembly is regularly verified and documented through an ongoing maintenance program.
Reference NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls ...
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces