HospitalInspections.org

Based on observation and interview, the facility failed to ensure that all means of egress be maintained free of obstructions to full instant use in the case of fire or other emergency. This was evidenced by unattended carts and chairs in the corridor. This could result in delay evacuation and possible harm to patients and staff in the event of a fire or other emergency. This affected 3 of 4 floors and a basement of the main hospital building.

NFPA 101, Life Safety Code 2012 Edition.

19.2.3.4 Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in.(1525 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c) The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
(5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft.2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft. (3050 mm).
(f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8.

Findings:

During a tour of the facility with the Engineering Staff and Safety Staff 3 from 9/18/17 to 9/21/17, the means of egress were observed.

Main Hospital Building on 9/19/17:
1. At 11:30 a.m., there were unattended tables (approximately 4 tables)placed in the corridor length wise against the wall infront of the north nurses station on the 4th floor. Staff stated the tables were placed in the corridor so nurses can chart.

2. At 12:04 p.m., there were workstations (tables, chairs and computers)placed lengthwise in the corridor on 3rd floor north.

3. At 12:05 p.m., there were unattended workstations (tables and chairs)placed in the corridor infront of the entrance to the intensive care unit on the 3rd floor. Staff stated the table and chairs were workstations for hospital staff.

4. At 2:05 p.m., there were 2 bio-hazard carts and trash can stored in the exit corridor by the exit door in the operating rooms suite on the 1st floor.

Main Hospital 4W on 9/20/17:

5. At 11:02 a.m., there was a stair steps made out of wood that was used for rehab therapy and a desk with three chairs that was used for charting. The steps, the desk and the chairs were obstructing the egress outside of resident room 423. This was acknowledged by Facility Staff and Nurse Manager during the survey.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke. This was evidenced by a door that failed to fully close and latch. This could result in the failure to contain the transfer of smoke in the event of a fire affecting patients and staff in the surgery suite.

NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies
19.3.6.3 * Corridor Doors.
19.3.6.3.1 *Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13/ 4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

Findings:

During a tour of the facility with Engineering Staff on 9/18/17 through 9/21/17, the doors were observed.

Main Hospital First Floor on 9/19/17:
At 2:06 p.m., the corridor door to the storage supply room located in the surgery suite and near operating room 9 failed to latch upon self closure. The door was tested twice by staff and failed to latch both times.

Based on observation and interview, the facility failed to maintain the emergency lighting with battery back up. This was evidenced by emergency lights with battery back up in the operating rooms failing to illuminate during the 30 second test. This could result in failure to provide emergency lighting in the event of a power loss and generator failure and affected one of four floors in the main hospital.

NFPA 101, Life Safety Code 2012 Edition
7.9 Emergency Lighting.
7.9.2.1 Emergency illumination shall be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 1/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

7.9.2.3 The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following:
(1) Failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities

Findings:

During a tour of the facility with Facility Staff, Engineering Staff and Staff 3, on 9/18/17 through 9/21/17, the emergency lights in the operating rooms were tested and observed.

Main Hospital on 9/19/17
1st Floor Surgery Suite:
1. At 2:09 p.m., the battery backed-up emergency light in operating room six failed to illuminate when the Facility Staff unplugged the light.
2. At 2:15 p.m., the battery backed up emergency light in operating room nine failed to illuminate when Facility Staff unplugged the light.

Based on observation, the facility failed to maintain the soiled linen/garbage storage room door. This was evidenced by the soiled linen room door that failed to close and latch. This could result in the spread of smoke and fire throughout the facility and the increased risk of injury to the patients due to smoke and fire. This affected 1 of 4 floors and the basement of Main Hospital Building.

Findings:

During tour of facility with the Engineering Staff from 9/18/17 to 9/21/17, the soiled linen room was observed.

Main Hospital Building on 9/21/17
At 10:26 a.m., the Bio-hazard room (soiled utility room for the operating room) on the 1st floor failed to close and latch. The Engineering staff confirmed this finding.

Based on observation and interview, the facility failed to maintain the fume hood in a reliable operating condition. This was evidenced by failure to provide documentation of current certification of the pathology fume hood. This affected 1 of 4 floors and the basement of the Main Hospital Building. This could cause the hood to malfunction and possibly create a hazardous condition causing harm to patients and staff.

NFPA 101 Life Safety Code 2012 Edition
4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.


4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

Findings:

During record review with Facility Staff 1 from 9/18/17 to 9/21/17, the maintenance document for the Surgical Pathology laboratory hood was requested. The Lead laboratory technician stated the labs used alcohol and formalin as hazardous materials.

Main Hospital Building on 9/21/17:
At 10:38 a.m., on the 1st floor, the sticker on the surgical pathology laboratory fume hood indicated retest due date was 5/2017. The Lead laboratory technician stated her supervisor was on vacation and she could not provide documentation to show if the hood was retested during or after 5/2017. The Facility failed to provide documents to show current certification of their surgical pathology fume hood.

Based on document review and interview, the facility failed to maintain the humidity levels within acceptable range according to their written policy and failed to make corrective actions when the humidity level was below the target range. This was evidenced by the humidity log indicating the humidity levels in the operating rooms were below the acceptable designated range and by no documentation of acknowledging and responding and making corrective actions when their humidity level was below the target range. This had the potential to increase the risk of a fire in the operating rooms, resulting in harm to patients and staff in the surgery suite. This affected the main hospital first floor surgery suite.

Findings:

During document review and interview, with Facility Staff on 9/18/17 through 9/21/17, the humidity logs for the operating rooms were observed.

Main Hospital First Floor on 9/21/17.

At 10:07 a.m., the humidity levels for operating rooms located in the main hospital surgery suite were observed to be monitored by computer in the engineering department. The Trend Interval report for operating room 9 was printed for the month of March 2017, the report indicated the humidity levels were below the acceptable range, which was 12.11 percent on 3/2/17 through 3/3/17. The policy identifier: S-FW-EC-7210, dated 10/16 page two, noted the acceptable relative humidity range is 20-60%. The policy also noted that when the humidity level is not within the specified limits, Engineering Staff will; 1. Verify, and 2. Adjust. The policy also noted that if unable to correct, Engineering Staff will notify the Clinical Leadership team and when procedural room is brought back to the acceptable range and is approved to be put back in use, the correction must be documented on the Temperature, Relative Humidity and Differential Pressure Readings form. During an interview, the Facility staff stated he did not have any documentation for the corrective actions taken for the dates in question 3/2/17 and 3/3/17.

Based on observation and record review, the facility failed to maintain cooking equipment in accordance with NFPA 96, 2011 Edition. This was evidenced by failure to provide documents to show inspection and servicing of the cooking equipment in the Kitchen. This affected 1 of 4 floors and the basement of the main hospital building. This could cause cooking equipment to malfunction and could possible cause a fire in the facility. The fire could potential harm residents and staff.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Editions

11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons.

11.7.2 Cooking equipment that collects grease below the surface, behind the equipment, or in cooking equipment flue gas exhaust, such as griddles or charbroilers, shall be inspected and, if found with grease accumulation, cleaned by a properly trained, qualified, and certified person acceptable to the authority having jurisdiction.

Findings:

During tour of facility with the Engineering Staff from 9/18/17 to 9/21/17, the Kitchen was observed and maintenance record reviewed.

Main Hospital Building on 9/18/17:
At 10:12 a.m., facility Kitchen had gas stoves, griddles, fryers, ovens and other cooking equipment. There was a built-up of grease on the deep fryers and behind the gas stoves. Written documentation for servicing of their cooking equipment were requested on 9/19/17 at 8:45 a.m. There was no documents provided to show annual inspection and servicing of their cooking equipment was done.

Based on observation, the facility failed to maintained the fire rating for its walls and ceilings, as evidenced by unsealed penetrations. This failure could result in the transfer of smoke during a fire and affected three of four floors in the main hospital.

Findings:

During a tour of the facility with Facility Staff on 9/18/17 throught 9/21/17, the facility interior walls and ceiling were observed.

Main Hospital 4N on 9/20/17:
1. At 11:28 a.m., the hard ceiling entering patient room 478 had two 1/2 inch unsealed penetrations.
Main Hospital 3N on 9/20/17:
2. At 3:35 p.m., there was a 3/4 inch penetration in the back wall inside the environmental closet N3352.
Main Hospital first floor on 9/20/17:
3. At 4:30 p.m., there was a 2 1/2 inch unsealed penetration in the wall where the door handle hits the wall in CT room 3, that is located inside of Room C150.

Based on observation and interview, the facility failed to ensure that the fire alarm could be heard in all areas of the facility. This was evidenced by not hearing the alarm in certain areas when the fire alarm system was activated. This affected 2 of 4 floors and the basement of the Main Hospital building. This could result in delay in notification of fire to the building occupants and possible harm to patients, visitors and staff in the event of a fire.

NFPA 101 Life Safety Code, 2012 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6.3.7 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level that exits under normal conditions of occupancy.
Findings:
During the testing of the fire alarm system with the Engineering Staff from 9/18/17 to 9/21/17, the strobes and audio alarm boxes were tested and observed.

Main Hospital Building on 9/19/17:
At 11:45 a.m., the Engineering Staff activated the fire alarm manual pull box. The alarm could not be heard in the interior stairwell by exit 4. The Safety Officer and Engineer Staff went into the stairwell during the alarm testing and confirmed that they could not hear the alarm in the stairwell.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system in reliable operating conditions. This was evidenced by incomplete documentation for the maintenance of the sprinkler system, by failure to repair deficiencies for the backflow system and exterior bell, by sprinkler valves that were not identified, by sprinklers missing the escutcheon rings, by sprinkler contaminated with paint and corrosion and by a sprinkler with a gap. This could affect the operation of the sprinkler system and could delay extinguishing a fire. This could result in potential harm to patients, staff and visitors in the main hospital, ambulatory surgery building and radiotherapy building.

NFPA 101, Life Safety Code 2012 Edition-Chapter 9 Building Service and Fire Protection Equipment
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
9.7.6 Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
9.7.7 Documentation. All required documentation regarding the design of the fire protection system and the procedures for maintenance, inspection, and testing of the fire protection system shall be maintained at an approved, secured location for the life of the fire protection system.
9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition-Chapter 5 Sprinkler Systems
5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.4.2 Gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained.
5.2.4.3 Where air pressure supervision is connected to a constantly attended location, gauges shall be inspected monthly.
5.2.4.4* For dry pipe or preaction systems protecting freezers with two air pressure gauges on the air line(s) between the compressor and the dry pipe or preaction valve, the air pressure gauge near the compressor shall be compared weekly to the pressure gauge above the dry pipe or preaction valve.

Chapter 13 Valves, Valve Components, and Trim
13.2.6 Alarm Devices.
13.2.6.1 Mechanical waterflow devices, including but not limited to water motor gongs, shall be tested quarterly.
13.2.7 Gauges.
13.2.7.1 Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.
13.2.7.1.1 Where other sections of this standard have different frequency requirements for specific gauges, those requirements shall be used.
13.2.7.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.
13.2.7.3 Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification
13.4.1.1 Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.
13.4.3 Preaction Valves and Deluge Valves.
13.4.3.1 Inspection.
13.4.3.1.1 Valve enclosure heating equipment for preaction and deluge valves subject to freezing shall be inspected daily during cold weather for its ability to maintain a minimum temperature of at least 40°F (4.4°C).

13.4.3.1.1.1 Valve enclosures equipped with low temperature alarms shall be inspected weekly.

13.4.3.1.2 Low temperature alarms, if installed in valve enclosures, shall be inspected annually at the beginning of the heating season.
13.4.3.1.3 Gauges shall be inspected weekly.
13.4.3.1.6 The preaction or deluge valve shall be externally inspected monthly to verify the following:
(1) The valve is free from physical damage.
(2) All trim valves are in the appropriate open or closed position.
(3) The valve seat is not leaking.
(4) Electrical components are in service.
13.4.3.2.6 Preaction systems shall be tested once every 3 years for air leakage, using one of the following test methods:
(1) A pressure test at 40 psi (3.2 bar) for 2 hours. The system shall be permitted to lose up to 3 psi (0.2 bar) during the duration of the test. Air leaks shall be addressed if the system loses more than 3 psi (0.2 bar) during this test.
(2) With the system at normal system pressure, shut off the air source (compressor or shop air) for 4 hours. If the low air pressure alarm goes off within this period, the air leaks shall be addressed.
13.4.3.2.12* Records indicating the date the preaction or deluge valve was last tripped and the tripping time, as well as the individual and organization conducting the test, shall be maintained at a location or in a manner readily available for review by the authority having jurisdiction.

Findings:

During the facility tour with Facility Staff on 9/18/17 through 9/21/17, the fire sprinkler system was observed and tested.

Main Hospital 4 West on 9/19/17:
1. At 11:22 a.m., during the testing of the sprinkler system Inspectors Test Valve (ITV), the Facility Staff could not determine which valve to open and test. There was no identification sign on the valve indicating it was the Inspector Test Valve.

Main Hospital 4 North on 9/20/17
2. At 11:10 a.m., the sprinkler escutcheon ring was missing in the ceiling above north nurse station.

Main Hospital 3 West on 9/20/17:
3. At 3:04 p.m., the sprinkler escutcheon ring was missing and revealed a penetration in the ceiling inside room 306.

Main Hospital First Floor on 9/20/17:
4. At 4:07 p.m., the sprinkler deflector was contaminated with paint in the bathroom located inside ultrasound room 4.

5. At 4:10 p.m., the sprinkler was not flush with the ceiling, revealing a penetration in ultrasound room 2.



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Main Hospital Building on 9/18/17:
First Floor

6. At 10:08 a.m., in the Kitchen, the sprinkler head in the walk-in refrigerator had accumulation of debri.

7. At 10:10 a.m., in the Kitchen, there were corroded sprinkler heads and rusty escutcheon ring by the dishwashing area of the Kitchen.

8. At 10:11 a.m., in the Kitchen, there was paint on the sprinkler head in the housekeeping closet.

9. At 10:23 a.m., in the Cafeteria, the sprinkler head had a built up of debri.

On 9/20/17 in Main Hospital

10. At 9:20 a.m., there were 6 corroded sprinkler heads on the dock (receiving area).

During record reviewed with the Engineer Staff, the sprinkler system maintenance report was reviewed.

Main Hospital on 9/19/17:
11. At 3:55 p.m., the Vendor report dated 9/14/17 indicated the exterior bell alarm of the ambulatory surgery center building failed. During interview with the Vendor, he stated as of today the automatic sprinkler 911 exterior bell was not repaired.

Ambulatory Surgical Building on 9/19/17:
12. At 2:30 the Vendor report dated 9/7/17 indicated the backflow preventer failed inspection and testing.

Radiotherapy Building on 9/21/17:
13. There was no written evidence to show monthly inspection of their automatic sprinkler system was done.

Based on observation, the facility failed to ensure that fire-extinguishers were readily accessible. This was evidenced by a obstructions to ready access to the fire-extinguisher. This could delay extinguishing a fire and cause harm to patients and staff, in the event of a fire. This affected 2 of 4 floors and the basement of the Main Hospital, and ambulatory surgery center (ASC).

National Fire Prevention Association (NFPA) 101, Life Safety Code 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, in- stalled, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in
the event of fire.

6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

Findings:

During the facility tour with the Engineering Staff from 9/18/17 to 9/21/17, the fire-extinguishers were observed.

Main Hospital Building on 9/18/17:
1. At 10:46 a.m., a tile tool equipment placed on top of the fire extinguisher in the electrical room on the 1st floor. The tool equipment blocked ready access to the fire extinguisher. Engineering Staff confirmed the above finding.

Main Hospital Building on 9/19/:17
2. At 11:10 a.m., a ladder was placed against the fire extinguisher in the elevator room of the 4th floor.
3. At 1:55 p.m., an operating room equipment was blocking ready access to the fire extinguisher in the operating room 1 on the 1st floor.

Ambulatory Surgical Building on 9/20/17:

4. At 3:11 p.m., a bio-hazard garbage bin was blocking ready access to the fire extinguisher located in the aisle across from sterile room.

Based on observation, the facility failed to maintain the fire rating of its corridor walls. This was evidenced by an unsealed penetration a corridor wall. This had the potential to allow the spread of smoke in the event of a fire and affected one of four floors in the main hospital.

NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies
19.3.6.2 Construction of Corridor Walls.
19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8.
19.3.6.2.2 *Corridor walls shall have a minimum 1/ 2-hour fire resistance rating.
19.3.6.2.3 *Corridor walls shall form a barrier to limit the transfer of smoke.

Findings:

During the facility tour with Facility Staff on 9/18/17 through 9/21/17, the facility corridor walls were observed.

Main Hospital First Floor on 9/19/17:
At 3:27 p.m., the corridor wall located out side fire alarm panel room on the first floor had a 2 1/2 inch penetration in the corridor wall. This was acknowledged by Facility Staff during the survey.

Based on observation, the facility failed to maintain its smoke barrier doors. This was evidenced by smoke barrier doors that failed to close during testing of the fire alarm system. This affected 3 of 4 floors and the basement of the Main Hospital Building. This finding could result in the spread of smoke and fire and increase the risk of injury to patients and staff in the event of a fire.

Findings:

During the facility tour with the Engineering Staff from 9/18/17 to 9/21/17, the smoke barrier doors were observed.

On 9/19/17 in Main Hospital Building
1. At 11:26 a.m., on the 4th floor, the smoke barrier double doors by Room 409 were held open with electronic automatic-closing devices. The left door failed to close upon activation of the fire alarm system leaving a gap between doors. The door was equipped with a fire exit hardware latching mechanism.

2. At 11:38 a.m., on the 4th floor, the smoke barrier double doors by Room 459 were held open with electronic automatic-closing devices. One door leaf failed to release and close upon activation of the fire alarm system. The test was conducted more than once and door failed to release and close more than once. The door was equipped with a latching mechanism. Engineer Staff confirmed this finding.

3. At 1:34 p.m., on the 2nd floor, the smoke barrier double doors 2 west (room 258) were held open with electronic automatic-closing devices. One of the door leaf failed to close with the activation of the fire alarm system leaving a gap between the door leaves. The Engineering Staff stated the doors did not close due to the air balance from the heating ventilating air condition system.

4. At 2:54 p.m., on the 1st floor, the smoke barrier double doors by Recovery were held open with electronic automatic-closing devices. One door leaf failed to close upon activation of the fire alarm system leaving a gap between door leaves.

Based on record review, observation and interview, the facility failed to maintain the fire/smoke dampers in a reliable operating condition. This was evidenced by the failure to provide complete documentation to show the smoke/fire dampers were repaired after failing the test and inspection. This affected 4 of 4 floors and the basment of main hospital building. This could result in the spread of smoke during a fire and possible harm to patients and staff, in the event of mal-function dampers during a fire.

NFPA 90A Standard for the Installation of Air Conditioning and Ventilating System 2012 Edition
5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protective's.

5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition

19.4.1 Each damper shall be tested and inspected 1 year after installation.

19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

19.4.2 All tests shall be completed in a safe manner by personnel wearing personal protective equipment.

19.4.3 Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required.

19.4.4 If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped.

19.4.5 The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.

19.4.6 The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations.

19.4.7 The damper shall not be blocked from closure in any way.

19.4.8 The fusible link shall be reinstalled after testing is complete.

19.4.8.1 If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating.

19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered.

NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives, 2010 Edition.

6.5.11 All inspections and testing shall be documented indicating the location of the damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected.

6.5.12 All documentation shall be maintained by the property owner and available for review by the authority having jurisdiction.

6.6 Maintenance.
6.6.1 Any reports of abrupt changes in airflow or noise from the duct system shall be investigated to verify that it is not related to damper operation.

6.6.2* All exposed moving parts of the damper shall be dry lubricated as required by the manufacturer.

6.6.3 If the damper is not operable, repairs shall begin as soon as possible.

6.6.4 Following any repairs, the damper shall be tested for proper operation in accordance with Section 6.5.

6.6.6 All maintenance shall be documented and records shall be retained in accordance with 6.5.11 and 6.5.12.

Findings:

During record review and tour of the facility with the Engineering Staff from 9/18/17 to 9/21/17, the fire/smoke dampers maitenance records were reviewed and the fire/smoke dampers were observed.

On 9/18/17 in Main Hospital Building
1. At 3:58 p.m., the Vendor report dated 1/20/14 indicated the facility had dampers that failed during inspection and testing. The Facility failed to provide documents to show repairs were done for the smoke/fire dampers that failed during the inspection and testing. During interview with the Plant Engineer, he stated some of the dampers that failed were inaccessible. The Vendor report dated 1/20/14 indicated these dampers failed and the inaccessible ones were not inspected or tested.

2. The Smoke/fire dampers that failed and not repaired were: #7762 ,#7714,#7816, 7145, #7146, #7853, #7854, #7867, #7143, #7144 and #7636.

3. The Smoke/fire dampers that were inaccessible and could not be observed and tested were #7747,#7627, #7615, #7596, #7376, #7412, #7410, #7533, #7506, #7505, #7565, #7562, #7535, #7396, #7487, #7486, #7485, #7382, #7422, #7425, #7407,# 7408, #7430, #7435, #7834, #7320, #7311, #7312, #7068,#7160, #7166, #7171, #7297, #7294, #7853, #7854, #7867, #7143, #7144, #7882, #7280, #7581 and #7588.

Based on record review and interview, the facility failed to ensure that fire drills were conducted in accordance with NFPA 101, 2012 Edition. This was evidenced by records showing that fire drills were conducted at similar times during the overnight and evening shifts, by staff not familiar with their fire safety procedures, by incomplete fire drill record for participating department staff, and by failure to instruct their staff on the location of the newly installed fire alarm pull stations. The failure to conduct the fire drills at un-expected times and varying conditions could result in staff not familiar with how to respond to a fire during meal-time, bedtime, shift change and other conditions that arises during a shift. This affected 4 of 4 floors and the basement of main hospital and ambulatory surgical center building. This could result in a delay in staff response, in the event of a fire.

NFPA 101 Life Safety Code, 2012 Edition

19.1.1.1.3 General. The provisions of Chapter 4, General, shall apply.

4.7.3 Orderly Evacuation. When conducting drills, emphasis shall be placed on orderly evacuation rather than on speed.

4.7.4* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

4.8.2.1* Emergency plans shall include the following:
(1) Procedures for reporting of emergencies
(2) Occupant and staff response to emergencies
(3)*Evacuation procedures appropriate to the building, its occupancy, emergencies, and hazards (see Section 4.3)
(4) Appropriateness of the use of elevators
(5) Design and conduct of fire drills
(6) Type and coverage of building fire protection systems
(7) Other items required by the authority having jurisdiction

19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

19.7.1.8 Employees of health care occupancies shall be instructed in life safety procedures devices.

19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective re- response of health care personnel.

19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon
staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy ' s fire safety plan

19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(9) Extinguishment of fire

19.7.2.3.2 All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered
person
(2) During a malfunction of the building fire alarm system

Findings:

During document review with Safety Staff 1 from 9/18/17 to 9/21/17, the fire drills records were reviewed. . There was a space in the fire drill report for participating department/units fire drill report to document overall response to fire/drill comments, suggestion, improvements.

The Facility's fire safety plan (emergency Response) dated 8/17 indicated to go to the nearest pull station and activate the fire alarm during fire. This notifies the Fire Department and mobilizes staff responding to the fire. Staff will call the hospital emergency number to notify the operator of the location of the fire. The operator will then make an overhead page Code Red. Staff will remove all wheeled equipment from the corridor.

On 9/18/17 in Main Hospital Building
During interview with the Safety Staff 1 at 10:50 a.m., he stated he and his staff conducted the fire drills monthly for the hospital. He stated the fire drills start in one unit and other units participate and staff signatures were used to show participation in the fire drills. He stated staff were trained to use the acronym R.A.C.E. rescue the patients, pull the alarm and call 911, contain the fire by closing the doors to patient rooms and extinguish the fire using the fire extinguisher.

1. The Facility's Fire safety plan does not state to a call to 911.

2. During a review of the Fire drills record, it indicated no documentation of scenarios (to simulate fire condition), and missing signatures of other departments participating in the drills. Fire drills record dated 2/27/17 indicated no signatures for staff from the 3rd floor north wing, intensive care units, 4th floor north wing and 3rd floor west wing.

3. The Fire drill record indicated no afternoon fire drill conducted for the 1st quarter January, February and March 2017, no overnight fire drill conducted for the 2nd quarter April, May and June 2017. The Fire drill conducted were used for both shifts. The Fire drills conducted on 6/17/17 day shift was used for both days and overnight shift, and fire drill conducted on 2/27/17 was used for day and afternoon shift. There was no individual drill conducted for each shift for the dates above.

4. At 11:05 a.m., Safety Staff 1 acknowledged that the fire drills documents failed to identify employees that participated in the fire drills by their signatures.

5. Kitchen staff 1 was interviewed on 9/18/17 at 10:13 a.m on what to do if there was a fire in the kitchen. He stated in the event of a fire he would activate the kitchen suppression system, make sure doors were shut and use the fire extinguisher.

6. During interview with the Licensed staff 1 and 2 on 9/19/17 at 8:40 a.m., they stated in the event of a fire they would not panic, get patients to safety, call for help, call 77# close the door and use the fire extinguishers. Licensed Staff 1 and 2 failed to identify the working manual pull stations during the testing of the fire alarm. Licensed staff 1 stated she was not aware that there were manual pull stations that were not working and was not instructed by facility of the location of working manual pull stations.

7. During interview with Radiotherapist Staff 1 and 2 on 9/20/17 at 10:20 a.m., they stated they were not familiar with the type of portable fire extinguishers installed in the Radiotherapy Building.

8. During interview with certified staff 1 on 9/20/17 at 11:59 a.m., she identify a non-working manual pull station as a working manual pull station. There were no sign attatched to indicate the manual pull box was not functioning.

9. During interview with Pharmacist Staff on 9/20/17 at 3:48 p.m., she stated in the event she discover a fire she would close all doors, go to the escape route, make sure everything was secure and if she needed a fire extinguisher she would use R.A.C.E and call 911. The Pharmacy Staff did not say that the manual pull station will be activated.

10. On 9/20/17 at 10:30 a.m., the Facility's Inspector of Records (IOR) said both fire alarm panels were still in use. On 9/20/17 at 4:09 p.m., Staffs in the private box exchange room were not aware that one of two fire alarm panel was in trouble mode and stated the fire alrm panel in trouble was not working. The Facility failed to instruct their staff on the capability of the fire alarm panel that was showing a trouble signal at the private box exchange room.

11. The Facility staff failed to mention during interview the clearing of the corridors for obstructions in the event of an emergency situation as mentioned in their fire emergency/fire procedure policy.


21101


Main Hospital 3N on 9/19/17:
12. At 11:59 a.m., the Nurse Manager and two staff were interviewed regarding fire procedures. The staff were asked where the manual pull boxes were located and staff pointed to the manual pull boxes that were taped and no longer working. The facility installed new manual pull boxes four months ago and have not removed the old ones until Office of Statewide Health Planning and development (OSHPD) had signed off on the project. The new manual pull boxes were not installed in the same area where the old boxes were. The Nurse Manager stated she and staff had not been in serviced in regards to where the new pull boxes were located. Three of three staff interviewed did not know where the new pull boxes were located.

Main Hospital 4N on 9/19/17:
13. At 11:22 a.m., 1 of 1 nursing staff was interviewed regarding their fire safety procedures. The staff was asked where the manual pull box was located and staff pointed to the manual pull box that was taped and no longer working. The Staff stated she did not know where the new manual pull box was located.

Based on observation and interview, the facility failed to maintain an unobstructed corridor and failed to store oversized trash containers in proper storage areas. This was evidenced by the oversized trash container stored in the corridor. This affected 1 of 4 floors and a basement of main hospital building. This could be a hazardous and result in the delay evacuation and the increased risk of injury to patients, staff and visitors, in the event of a fire.

Findings:

During the facility tour with the Engineer Staff from 9/18/17 to 9/21/17, the trash carts were observed.

Main Hospital Building on 9/20/17:
At 3:41 p.m., there were two unattended trash utility trucks greater than 32 gallons storage capacity stored in the corridor by admit and discharge unit on the 1st floor. The carts were approximately 600 lbs capacity carts. The Engineering Staff stated the staff leave them there while doing rounds in the facility.

During document review and interview, the facility failed to maintain its medical gas system, as evidenced by no documentation for the needed repairs that were noted in the annual Medical Gas Report. This could result in failure of the medical gas system and affected two of four floors in the main hospital.
floors affected second and third floors.

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 5 Gas and Vacuum Systems
5.1.14.2.2.4 Maintenance Schedules.
Scheduled maintenance for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.
5.1.14.2.2.5 Qualifications.
Persons maintaining these systems shall be qualified to perform these operations. Appropriate qualification shall be demonstrated by any of the following:
(1) Training and certification through the health care facility by which such persons are employed to work with specific equipment as installed in that facility
(2) Credentialing to the requirements of ASSE 6040, Professional Qualification Standard for Medical Gas Maintenance Personnel
(3) Credentialing to the requirements of ASSE 6030, Professional Qualification Standard for Medical Gas Systems Verifiers
5.1.14.2.3 Inspection and Testing Operations.
5.1.14.2.3.1 General.
The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program

Findings:

During document review and interview with Facility Staff, Safety Staff 1 and Safety Staff 2 on 9/19/17 through 9/21/17, the annual Medical Gas inspection and testing report was reviewed.

Main Hospital on 9/19/17:
At 3:51 p.m., the report for the testing of the medical gas by an outside vendor dated 3/28/17, noted discrepancies on page 3-18 for the Medical Gas Zone Valves. The discrepancies were noted as leakage second floor Cardiology and third floor ICU. Under the Technician Notes indicates Quote 9968RI, not approved and Quote 10042RI not approved. During an interview, Facility Staff stated he did not know if the repairs were completed. No additional documentation was provided.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70, 2011 Edition. This was evidenced by electrical panels with open circuit spaces and a broken electrical receptacle ground port. This had the potential to increase the risk of a fire and or shock and affected the first floor and 4th floor in the Main Hospital.

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 6 Electrical Systems
6.3 Electrical System.
6.3.2 Distribution.
6.3.2.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.
6.3.2.1.1 Distribution system arrangements shall be designed to minimize interruptions to the electrical systems due to internal failures by the use of adequately rated equipment.

NEC 70: National Electrical Code, 2011 Edition - Chapter 1 General
110.12 Mechanical Execution of Work.
Electrical equipment shall be installed in a neat and workmanlike manner.
110.12(A) Unused Openings.
Unused openings, other than those intended for the operation of equipment, those intended for mounting purposes, or those permitted as part of the design for listed equipment, shall be closed to afford protection substantially equivalent to the wall of the equipment. Where metallic plugs or plates are used with nonmetallic enclosures, they shall be recessed at least 6 mm (1? 4 in.) from the outer surface of the enclosure.
110.12(B) Integrity of Electrical Equipment and Connections.
Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

Findings:

During a tour of the facility with Facility Staff on 9/18/17 through 9/21/17, the electrical equipment and wiring was observed.

Main Hospital 4N on 9/20/17:
1. At 11:13 a.m., the electrical ground port in room N435(f) was observed to be broken.
Main Hospital First Floor on 9/20/17
2. At 4:36 p.m., electrical panel 1ECB1-Crtical Branch did not have a blank cover for space 12. The panel was located in the Cath Lab electrical room.
3. At 4:38 p.m., electrical panel 1EQL-Equipment Branch did not have a blank cover for space 29 and 43. The panel was located in the Cath Lab electrical room.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by non compliant multi plugs adapters in use and power strip plugged into multi-plug adapters . This affected radiotherapy building. This could potentially cause a hazard and potential harm to patients and staff, in the event of a fire.

Findings:

During tour of the facility with the Engineer Staff on 9/18/17 to 9/21/17, the electrical appliances were observed.

Radiotherapy Building on 9/20/17
At 10:26 a.m., in the patient care bay with two gurney beds, there were non-compliant multi-plug adapters plugged into the wall outlets. The multi plug adapter had a multi-plug power strip plugged into it. The multi plug adaptors and power strips were not United laboratory(UL) Standards. Engineering staff 1 confirmed the multi plug adapters were not UL listed and not approved for use in patient care vicinity.

Based on observation, the facility failed to maintain oxygen cylinders safety. This was evidenced by oxygen cylinders that were not secured, by no precautionary sign of oxygen in use inside a patient room and by storing flammable liquids in the oxygen cylinder storage room. This had the potential to cause cylinder damage should the oxygen cylinder fall and could result in potential harm to patients, staff and visitors. This affected two of four floors in the main hospital.

NFPA 99, Health Care Facilities Code 2012 Edition
11.3 Cylinder and Container Storage Requirements.
11.3.3.3 When small-size (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or to medical equipment designed to receive and hold compressed gas cylinders.
11.3.4 Signs.
11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.

Findings:

During a tour of the facility with Facility Staff on 9/18/17 through 9/21/17, the oxygen cylinders and oxygen storage was observed.

Main Hospital 4N on 9/20/17:
1. At 11:12 a.m., there were two (E) oxygen cylinders unsecured and free standing in the Unit Supervisor office.

2. At 11:26 a.m., there was a oxygen cylinder in room 474 and there was no sign displayed on the patient room door or door frame.


29566

Main Hospital Building on 9/19/17:

3. At 2:15 p.m., in the operating room suite storage room, there were flammable liquids stored in the room with the oxygen cylinders. There were alcohol hand sanitizers, containers stored in the storage room. The storage room had 15 oxygen E-sized cylinders, and 14 carbon dioxide E-sized cylinders.

Based on observation, record review and interview, the facility failed to ensure staff were trained on safe handling of medical gases and cylinders. This was evidenced by no documentation of training on safe handling of medical gases and cylinders . This affected 1 of 4 floors and the basement of main hospital building, radiotherapy building and the ambulatory surgery center (ASC) building. This could cause a potential hazard for the facility and possible harm to patients and staff due to a hazardous condition.

National Fire Protection Association 99, Health Care Facilities, 2012 Edition
3.1 General. The definitions contained in this chapter shall apply to the terms used in this code. Where terms are not defined in this chapter or within another chapter, they shall be defined using their ordinarily accepted meanings within the context in which they are used. Merriam-Webster's Collegiate Dictionary, 11th edition, shall be the source for the ordinarily accepted meaning.
11.5.1.1.2* No sources of open flame, including candles, shall be permitted in the area of administration.
11.5.1.1.3* Sparking toys shall not be permitted in any patient care room.
11.5.1.1.4 Non-medical appliances that have hot surfaces or sparking mechanisms shall not be
permitted within oxygen delivery equipment or within the site of intentional expulsion.
11.5.1.2.1 Flammable or combustible aerosols or vapors, such as alcohol, shall not be used in oxygen-enriched atmospheres.
11.5.1.2.2 Oil, grease, or other flammable substances shall not be used on/in oxygen equipment.
11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel.
11.5.2.1.3 Continuing education programs shall include periodic review of safety guidelines and usage requirements for medical gases and their cylinders.
11.5.2.1.4 Equipment shall be serviced only by personnel trained in the maintenance and operation of the equipment.
Merriam Webster's Collegiate Dictionary 11th Edition
Periodic 'occurring or recurring at regular interval'

Findings:

During tour of facility with the Engineer Staff and Safety Staff 3 from 9/18/19 to 9/21/17, the staffs were interviewed on the risk associated with handling medical gas and cylinders.

Main Hospital Building on 9/19/17:
1. At 11:55 a.m., during interview with licensed staff, they were not able to identify risks of handling oxygen cylinders such as no oil, grease and flammable substance used around oxygen cylinders, and no sparking toys or sparking equipment permitted within oxygen delivery area.

Radiotherapy Building on 9/20/17:
2. At 10:25 a.m. during interview with radiotherapy staff and the Supervisor, they stated they could not recall a safety training was done for the safe handling of medical gas cylinders.

Ambulatory Surgical Building on 9/20/17:
3. At 2:15 p.m., there was no written documents to show engineering staff handling medical gases and cylinders were trained in the safe handling of medical gases and cylinders.