HospitalInspections.org

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors due to lack of positive latching hardware on exit access doors that protected openings in corridor walls in four locations in accordance with NFPA 101 18.3.6.3.2. This deficient practice affected 3 of 18 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/25/2010, Surveyor 12316 observed at 12:50 pm that the double doors in one corridor wall of the C-Section suite on the 2nd Floor did not have a positive latching hardware.

Item 2. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/25/2010, Surveyor 12316 observed between 2:15 pm and 2:40 pm that the exit access doors 17D1 and 17D02 in the east and west corridors of the Intensive Care Unit (ICU) suite on the 1st Floor did not have positive latching hardware. The double doors protected openings in the corridor walls of the ICU suite.

Item 3. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 11:20 am that the exit access doors 18D03 of the Emergency Department suite on the 1st Floor did not have a positive latching hardware.

Surveyor 12316 also observed more than 1/8 inch gap at the meeting edge of the double doors 17D02. This clearance at the meeting edge of doors did not make the corridor wall smoke-tight in accordance with NFPA 101 18.3.6.2.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to lack of astragals in smoke doors required by NFPA 18.3.7.8. This deficient practice affected 4 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed between 10:30 am and 11:30 am that there were no astragals at the meeting edge of smoke doors adjacent to the Patient Rooms 3102 and 2102 on the 3rd and 2nd Floor respectively.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and interview, the facility failed to properly maintain one corridor door to hazardous area due to non-latching in accordance with NFPA 101 18.3.2.1, 18.3.6.3.2, 8.4.1.3. This deficient practice affected 1 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 11:31 am that the door to Storage G172 on the Garden Level Floor did not positively latch when tested. This did not meet the requirement of NFPA 101 8.4.1.3 and 18.3.6.3.2.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to exits not readily accessible from the Emergency Department (ED) and Intensive Care Unit (ICU) in accordance with NFPA 101 18.2.2.2.4. This deficient practice affected 2 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed between 2:15 pm and 3:30 pm that 15-second delayed egress locked doors were located in more than two locations in the egress path from each of the ED and ICU suites on the 1st Floor, which is not permitted by the Life Safety Code requirement NFPA 101 18.2.2.2.4 Exception No.2. The exit access doors coming out of both ED and ICU suites had delayed egress locking arrangements. The second location of delayed egress locked doors was at the west end of Corridor 14C18 adjacent to the Security Office 1211 and at the east end of Corridor 15C16 adjacent to the Clean Storage Room 1711. At the time of survey, the delayed egress locking devices on doors in Corridors 14C18 and 15C16 were not enabled.

When interviewed on June 8 at 3:30 pm, Staff N stated that the delayed egress devices on the second set of doors i.e. the second location of doors in an egress path in the East-West Corridor were normally in unlocked position during both day and night hours, but enabled when the motion sensor installed above each door fails. The doors would then go into delayed egress locked mode causing access to exits from ICU and ED suites not readily accessible due to two delayed egress locked doors in an egress path. Surveyor 12316 determined that such an arrangement did not make the exits readily accessible in accordance with the NFPA 101 7.2.1.5 and 7.2.1.5.4 requirements, if and when the motion sensor fails.

The above observation was acknowledged by with the facility management director at the time of discovery, but confirmed with the facility management director in phone interview on 6/8/2010 at 3:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to objects stored in one corridor, and not keeping the corridor clear in accordance with NFPA 101 18.2.3.3. This deficient practice affected 1 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/24/2010, Surveyor 12316 observed at 3:07 pm that there were some gurneys, and patient care equipment stored in the corridor adjacent to Operation Room 2 & 4, and near the east exit on the 1st Floor. The corridor was not maintained clear and obstructed as required.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to ensure safety to visitor and staff of the facility due to one means of egress out of an interior room of the Lab Suite not installed in accordance with NFPA 101 18.2.5.8. This deficient practice affected 1 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 4:10 pm that the arrangement of means of egress from the AFB Room to exit access door required an occupant to pass through 2 intervening spaces, but the travel distance was more than 50 ft. The travel distance may not exceed 50 ft in accordance with NFPA 101 18.2.5.8. The AFB Room is located within the Lab suite on the Garden Level Floor.

When interviewed on 5/26/2010 at 4:10 pm, Staff N stated that the travel distance from the AFB Room to corridor door was measured to be 78 ft, and that the facility has conducted an FSES study.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to the lack of double bulb lighting fixture in the outside of building above 1 of 9 exit doors in accordance with NFPA 101 7.8.1.4. This affected all patients, staff and visitors in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 11 am that the lighting fixture on the outside of the Stairwell Exit 2 in the west side of hospital did not have double lamps to illuminate the exit discharge in accordance with NFPA 101 7.8.1.4.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation, the facility failed to ensure safety to patients, staff and visitors of the facility due to lack of sprinkler protection or alternative fire extinguishing system in five telecommunication rooms on the various floors. This deficient practice affected the entire facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) between 5/24 and 5/27/2010, Surveyor 12316 observed that communication Rooms 1128, 3401, 2401, 1401, and G221 did not have sprinkler protection or alternative fire extinguishing system. NFPA 101 requires sprinkler protection in accordance with the NFPA 13 requirements; Section 5-13.11 of NFPA 13 does not exempt sprinkler installation in telecommunication rooms.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to ensure safety to patients due to 2 corridors used as return air plenums which is not permitted by NFPA 90A 2-3.11.1. This deficient practice could affect patients in 2 of 18 smoke compartments, undetermined number of visitors and staff in the facility, if there was a fire in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/25/2010, Surveyor 12316 observed that (i) at 10 am, the corridor of the patient sleeping area with patient rooms 3201-3210 in SC#2 was partially used as a return air plenum as evidenced by the airflow from the SC#1 into SC#2 through the undercut of smoke doors of SC#2, when the smoke doors were kept in closed position; and
(ii) at 1:30 pm, the corridor of the patient sleeping area with patient rooms 2201-2210 in SC#2 was partially used as a return air plenum as evidenced by the airflow occurring from the SC#1 into SC#2 through the undercut of smoke doors of SC#2 when smoke doors were kept in closed position.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to trash receptacles not stored in a room protected as a hazardous area in two locations in accordance with NFPA 101 18.7.5.5. This deficient practice affected 2 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor), Surveyor 12316 observed that (i) on 5/24/2010 at 2:38 pm that 3 trash receptacles of the combined capacity of more than 32 gal were stored in the Operation Room 1 on the 1st Floor, and not in a room protected as a hazardous area; and (ii) on 5/25/2010 at 12:55 pm that one soiled linen and two trash receptacles of the combined capacity of more than 32 gal were stored in the C-Section Room 2411B on the 2nd Floor, and not in a room protected as a hazardous area.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and interview, the facility failed to store one empty oxygen cylinder in accordance with NFPA 99 4-3.5.2.2. This deficient practice affected 1 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director) and Staff P (facilities management supervisor), Surveyor 12316 observed on 5/25/2010 at 10:50 am that one " E " size empty oxygen cylinder was stored with one other full cylinder in the same cart, and not separated from full cylinder as required. The oxygen cylinders located in the Medication Room 3609 on the 3rd Floor.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed with them at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to ensure safety to patients due to lack of remote emergency manual stop for the emergency generator of the essential electrical system. This deficient practice affected the entire facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 4:30 pm that there was no remote emergency stop for the emergency generator as required by NFPA 110 3-5.5.6, Table 3-5.5.2(d). The generator is located outside.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed with them at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to (ii) ensure mechanical ventilation in patient sleep study rooms without windows; (ii) install exhaust duct to exhaust air from the toilet room; (iii) store oxygen cylinders properly; and (iv) install door in one storage room. This could affect all patients and staff of the facility.

Findings include

Item 1. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 3:20 pm that (i) the HVAC unit serving the patient sleep study rooms without windows was on "Auto" mode as indicated by the wall thermostat and cycled on and off, and not on "ON " mode to provide room air movement and air changes, and outside air for ventilation even during periods when there was no call for heat or cooling in accordance with the building and mechanical code, and (ii) the exhaust grille in the ceiling of patient toilet room was not ducted to the outside, but transferred air into the ceiling return air plenum instead. The toilet exhaust is required to be ducted to outside.

Item 2. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 3:27 pm that two "H" size part full oxygen cylinders were stored with other combustibles in the Cleaning Room and not separated by at least 5 ft from combustibles in accordance with NFPA 99 8-3.1.11.2, NFPA 101 4.6.1.2.

Item 3. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 3:27 pm that the Cleaning Room with combustible storage had an opening with a door frame but did not have a door. The Cleaning Room was open to the passage in the Sleep Center. Furthermore, the space was neither enclosed with 1-hr fire-rated walls, nor sprinkler protected. This did not meet the requirement of NFPA 101 39.3.2.1, 8.4.1.1

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to (i) label some emergency electrical wall outlets in the post anesthesia care unit, intensive care unit and emergency department in accordance with NFPA 70 517-19(a), and (ii) to provide working space in front of electrical switches in two locations in accordance with NFPA 70 110-26. This affected 4 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor), Surveyor 12316 observed that (i) on 5/24/2010 at 4 pm, critical branch electrical duplex receptacles in 5 patient bed locations in the PACU area did not have labels to identify as to which critical branch electrical panel and circuit breaker the power is supplied from; (ii) on 5/25/2010 at 11:26 am, ladders and fluorescent light fixtures were stored in front of electrical panels in the Electrical Room 2403; (iii) on 5/25/2010 at 2:30 pm, the critical branch electrical wall receptacles of 6 rooms in the Intensive Care Unit (ICU) were not identified as to which electrical panel and branch circuit the power is supplied by; (iv) on 5/25/2010 at 2:50 pm, the critical branch electrical duplex receptacles of the Trauma Room #4 in the Emergency Department were not identified to indicate the electrical panel and branch circuit the power is supplied by; (v) on 5/25/2010 at 3:08 pm, the critical branch duplex outlets of the Ortho Room 1818 and some exam rooms in the Emergency Department were not labeled to indicate the electrical panel and circuit breaker; and (vi) on 5/26/2010 at 9:53 am, one ladder was stored in front of a electrical panel in the Electrical Room 1203 in the Admitting area.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

NFPA 70 110-26.
"Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment ....."

NFPA 70 110-26(b) Clear Spaces.
"Working space required by this section shall not be used for storage ..."

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors due to lack of positive latching hardware on exit access doors that protected openings in corridor walls in four locations in accordance with NFPA 101 18.3.6.3.2. This deficient practice affected 3 of 18 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/25/2010, Surveyor 12316 observed at 12:50 pm that the double doors in one corridor wall of the C-Section suite on the 2nd Floor did not have a positive latching hardware.

Item 2. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/25/2010, Surveyor 12316 observed between 2:15 pm and 2:40 pm that the exit access doors 17D1 and 17D02 in the east and west corridors of the Intensive Care Unit (ICU) suite on the 1st Floor did not have positive latching hardware. The double doors protected openings in the corridor walls of the ICU suite.

Item 3. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 11:20 am that the exit access doors 18D03 of the Emergency Department suite on the 1st Floor did not have a positive latching hardware.

Surveyor 12316 also observed more than 1/8 inch gap at the meeting edge of the double doors 17D02. This clearance at the meeting edge of doors did not make the corridor wall smoke-tight in accordance with NFPA 101 18.3.6.2.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to lack of astragals in smoke doors required by NFPA 18.3.7.8. This deficient practice affected 4 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed between 10:30 am and 11:30 am that there were no astragals at the meeting edge of smoke doors adjacent to the Patient Rooms 3102 and 2102 on the 3rd and 2nd Floor respectively.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and interview, the facility failed to properly maintain one corridor door to hazardous area due to non-latching in accordance with NFPA 101 18.3.2.1, 18.3.6.3.2, 8.4.1.3. This deficient practice affected 1 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 11:31 am that the door to Storage G172 on the Garden Level Floor did not positively latch when tested. This did not meet the requirement of NFPA 101 8.4.1.3 and 18.3.6.3.2.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to exits not readily accessible from the Emergency Department (ED) and Intensive Care Unit (ICU) in accordance with NFPA 101 18.2.2.2.4. This deficient practice affected 2 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed between 2:15 pm and 3:30 pm that 15-second delayed egress locked doors were located in more than two locations in the egress path from each of the ED and ICU suites on the 1st Floor, which is not permitted by the Life Safety Code requirement NFPA 101 18.2.2.2.4 Exception No.2. The exit access doors coming out of both ED and ICU suites had delayed egress locking arrangements. The second location of delayed egress locked doors was at the west end of Corridor 14C18 adjacent to the Security Office 1211 and at the east end of Corridor 15C16 adjacent to the Clean Storage Room 1711. At the time of survey, the delayed egress locking devices on doors in Corridors 14C18 and 15C16 were not enabled.

When interviewed on June 8 at 3:30 pm, Staff N stated that the delayed egress devices on the second set of doors i.e. the second location of doors in an egress path in the East-West Corridor were normally in unlocked position during both day and night hours, but enabled when the motion sensor installed above each door fails. The doors would then go into delayed egress locked mode causing access to exits from ICU and ED suites not readily accessible due to two delayed egress locked doors in an egress path. Surveyor 12316 determined that such an arrangement did not make the exits readily accessible in accordance with the NFPA 101 7.2.1.5 and 7.2.1.5.4 requirements, if and when the motion sensor fails.

The above observation was acknowledged by with the facility management director at the time of discovery, but confirmed with the facility management director in phone interview on 6/8/2010 at 3:30 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to objects stored in one corridor, and not keeping the corridor clear in accordance with NFPA 101 18.2.3.3. This deficient practice affected 1 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/24/2010, Surveyor 12316 observed at 3:07 pm that there were some gurneys, and patient care equipment stored in the corridor adjacent to Operation Room 2 & 4, and near the east exit on the 1st Floor. The corridor was not maintained clear and obstructed as required.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to ensure safety to visitor and staff of the facility due to one means of egress out of an interior room of the Lab Suite not installed in accordance with NFPA 101 18.2.5.8. This deficient practice affected 1 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 4:10 pm that the arrangement of means of egress from the AFB Room to exit access door required an occupant to pass through 2 intervening spaces, but the travel distance was more than 50 ft. The travel distance may not exceed 50 ft in accordance with NFPA 101 18.2.5.8. The AFB Room is located within the Lab suite on the Garden Level Floor.

When interviewed on 5/26/2010 at 4:10 pm, Staff N stated that the travel distance from the AFB Room to corridor door was measured to be 78 ft, and that the facility has conducted an FSES study.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to the lack of double bulb lighting fixture in the outside of building above 1 of 9 exit doors in accordance with NFPA 101 7.8.1.4. This affected all patients, staff and visitors in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 11 am that the lighting fixture on the outside of the Stairwell Exit 2 in the west side of hospital did not have double lamps to illuminate the exit discharge in accordance with NFPA 101 7.8.1.4.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation, the facility failed to ensure safety to patients, staff and visitors of the facility due to lack of sprinkler protection or alternative fire extinguishing system in five telecommunication rooms on the various floors. This deficient practice affected the entire facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) between 5/24 and 5/27/2010, Surveyor 12316 observed that communication Rooms 1128, 3401, 2401, 1401, and G221 did not have sprinkler protection or alternative fire extinguishing system. NFPA 101 requires sprinkler protection in accordance with the NFPA 13 requirements; Section 5-13.11 of NFPA 13 does not exempt sprinkler installation in telecommunication rooms.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to ensure safety to patients due to 2 corridors used as return air plenums which is not permitted by NFPA 90A 2-3.11.1. This deficient practice could affect patients in 2 of 18 smoke compartments, undetermined number of visitors and staff in the facility, if there was a fire in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/25/2010, Surveyor 12316 observed that (i) at 10 am, the corridor of the patient sleeping area with patient rooms 3201-3210 in SC#2 was partially used as a return air plenum as evidenced by the airflow from the SC#1 into SC#2 through the undercut of smoke doors of SC#2, when the smoke doors were kept in closed position; and
(ii) at 1:30 pm, the corridor of the patient sleeping area with patient rooms 2201-2210 in SC#2 was partially used as a return air plenum as evidenced by the airflow occurring from the SC#1 into SC#2 through the undercut of smoke doors of SC#2 when smoke doors were kept in closed position.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to trash receptacles not stored in a room protected as a hazardous area in two locations in accordance with NFPA 101 18.7.5.5. This deficient practice affected 2 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor), Surveyor 12316 observed that (i) on 5/24/2010 at 2:38 pm that 3 trash receptacles of the combined capacity of more than 32 gal were stored in the Operation Room 1 on the 1st Floor, and not in a room protected as a hazardous area; and (ii) on 5/25/2010 at 12:55 pm that one soiled linen and two trash receptacles of the combined capacity of more than 32 gal were stored in the C-Section Room 2411B on the 2nd Floor, and not in a room protected as a hazardous area.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and interview, the facility failed to store one empty oxygen cylinder in accordance with NFPA 99 4-3.5.2.2. This deficient practice affected 1 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director) and Staff P (facilities management supervisor), Surveyor 12316 observed on 5/25/2010 at 10:50 am that one " E " size empty oxygen cylinder was stored with one other full cylinder in the same cart, and not separated from full cylinder as required. The oxygen cylinders located in the Medication Room 3609 on the 3rd Floor.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed with them at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to ensure safety to patients due to lack of remote emergency manual stop for the emergency generator of the essential electrical system. This deficient practice affected the entire facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 4:30 pm that there was no remote emergency stop for the emergency generator as required by NFPA 110 3-5.5.6, Table 3-5.5.2(d). The generator is located outside.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed with them at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to (ii) ensure mechanical ventilation in patient sleep study rooms without windows; (ii) install exhaust duct to exhaust air from the toilet room; (iii) store oxygen cylinders properly; and (iv) install door in one storage room. This could affect all patients and staff of the facility.

Findings include

Item 1. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 3:20 pm that (i) the HVAC unit serving the patient sleep study rooms without windows was on "Auto" mode as indicated by the wall thermostat and cycled on and off, and not on "ON " mode to provide room air movement and air changes, and outside air for ventilation even during periods when there was no call for heat or cooling in accordance with the building and mechanical code, and (ii) the exhaust grille in the ceiling of patient toilet room was not ducted to the outside, but transferred air into the ceiling return air plenum instead. The toilet exhaust is required to be ducted to outside.

Item 2. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 3:27 pm that two "H" size part full oxygen cylinders were stored with other combustibles in the Cleaning Room and not separated by at least 5 ft from combustibles in accordance with NFPA 99 8-3.1.11.2, NFPA 101 4.6.1.2.

Item 3. During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) on 5/26/2010, Surveyor 12316 observed at 3:27 pm that the Cleaning Room with combustible storage had an opening with a door frame but did not have a door. The Cleaning Room was open to the passage in the Sleep Center. Furthermore, the space was neither enclosed with 1-hr fire-rated walls, nor sprinkler protected. This did not meet the requirement of NFPA 101 39.3.2.1, 8.4.1.1

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

Based on observation and staff interview, the facility failed to (i) label some emergency electrical wall outlets in the post anesthesia care unit, intensive care unit and emergency department in accordance with NFPA 70 517-19(a), and (ii) to provide working space in front of electrical switches in two locations in accordance with NFPA 70 110-26. This affected 4 of 18 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor), Surveyor 12316 observed that (i) on 5/24/2010 at 4 pm, critical branch electrical duplex receptacles in 5 patient bed locations in the PACU area did not have labels to identify as to which critical branch electrical panel and circuit breaker the power is supplied from; (ii) on 5/25/2010 at 11:26 am, ladders and fluorescent light fixtures were stored in front of electrical panels in the Electrical Room 2403; (iii) on 5/25/2010 at 2:30 pm, the critical branch electrical wall receptacles of 6 rooms in the Intensive Care Unit (ICU) were not identified as to which electrical panel and branch circuit the power is supplied by; (iv) on 5/25/2010 at 2:50 pm, the critical branch electrical duplex receptacles of the Trauma Room #4 in the Emergency Department were not identified to indicate the electrical panel and branch circuit the power is supplied by; (v) on 5/25/2010 at 3:08 pm, the critical branch duplex outlets of the Ortho Room 1818 and some exam rooms in the Emergency Department were not labeled to indicate the electrical panel and circuit breaker; and (vi) on 5/26/2010 at 9:53 am, one ladder was stored in front of a electrical panel in the Electrical Room 1203 in the Admitting area.

The above observation was acknowledged by the facility management director, facility management supervisor at the time of discovery, and confirmed at the exit conference on 5/27/2010 at 11:50 am.

NFPA 70 110-26.
"Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment ....."

NFPA 70 110-26(b) Clear Spaces.
"Working space required by this section shall not be used for storage ..."