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Based on observation, the facility failed to maintain doors to resist the passage of smoke and fire. This was evidenced by corridor doors with penetrations, corridor doors obstructed from closing or latching, and by not repairing door in accordance with applicable standards. This had the potential to allow the migration of smoke and fire, resulting in injury patients. This affected 2 of 6 floors in Hospital A, 1 of 2 floors in the Cottage of Hospital B, and 1 of 4 floors in Hospital B.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the corridor doors were observed.

Sixth Floor, Hospital A:
1. On 1/13/2014, at 10:24 A.M., the corridor door to Room 669 had four penetrations going through the door that measured approximately 1/4-inch each.

2. On 1/13/2014, at 10:25 A.M., the corridor door to Room 670 had four penetrations going through the door that measured approximately 1/4-inch each.

3. On 1/13/2014, at 10:26 A.M., the corridor door to Room 671 had four penetrations going through the door that measured approximately 1/4-inch each.

4. On 1/13/2014, at 10:27 A.M., the corridor door to Room 672 had four penetrations going through the door that measured approximately 1/4-inch each.
Third Floor, Hospital A:
5. On 1/13/2014, at 3:09 P.M., the corridor door to Room 365 had two penetrations going through the door that measured approximately 1/4-inch each.

6. On 1/13/2014, at 3:10 P.M., the corridor door to Room 66 had two penetrations going through the door that measured approximately 1/4-inch each.


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The Cottage at Hospital B:
7. On 1/13/14, at 3:45 P.M., there was tape over the holes left by the missing bolt and face-plate on the door to Room 10.

8. On 1/13/14, at 3:46 P.M., there was tape over the holes left by the missing bolt and face-plate on the door to Room 11.

9. On 1/13/14, at 3:55 P.M., the door to the library room had a broken frame and a gap between the frame and door leaf. The door was obstructed from closing due the broken door frame.

Hospital B:
10. On 1/14/14, at 9 A.M., the door to Room 337 failed to latch because the bolt and faceplate were missing. The area was covered with duct tape.

Based on observation and interview, the facility failed to maintain their smoke barrier walls. This was evidenced by penetrations in smoke barrier walls. This could result in the spread of smoke and fire, in the event of a fire. This affected 1 of 3 floors in the Senior Health Center.

Findings:

During a tour of the facility with the Head Engineer (ENG 81), the smoke barrier walls were observed.

Senior Health Center - Suite 202:
On 1/15/14, at 11:20 A.M., there were 3 penetrations in the smoke barrier wall by the reception area. The penetrations measured approximately 1/2 inch in diameter.

Based on observation, the facility failed to maintain their fire doors to prevent the passage of smoke or fire. This was evidenced by fire doors to stairwells and cross corridor fire doors that failed to close and positive latch. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the fire doors were observed.

Second Floor, Hospital A:
1. On 1/14/2014, at 10:19 A.M., the fire door to the North Stairwell by the Information System Office failed to close and positive latch. The door was observed to be equipped with a self-closure and latching mechanism.

Third Floor, Hospital A:
2. On 1/15/2014, at 2:14 P.M., 1 of 2 cross corridor fire doors by the Gift Shop failed to close and positive latch upon activation of the fire alarm system. The doors were observed to be equipped with automatic closing and latching mechanisms.

Based on observation, the facility failed to protect the corridor from hazardous areas. This was evidenced by no self-closing device on the doors to two Housekeeper Storage Rooms and a staff office. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff, in the event of a fire. This affected 1 of 4 floors in Hospital B and 1 of 2 floors in the Cottage of Hospital B.

National Fire Prevention Association 101, Life Safety Code 2000 Edition:
19.3.2.1 Hazardous Areas. Any Hazardous area shall be safe guarded by a fire barrier having a 1 -hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke -resisting partitions and doors. The doors shall be self-closing or automatic closing. Hazardous shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square ft (9.3 square m)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square ft (4.6 square m), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory-or field -applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a tour of the facility with the Head Engineer (ENG 81), corridor rooms were observed.

Hospital B
1. On 1/13/14, at 11:20 A.M., there were 2 environmental storage rooms not equipped with self-closure devices. The rooms stored flammable cleaning supplies and paper-products.

Second Floor, The Cottage at Hospital B:
2. On 1/13/14 at 3:40 P.M., the door to the Manager's office on the 2nd floor, had self-closure-device arms that were unattached to the door leaf. The self-closure device failed to self-close. The room stored approximately over 45 gallons of motor oil and other flammable liquids in a unlocked/open flammable NFPA rated cabinet.

Based on observation, the facility failed to ensure that a safe means of egress was maintained from the bedrooms. This was evidenced by a door to a patient's sleeping room that would not readily open from inside the room. This had the potential to delay evacuation during an emergency, resulting in injury to patients and staff. This affected 1 of 6 floors at Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the doors were observed.

Third Floor, Hospital A:
On 1/13/2014, at 1:53 P.M., the door to Patient Room 341 was observed to not unlatch when turning the door knob from inside the room.

Based on observation, the facility failed to maintain illumination on its means of egress as evidenced by lighting units that failed to illuminate. This could cause delay in evacuation due to low or no viability, and result in injury to patients, visitors, and staff. This affected 3 of 6 floors in Hospital A, 4 of 4 floors in Hospital B, and 1 of 2 floors in the Cottage of Hospital B.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the lighting units throughout the means of egress were observed.

Fifth and Fourth Floors, Hospital A:
1. On 1/13/2014, at 10:49 A.M., on the 5th and 4th Floors in the North Stairwell, two lighting fixtures with two light bulbs each did not illuminate and left the means of egress in darkness.

Third Floor, Hospital A:
2. On 1/13/2014, at 11:29 A.M., on the 3rd Floor in the South Stairwell, the light bulbs to the lighting fixture did not illuminate and left the means of egress in darkness.

3. On 1/13/2014, at 11:50 A.M., on the 3rd Floor in the North Stairwell, the light bulbs to the lighting fixture did not illuminate and left the means of egress in darkness.

4. On 1/13/2014, at 1:14 P.M., on the 3rd Floor in the stairwell used as an exit from the 4-East North Wing, the light bulbs to the lighting fixture did not illuminate and left the means of egress in darkness.


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The Cottage at Hospital B:
5. On 1/13/14, at 3:28 P.M., the exit egress light by the staircase landing failed to illuminate the area. The 2 lights bulbs were out.

Hospital B:
6. On 1/14/14, at 9:10 A.M., the exit egress lights in the North stairwell basement level failed to illuminate the area. The light bulbs were out.

7. On 1/14/14, at 9:19 A.M., the exit egress lights in the South stairwells of floor 2 and 3 failed to illuminate the area. The light bulbs were out.

Based on observation and record review, the facility failed to maintain the emergency lights. This was evidenced by emergency lights that failed to illuminate and by no documentation for checking the emergency lights that failed on a monthly basis and for 90-minutes annually. This could result in injury during an emergency evacuation and in the event of a power outage. This affected 1 of 6 floors in Hospital A and the MRI Trailer of Hospital A.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the records for the testing of the emergency lights were requested and the emergency lights were observed.

MRI Trailer, Hospital A:
1. On 1/14/2014, at 9:06 A.M., the battery powered lighting unit connected to an exit sign, located by the exit door to the MRI Trailer, failed to illuminate when pushing down on the test button.

Second Floor, Hospital A:
2. On 1/14/2014, at 10:07 A.M., the two battery powered lighting units located in the Pharmacy failed to illuminate when pushing down on their test buttons.

3. On 1/16/2014, at 11:13 A.M., there was no records that showed that the battery powered emergency lights that failed in the MRI Trailer and in the Pharmacy had been checked monthly or had been tested annually for 90-minutes.

Based on observation and interview, the facility failed to instruct their staff on their role in a fire and emergency procedures. This was evidenced by the staff's lack of familiarity with the trouble alarms on the fire alarm panel and knowledge on the type of fire alarm notification system installed in the facility. This could result in facility staff to not accomplish all of the tasks required of him or her during conditions that is expected to exist in the event of a fire and the increased risk of injury to the patients and staff. This affected the Senior Health Center and Hospital B.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During tour of the facility with the Head Engineer (ENG 81), staffs were interviewed on their knowledge of fire and emergency procedures of their facility.

Hospital B:
1. There were written instructions on how to respond to the fire alarm panel alarms in a training folder at the Security desk by entrance of the hospital; the instruction failed to address who should reset the trouble alarm.
On 1/14/14 at 2:38 P.M., Public Safety Officer 1 (STAFF 86) was interviewed and he stated that if the fire alarm panel trouble lights activated, he would investigates and resets the trouble alarm on the panel.
On 1/15/14 at 2:15 P.M., the Public Safety Manager (STAFF 83) was interviewed and he stated that only Engineers can reset the trouble signal from the fire alarm panel, and it is written in the safety training folder at the security desk. Public Safety Manager failed to provide documents that only Engineers could reset the trouble alarm of the fire alarm panel.

Senior Health Center:
2. The Senior Health Center building is not equipped with pull stations and fire alarm system.
On 1/15/14, at 11:56 A.M., the receptionist (STAFF 84) was interviewed and she stated that for a fire in the building, she would activate the pull station.
At 12:01 P.M., the Medical Assistant (STAFF 85) was interviewed and she stated that if a fire broke out in the building, she would activate the pull station to notify staff.
Both staff failed to familiarize themselves with the notifications system of the building.

Based on observation and interview, the facility failed to provide a fire alarm system in accordance with NFPA 101, 2000 edition. This was evidenced by a fire alarm system installed in a business occupancy using four smoke detectors as notification devices, which were not providing signal alert notification to all occupants and all areas of the building. This affected 3 of 3 floors of Senior Health Center Building and could in result in delay in the evacuation of the building during fire or other emergencies.

NFPA 101, Life Safety Code, 2000 Edition
39.3.4.1 General. A fire alarm system in accordance with Section 9-6 shall be provided in any business occupancy where any one of the following conditions exits.
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
39.3.4.2 Initiation. Initiation of the required fire alarm system shall be by manual means in accordance with 9.6.2.1(1).
Exception No. 1: Initiation shall be permitted by means of an approved automatic fire detection system in accordance with 9.6.2.1(2) that provides protection throughout the building.
Exception No. 2: Initiation shall be permitted by means of an approved automatic sprinkler system in accordance with 9.6.2.1(3) that provides protection throughout the building.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-1.4.2.1 Total (Complete) Coverage. If required, total coverage shall include all rooms, halls, storage areas, basements, attics, lofts, spaces above suspended ceilings, and other subdivisions and accessible spaces; and the inside of all closets, elevator shafts, enclosed stairways, dumbwaiter shafts, and chutes. Inaccessibly areas shall not be required to be protected by detectors.

Findings:

During a tour of the facility on 1/15/14 with the Head Engineer of Hospital B, the fire alarm system in the Senior Health Center building, Suite #202 was observed. The building is a 3 story, non- sprinklered, with exit discharge on the 1st floor level. The first floor is used as a parking garage, elevator lobby and discharge from stairways.
On 1/15/14 at 11:40 A.M., the Supervisor (STAFF 89) was interviewed and stated that the facility occupancy is over 100 patients per day depending on the number of doctors seeing patients. During the tour of the facility with Head Engineer (ENG 81), smoke detectors were observed in the Medical Records room, in the lobby area, over the receptionist desk, and in the laboratory room. There were no smoke detectors observed in the Doctors examination rooms and offices, employees area and hazardous material room. There was no notification device found in the area where no smoke detectors were installed to notify occupant of fire in the facility.

Based on observation and interview, the facility failed to ensure that the fire alarm system was properly maintained in accordance with NFPA 101, 2000 edition. This was evidenced by the fire alarm not heard throughout all occupied spaces. This had the potential for occupants to not be notified of a fire in the building, increasing the risk for injury. This affected 2 of 6 floors at Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) and the Fire Alarm Technician (VEND 78) from 1/13/2014 through 1/16/2014, the fire alarm system was tested and observed.

Third Floor, Hospital A:
1. On 1/15/2014, at 2:33 P.M., the fire alarm was not heard throughout the corridor by the ambulance entrance when the fire alarm system was activated. There was an audible notification device installed in the area that was not alarming when two fire alarm pull stations were activated in the area at 2:32 P.M. and 2:36 P.M. The Fire Alarm Technician acknowledged that the audible notification device was not functioning.

Second Floor, Hospital A:
2. On 1/15/2014, at 3:02 P.M., the fire alarm was not heard throughout the corridor by the Health Information Management Office when the fire alarm system was activated. Two staff were interviewed in the area and they both stated that they could not hear the fire alarm. There were no audible or visual notification device installed in the area.

Based on observation, review of records and interview, the facility failed to ensure that the smoke detectors were maintained in a reliable operating condition. This was evidenced by 4 of 4 smoke detectors that had no record of sensitivity testing and maintenance. This could result in failure to notify the building occupants of a fire in the facility and cause delay in evacuation.


Findings:

Senior Health Center
During the tour of the facility with Head Engineer (ENG 81), the fire alarm system in the Senior Health Center, located on the 2nd floor, was observed. There was a smoke detector in the Medical Records room, in the lobby area, over the receptionist desk, and in the laboratory room.

On 1/15/14 at 11:35 A.M., there were no recorded documents of a sensitivity test and function test for the four detectors installed in the suite. On 1/15/14 at 11:40 A.M., the Supervisor (STAFF 89) was interviewed and stated that the Senior Health Center sees approximately 100 patients depending on the number of Doctors seeing patients. During interview with the Corporate Director of Plant Operations (DIR 77), he confirmed that there were no records for sensitivity testing and functional testing of the smoke detectors.

Based on observation and interview, the facility failed to maintain their sprinkler system in a reliable operating condition. This was evidenced by Supervisory Valves not constantly monitored at the facility or a remote location, and by a broken supervisory valve. This could result in facility's staff unaware of any trouble with sprinkler system and possible failure of the sprinkler system, in the event of a fire. This affected the Cottage of Hospital B and the RTC (Residential Treatment Center) building of Hospital B.

NFPA 101 (2000 Edition) 9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 72 (1999 Edition) 1-5.4.4 Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

NFPA 72 (1999 Edition) 3-8.3.3.1 General. The provisions of 3-8.3.3 shall apply to the monitoring of sprinkler systems, other fire suppression systems, and other systems for the protection of life and property for the initiation of a supervisory signal indicating an off-normal condition that could adversely affect the performance of the system.

Findings:

During the facility tour with the Head Engineer (ENG 81), the automatic sprinkler system devices were observed and tested.

Hospital B:
On 1/14/14, from 9:41 to 9:44 A.M., the supervisory valve on the main riser for the RTC building area failed to alarm and send a signal to the monitored fire alarm panel on facility's ground and the monitoring company when tested.

The Cottage at Hospital B:
On 1/13/14 at 3:50 P.M., the supervisory valve on main riser failed to send a signal to the monitored fire alarm panel in the main building, but sent a signal to the unmonitored fire alarm panel in the cottage.

On 1/16/17 at 9:55 A.M., during interview with the Corporate Director of Plant Operations (DIR 77), he stated due to the age of the sprinkler system, the supervisory valve is not equipped with the ability to be monitored by the fire alarm panel in the main building or the remote monitoring company.

Based on observation, interview, and record review, the facility failed to maintain their automatic sprinkler system. This was evidenced by no current 5-year certification that showed that the required maintenance and testing was completed for all buildings, by sprinklers with debris and corrosion, sprinklers installed at distance less than the minimum allowed from each other, sprinklers with missing escutcheon rings, and by a dislodged sprinkler escutcheon plate with cables installed through the same opening as the sprinkler. Sprinkler heads and scutcheon rings are listed to respond to a calculated ceiling temperature and a missing or detached escutcheon ring could allow heat and smoke to affect other areas in the building and cause failure of the sprinkler system in the event of a fire. This affected 6 of 6 floors in Hospital A, the Boiler Building of Hospital A, the Generator Building of Hospital A, and 1 of 4 floors of Hospital B.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
5-6.3.4 Minimum Distance Between Sprinklers. Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
2.2.1.1 Sprinklers shall be 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, loaded, or in the improper orientation.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.2 Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
3-3 Testing. The tests shall be conducted by a qualified person. (See Section 1-5.)
1-5 Definitions:
Inspection, Testing, and Maintenance Service. A service program provided by a qualified contractor or owner's representative in which all components unique to the property's systems are inspected and tested at the required times and necessary maintenance is provided. This program includes logging and retention of relevant records.
Qualified. Having adequate knowledge of the installation, construction, or operation of apparatus and the hazards involved.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the sprinkler system was observed and maintenance records were requested.

Sixth Floor, Hospital A:
1. On 1/13/2014, at 9:54 A.M., the sprinkler head, located in Room 619, had accumulation of debri on its fusible link and deflector.

2. On 1/13/2014, at 10:00 A.M., two sprinkler heads, located in Room 634, were installed approximately 4-inches from each other. Both sprinkler heads were connected to water lines.

Fifth Floor, Hospital A:
3. On 1/13/2014, at 10:51 A.M., the sprinkler head, located in Room 534, had accumulation of debri on its fusible link and deflector.

Fourth Floor, Hospital A:
4. On 1/13/2014, at 11:27 A.M., the sprinkler head, located in the Shower Room next to Room 453, had corrosion around the sprinkler and on the escutcheon ring.

5. On 1/13/2014, at 11:31 A.M., the sprinkler head, located in Room 453, had accumulation of debri on its fusible link and deflector.

6. On 1/13/2014, at 11:35 A.M., the sprinkler head, located in Room 460, had accumulation of debri on its fusible link and deflector.

Third Floor, Hospital A:
7. On 1/14/2014, at 8:50 A.M., the sprinkler head, located in Rooms 4 and 5 in the Emergency Department, had accumulation of debri on its fusible link and deflector.

8. On 1/14/2014, at 8:52 A.M., the sprinkler head, located in the Shower Room to Rooms 10 in the Emergency Department, was missing an escutcheon ring.

9. On 1/14/2014, at 9:09 A.M., the sprinkler head, located in the Electric Room by the Main Lobby entrance, was missing an escutcheon ring.

Second Floor, Hospital A:
10. On 1/14/2014, at 10:22 A.M., the two sprinkler heads, located in the Information Systems Office, had accumulation of debri on their fusible links and deflectors.

Fourth Floor, Hospital A:
11. On 1/15/2014, at 11:49 A.M., the sprinkler head, located by the handwash area in the Special Care Nursery, had corrosion on its fusible link.

Boiler Building and Generator Building, Hospital A:
12. On 1/16/2014, at 2:52 P.M., the Corporate Director of Plant Operations (DIR 77) stated that the facility did not have a 5-year certification of the sprinkler system for the Boiler Building and the Generator Building. There was no record that showed that the proper maintenance and testing had been performed within the past 5 years and the risers did not contain a 5-year certificate tag or label when observed on 1/15/2014 at 10 A.M.

West Wing, Hospital A:
13. On 1/16/2014, at 3:10 P.M., the fire sprinkler control valves located in the Mechanical Equipment Room did not have a 5-year certificate tag or label on 3 of 4 risers. The three risers without the 5-year certificate were labeled for 1st Floor West Wing, 2nd Floor West Wing, and 3rd Floor West Wing. The vendor's inspection report stated that the gauges need replacement or calibration.


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First Floor, Hospital B:
14. On 1/13/14, at 11:34 A.M., 3 of 4 sprinklers escutcheon rings in the Medical Records office, on 1st floor, was dislodged and not flush to the ceiling. The penetrations behind the sprinkler escutcheon rings had cable cords running through them.

Based on record review, the facility failed to ensure that areas with flammable materials had warning signs to prevent fire. This was evidenced by a smoking policy that did not include provisions to prohibit smoking where flammable liquids, combustible gases and oxygen are used and stored. This could have the potential for causing fire, resulting in injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
19.7.4 Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) Smoking by patients classified as not responsible shall be prohibited.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the smoking policy was reviewed.

Hospital A:
On 1/14/2014, at 6:14 P.M., the smoking policy titled "86100-011 SMOKING, NON-SMOKING" did not contain the requirement of prohibiting smoking where flammable liquids, combustible gases and oxygen are used and stored. The facility was observed to have a portable supply of medical oxygen.

Based on observation, the facility failed to ensure that all means of egress were continuously maintained free of obstructions to full instant use in the case of fire or other emergency. This was evidenced by medication dispensing units that were not properly secured. This could result in a delay in evacuation in the event of a fire, or other emergency. This affected 1 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.2.2 There shall be no obstructions by railings, barriers, or gates that divide the open space into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the egress paths were observed.

Third Floor, Hospital A:
On 1/13/2014, at 9:54 A.M., there were two Pyxis Supply Stations in the corridor by the exit door to the Angio Room in the Imaging Department that were not anchored to prevent them from tipping over. The height of the unsecured medication dispensing units were approximately 6-feet each.

Based on observation and interview, the facility failed to ensure that soiled linen containers were not exceeding 32 gallons. This was evidenced by the oversized soiled linen container stored by the service elevators lobby area. This could posed a danger of fire with a container over the allowed capacity in the corridor during fire. This affected 2 of 4 floors in Hospital B.

Findings:

During the facility tour with the Head Engineer (ENG 81), the linen carts were observed.

Second Floor, Hospital B:
On 1/14/14 at 8:06 A.M., there was a soiled linen cart, greater than 32 gallons storage capacity, stored across from the elevator in the elevator room on the 2nd floor. The cart measured 28 inches by 47 inches, and a height of 68 inches.

Third Floor, Hospital B:
On 1/14/14 at 8:50 A.M., there was a soiled linen cart, greater than 32 gallons storage capacity, stored across from the elevator in the elevator room on the 3rd floor. The cart measured 28 inches by 47 inches, and a height of 68 inches.

Based on record review, the facility failed to maintain the emergency generator. This was evidenced by the facility failure to provide complete records for the weekly inspections on the emergency generators for 9 of 52 weeks. This could result in the failure of the emergency generator to provide power to the facility's Life Safety systems in the event of a power outage and increased the risk of injury to the patients. This affected 4 of 4 floors in Hospital B.

Findings:

During the record review with the Head Engineer (ENG 81), the weekly inspections for the two emergency generators in Hospital B were reviewed.

Hospital B:
On 1/13/14, at 2:15 P.M., the facility failed to provide records of weekly inspections for both emergency generators during the following weeks: 1/7/13, 1/14/13, 8/4/13, 10/11/13, 11/24/13 and for the month of September in 2013.

Based on observation, the facility failed to maintain electrical safety. This was evidenced by failing to properly install spliced wires and by electrical appliances equipment plugged into multi-plug surged protected power strips. This had the potential for increasing the risk of electrical fire and electrical shock that may result in the injury to patients, visitors, and staff. This affected 3 of 6 floors in Hospital A and 2 of 4 floors in Hospital B.

NFPA 72, National Fire Alarm Code, 1999 Edition
6-8.2.5.2 All conductors inside buildings shall be in conduit, electrical tubing, metal molding, or raceways. Installation shall be in accordance with NFPA 70, National Electrical Code.
6-8.2.5.3 Conductors shall have an approved insulation. The insulation or other outer covering shall be flame retardant and moisture resistant.
6-8.2.5.4 Conductors shall be installed as far as possible without joints. Splices shall be permitted only in listed junction or terminal boxes. Fire alarm circuits shall be identified by the use of red covers or doors and the words " municipal fire alarm circuit " shall be clearly marked on all terminal and junction locations to prevent unintentional interference. Wire terminals, terminal boxes, splices, and joints shall conform to NFPA 70, National Electrical Code.

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.
380-9. Provisions for Snap Switch Faceplates. (a) Position. Snap switches mounted in boxes shall have faceplates installed so as to completely cover the opening and seat against the finished surface.

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 a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the electrical equipments and devices were observed.

Sixth Floor, Hospital A:
1. On 1/13/2014, at 10:32 A.M., the fire alarm system cable conductors that were located above the ceiling tiles by Room 622 were observed to be spliced together with electrical splice screws. The cable conductors were not feed through a tubing or conduit, and the spliced cables were not in a junction or terminal box.

Third Floor, Hospital A:
2. On 1/14/2014, at 9:11 A.M., the electrical cable conductors that were connected to lights located on the Palm Trees by the Main Lobby were observed to be spliced together with electrical splice screws and were not in a junction or terminal box.


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During a tour of the facility with the Head Engineer (ENG 81), the electrical appliances were observed.

First Floor, Hospital B:
3. On 1/13/14 at 11:26 A.M., there was a microwave plugged into a multi-plug surged protected power strip, and a refrigerator and coffee pot plugged into another multi-plug surged protected power strips in the staff lounge of the Residential Treatment Center on the 1st floor.

Second Floor, Hospital B:
4. On 1/14/14 at 8:16 A.M., there was a refrigerator plugged into a multi-plug surged protected power strip in the rehab on the 2nd floor.

First Floor, Hospital A:
5. On 1/15/14 at 3:29 P.M., there was a microwave and water cooler unit plugged into a multi-plug surged protected power strip in the Engineer/Maintenance room on the 1st floor.

Based on observation, the facility failed to maintain doors to resist the passage of smoke and fire. This was evidenced by corridor doors with penetrations, corridor doors obstructed from closing or latching, and by not repairing door in accordance with applicable standards. This had the potential to allow the migration of smoke and fire, resulting in injury patients. This affected 2 of 6 floors in Hospital A, 1 of 2 floors in the Cottage of Hospital B, and 1 of 4 floors in Hospital B.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the corridor doors were observed.

Sixth Floor, Hospital A:
1. On 1/13/2014, at 10:24 A.M., the corridor door to Room 669 had four penetrations going through the door that measured approximately 1/4-inch each.

2. On 1/13/2014, at 10:25 A.M., the corridor door to Room 670 had four penetrations going through the door that measured approximately 1/4-inch each.

3. On 1/13/2014, at 10:26 A.M., the corridor door to Room 671 had four penetrations going through the door that measured approximately 1/4-inch each.

4. On 1/13/2014, at 10:27 A.M., the corridor door to Room 672 had four penetrations going through the door that measured approximately 1/4-inch each.
Third Floor, Hospital A:
5. On 1/13/2014, at 3:09 P.M., the corridor door to Room 365 had two penetrations going through the door that measured approximately 1/4-inch each.

6. On 1/13/2014, at 3:10 P.M., the corridor door to Room 66 had two penetrations going through the door that measured approximately 1/4-inch each.


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The Cottage at Hospital B:
7. On 1/13/14, at 3:45 P.M., there was tape over the holes left by the missing bolt and face-plate on the door to Room 10.

8. On 1/13/14, at 3:46 P.M., there was tape over the holes left by the missing bolt and face-plate on the door to Room 11.

9. On 1/13/14, at 3:55 P.M., the door to the library room had a broken frame and a gap between the frame and door leaf. The door was obstructed from closing due the broken door frame.

Hospital B:
10. On 1/14/14, at 9 A.M., the door to Room 337 failed to latch because the bolt and faceplate were missing. The area was covered with duct tape.

Based on observation and interview, the facility failed to maintain their smoke barrier walls. This was evidenced by penetrations in smoke barrier walls. This could result in the spread of smoke and fire, in the event of a fire. This affected 1 of 3 floors in the Senior Health Center.

Findings:

During a tour of the facility with the Head Engineer (ENG 81), the smoke barrier walls were observed.

Senior Health Center - Suite 202:
On 1/15/14, at 11:20 A.M., there were 3 penetrations in the smoke barrier wall by the reception area. The penetrations measured approximately 1/2 inch in diameter.

Based on observation, the facility failed to maintain their fire doors to prevent the passage of smoke or fire. This was evidenced by fire doors to stairwells and cross corridor fire doors that failed to close and positive latch. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the fire doors were observed.

Second Floor, Hospital A:
1. On 1/14/2014, at 10:19 A.M., the fire door to the North Stairwell by the Information System Office failed to close and positive latch. The door was observed to be equipped with a self-closure and latching mechanism.

Third Floor, Hospital A:
2. On 1/15/2014, at 2:14 P.M., 1 of 2 cross corridor fire doors by the Gift Shop failed to close and positive latch upon activation of the fire alarm system. The doors were observed to be equipped with automatic closing and latching mechanisms.

Based on observation, the facility failed to protect the corridor from hazardous areas. This was evidenced by no self-closing device on the doors to two Housekeeper Storage Rooms and a staff office. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff, in the event of a fire. This affected 1 of 4 floors in Hospital B and 1 of 2 floors in the Cottage of Hospital B.

National Fire Prevention Association 101, Life Safety Code 2000 Edition:
19.3.2.1 Hazardous Areas. Any Hazardous area shall be safe guarded by a fire barrier having a 1 -hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke -resisting partitions and doors. The doors shall be self-closing or automatic closing. Hazardous shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square ft (9.3 square m)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square ft (4.6 square m), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory-or field -applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a tour of the facility with the Head Engineer (ENG 81), corridor rooms were observed.

Hospital B
1. On 1/13/14, at 11:20 A.M., there were 2 environmental storage rooms not equipped with self-closure devices. The rooms stored flammable cleaning supplies and paper-products.

Second Floor, The Cottage at Hospital B:
2. On 1/13/14 at 3:40 P.M., the door to the Manager's office on the 2nd floor, had self-closure-device arms that were unattached to the door leaf. The self-closure device failed to self-close. The room stored approximately over 45 gallons of motor oil and other flammable liquids in a unlocked/open flammable NFPA rated cabinet.

Based on observation, the facility failed to ensure that a safe means of egress was maintained from the bedrooms. This was evidenced by a door to a patient's sleeping room that would not readily open from inside the room. This had the potential to delay evacuation during an emergency, resulting in injury to patients and staff. This affected 1 of 6 floors at Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the doors were observed.

Third Floor, Hospital A:
On 1/13/2014, at 1:53 P.M., the door to Patient Room 341 was observed to not unlatch when turning the door knob from inside the room.

Based on observation, the facility failed to maintain illumination on its means of egress as evidenced by lighting units that failed to illuminate. This could cause delay in evacuation due to low or no viability, and result in injury to patients, visitors, and staff. This affected 3 of 6 floors in Hospital A, 4 of 4 floors in Hospital B, and 1 of 2 floors in the Cottage of Hospital B.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the lighting units throughout the means of egress were observed.

Fifth and Fourth Floors, Hospital A:
1. On 1/13/2014, at 10:49 A.M., on the 5th and 4th Floors in the North Stairwell, two lighting fixtures with two light bulbs each did not illuminate and left the means of egress in darkness.

Third Floor, Hospital A:
2. On 1/13/2014, at 11:29 A.M., on the 3rd Floor in the South Stairwell, the light bulbs to the lighting fixture did not illuminate and left the means of egress in darkness.

3. On 1/13/2014, at 11:50 A.M., on the 3rd Floor in the North Stairwell, the light bulbs to the lighting fixture did not illuminate and left the means of egress in darkness.

4. On 1/13/2014, at 1:14 P.M., on the 3rd Floor in the stairwell used as an exit from the 4-East North Wing, the light bulbs to the lighting fixture did not illuminate and left the means of egress in darkness.


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The Cottage at Hospital B:
5. On 1/13/14, at 3:28 P.M., the exit egress light by the staircase landing failed to illuminate the area. The 2 lights bulbs were out.

Hospital B:
6. On 1/14/14, at 9:10 A.M., the exit egress lights in the North stairwell basement level failed to illuminate the area. The light bulbs were out.

7. On 1/14/14, at 9:19 A.M., the exit egress lights in the South stairwells of floor 2 and 3 failed to illuminate the area. The light bulbs were out.

Based on observation and record review, the facility failed to maintain the emergency lights. This was evidenced by emergency lights that failed to illuminate and by no documentation for checking the emergency lights that failed on a monthly basis and for 90-minutes annually. This could result in injury during an emergency evacuation and in the event of a power outage. This affected 1 of 6 floors in Hospital A and the MRI Trailer of Hospital A.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the records for the testing of the emergency lights were requested and the emergency lights were observed.

MRI Trailer, Hospital A:
1. On 1/14/2014, at 9:06 A.M., the battery powered lighting unit connected to an exit sign, located by the exit door to the MRI Trailer, failed to illuminate when pushing down on the test button.

Second Floor, Hospital A:
2. On 1/14/2014, at 10:07 A.M., the two battery powered lighting units located in the Pharmacy failed to illuminate when pushing down on their test buttons.

3. On 1/16/2014, at 11:13 A.M., there was no records that showed that the battery powered emergency lights that failed in the MRI Trailer and in the Pharmacy had been checked monthly or had been tested annually for 90-minutes.

Based on observation and interview, the facility failed to instruct their staff on their role in a fire and emergency procedures. This was evidenced by the staff's lack of familiarity with the trouble alarms on the fire alarm panel and knowledge on the type of fire alarm notification system installed in the facility. This could result in facility staff to not accomplish all of the tasks required of him or her during conditions that is expected to exist in the event of a fire and the increased risk of injury to the patients and staff. This affected the Senior Health Center and Hospital B.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During tour of the facility with the Head Engineer (ENG 81), staffs were interviewed on their knowledge of fire and emergency procedures of their facility.

Hospital B:
1. There were written instructions on how to respond to the fire alarm panel alarms in a training folder at the Security desk by entrance of the hospital; the instruction failed to address who should reset the trouble alarm.
On 1/14/14 at 2:38 P.M., Public Safety Officer 1 (STAFF 86) was interviewed and he stated that if the fire alarm panel trouble lights activated, he would investigates and resets the trouble alarm on the panel.
On 1/15/14 at 2:15 P.M., the Public Safety Manager (STAFF 83) was interviewed and he stated that only Engineers can reset the trouble signal from the fire alarm panel, and it is written in the safety training folder at the security desk. Public Safety Manager failed to provide documents that only Engineers could reset the trouble alarm of the fire alarm panel.

Senior Health Center:
2. The Senior Health Center building is not equipped with pull stations and fire alarm system.
On 1/15/14, at 11:56 A.M., the receptionist (STAFF 84) was interviewed and she stated that for a fire in the building, she would activate the pull station.
At 12:01 P.M., the Medical Assistant (STAFF 85) was interviewed and she stated that if a fire broke out in the building, she would activate the pull station to notify staff.
Both staff failed to familiarize themselves with the notifications system of the building.

Based on observation and interview, the facility failed to provide a fire alarm system in accordance with NFPA 101, 2000 edition. This was evidenced by a fire alarm system installed in a business occupancy using four smoke detectors as notification devices, which were not providing signal alert notification to all occupants and all areas of the building. This affected 3 of 3 floors of Senior Health Center Building and could in result in delay in the evacuation of the building during fire or other emergencies.

NFPA 101, Life Safety Code, 2000 Edition
39.3.4.1 General. A fire alarm system in accordance with Section 9-6 shall be provided in any business occupancy where any one of the following conditions exits.
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
39.3.4.2 Initiation. Initiation of the required fire alarm system shall be by manual means in accordance with 9.6.2.1(1).
Exception No. 1: Initiation shall be permitted by means of an approved automatic fire detection system in accordance with 9.6.2.1(2) that provides protection throughout the building.
Exception No. 2: Initiation shall be permitted by means of an approved automatic sprinkler system in accordance with 9.6.2.1(3) that provides protection throughout the building.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-1.4.2.1 Total (Complete) Coverage. If required, total coverage shall include all rooms, halls, storage areas, basements, attics, lofts, spaces above suspended ceilings, and other subdivisions and accessible spaces; and the inside of all closets, elevator shafts, enclosed stairways, dumbwaiter shafts, and chutes. Inaccessibly areas shall not be required to be protected by detectors.

Findings:

During a tour of the facility on 1/15/14 with the Head Engineer of Hospital B, the fire alarm system in the Senior Health Center building, Suite #202 was observed. The building is a 3 story, non- sprinklered, with exit discharge on the 1st floor level. The first floor is used as a parking garage, elevator lobby and discharge from stairways.
On 1/15/14 at 11:40 A.M., the Supervisor (STAFF 89) was interviewed and stated that the facility occupancy is over 100 patients per day depending on the number of doctors seeing patients. During the tour of the facility with Head Engineer (ENG 81), smoke detectors were observed in the Medical Records room, in the lobby area, over the receptionist desk, and in the laboratory room. There were no smoke detectors observed in the Doctors examination rooms and offices, employees area and hazardous material room. There was no notification device found in the area where no smoke detectors were installed to notify occupant of fire in the facility.

Based on observation and interview, the facility failed to ensure that the fire alarm system was properly maintained in accordance with NFPA 101, 2000 edition. This was evidenced by the fire alarm not heard throughout all occupied spaces. This had the potential for occupants to not be notified of a fire in the building, increasing the risk for injury. This affected 2 of 6 floors at Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) and the Fire Alarm Technician (VEND 78) from 1/13/2014 through 1/16/2014, the fire alarm system was tested and observed.

Third Floor, Hospital A:
1. On 1/15/2014, at 2:33 P.M., the fire alarm was not heard throughout the corridor by the ambulance entrance when the fire alarm system was activated. There was an audible notification device installed in the area that was not alarming when two fire alarm pull stations were activated in the area at 2:32 P.M. and 2:36 P.M. The Fire Alarm Technician acknowledged that the audible notification device was not functioning.

Second Floor, Hospital A:
2. On 1/15/2014, at 3:02 P.M., the fire alarm was not heard throughout the corridor by the Health Information Management Office when the fire alarm system was activated. Two staff were interviewed in the area and they both stated that they could not hear the fire alarm. There were no audible or visual notification device installed in the area.

Based on observation, review of records and interview, the facility failed to ensure that the smoke detectors were maintained in a reliable operating condition. This was evidenced by 4 of 4 smoke detectors that had no record of sensitivity testing and maintenance. This could result in failure to notify the building occupants of a fire in the facility and cause delay in evacuation.


Findings:

Senior Health Center
During the tour of the facility with Head Engineer (ENG 81), the fire alarm system in the Senior Health Center, located on the 2nd floor, was observed. There was a smoke detector in the Medical Records room, in the lobby area, over the receptionist desk, and in the laboratory room.

On 1/15/14 at 11:35 A.M., there were no recorded documents of a sensitivity test and function test for the four detectors installed in the suite. On 1/15/14 at 11:40 A.M., the Supervisor (STAFF 89) was interviewed and stated that the Senior Health Center sees approximately 100 patients depending on the number of Doctors seeing patients. During interview with the Corporate Director of Plant Operations (DIR 77), he confirmed that there were no records for sensitivity testing and functional testing of the smoke detectors.

Based on observation and interview, the facility failed to maintain their sprinkler system in a reliable operating condition. This was evidenced by Supervisory Valves not constantly monitored at the facility or a remote location, and by a broken supervisory valve. This could result in facility's staff unaware of any trouble with sprinkler system and possible failure of the sprinkler system, in the event of a fire. This affected the Cottage of Hospital B and the RTC (Residential Treatment Center) building of Hospital B.

NFPA 101 (2000 Edition) 9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 72 (1999 Edition) 1-5.4.4 Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

NFPA 72 (1999 Edition) 3-8.3.3.1 General. The provisions of 3-8.3.3 shall apply to the monitoring of sprinkler systems, other fire suppression systems, and other systems for the protection of life and property for the initiation of a supervisory signal indicating an off-normal condition that could adversely affect the performance of the system.

Findings:

During the facility tour with the Head Engineer (ENG 81), the automatic sprinkler system devices were observed and tested.

Hospital B:
On 1/14/14, from 9:41 to 9:44 A.M., the supervisory valve on the main riser for the RTC building area failed to alarm and send a signal to the monitored fire alarm panel on facility's ground and the monitoring company when tested.

The Cottage at Hospital B:
On 1/13/14 at 3:50 P.M., the supervisory valve on main riser failed to send a signal to the monitored fire alarm panel in the main building, but sent a signal to the unmonitored fire alarm panel in the cottage.

On 1/16/17 at 9:55 A.M., during interview with the Corporate Director of Plant Operations (DIR 77), he stated due to the age of the sprinkler system, the supervisory valve is not equipped with the ability to be monitored by the fire alarm panel in the main building or the remote monitoring company.

Based on observation, interview, and record review, the facility failed to maintain their automatic sprinkler system. This was evidenced by no current 5-year certification that showed that the required maintenance and testing was completed for all buildings, by sprinklers with debris and corrosion, sprinklers installed at distance less than the minimum allowed from each other, sprinklers with missing escutcheon rings, and by a dislodged sprinkler escutcheon plate with cables installed through the same opening as the sprinkler. Sprinkler heads and scutcheon rings are listed to respond to a calculated ceiling temperature and a missing or detached escutcheon ring could allow heat and smoke to affect other areas in the building and cause failure of the sprinkler system in the event of a fire. This affected 6 of 6 floors in Hospital A, the Boiler Building of Hospital A, the Generator Building of Hospital A, and 1 of 4 floors of Hospital B.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
5-6.3.4 Minimum Distance Between Sprinklers. Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
2.2.1.1 Sprinklers shall be 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, loaded, or in the improper orientation.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.2 Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
3-3 Testing. The tests shall be conducted by a qualified person. (See Section 1-5.)
1-5 Definitions:
Inspection, Testing, and Maintenance Service. A service program provided by a qualified contractor or owner's representative in which all components unique to the property's systems are inspected and tested at the required times and necessary maintenance is provided. This program includes logging and retention of relevant records.
Qualified. Having adequate knowledge of the installation, construction, or operation of apparatus and the hazards involved.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the sprinkler system was observed and maintenance records were requested.

Sixth Floor, Hospital A:
1. On 1/13/2014, at 9:54 A.M., the sprinkler head, located in Room 619, had accumulation of debri on its fusible link and deflector.

2. On 1/13/2014, at 10:00 A.M., two sprinkler heads, located in Room 634, were installed approximately 4-inches from each other. Both sprinkler heads were connected to water lines.

Fifth Floor, Hospital A:
3. On 1/13/2014, at 10:51 A.M., the sprinkler head, located in Room 534, had accumulation of debri on its fusible link and deflector.

Fourth Floor, Hospital A:
4. On 1/13/2014, at 11:27 A.M., the sprinkler head, located in the Shower Room next to Room 453, had corrosion around the sprinkler and on the escutcheon ring.

5. On 1/13/2014, at 11:31 A.M., the sprinkler head, located in Room 453, had accumulation of debri on its fusible link and deflector.

6. On 1/13/2014, at 11:35 A.M., the sprinkler head, located in Room 460, had accumulation of debri on its fusible link and deflector.

Third Floor, Hospital A:
7. On 1/14/2014, at 8:50 A.M., the sprinkler head, located in Rooms 4 and 5 in the Emergency Department, had accumulation of debri on its fusible link and deflector.

8. On 1/14/2014, at 8:52 A.M., the sprinkler head, located in the Shower Room to Rooms 10 in the Emergency Department, was missing an escutcheon ring.

9. On 1/14/2014, at 9:09 A.M., the sprinkler head, located in the Electric Room by the Main Lobby entrance, was missing an escutcheon ring.

Second Floor, Hospital A:
10. On 1/14/2014, at 10:22 A.M., the two sprinkler heads, located in the Information Systems Office, had accumulation of debri on their fusible links and deflectors.

Fourth Floor, Hospital A:
11. On 1/15/2014, at 11:49 A.M., the sprinkler head, located by the handwash area in the Special Care Nursery, had corrosion on its fusible link.

Boiler Building and Generator Building, Hospital A:
12. On 1/16/2014, at 2:52 P.M., the Corporate Director of Plant Operations (DIR 77) stated that the facility did not have a 5-year certification of the sprinkler system for the Boiler Building and the Generator Building. There was no record that showed that the proper maintenance and testing had been performed within the past 5 years and the risers did not contain a 5-year certificate tag or label when observed on 1/15/2014 at 10 A.M.

West Wing, Hospital A:
13. On 1/16/2014, at 3:10 P.M., the fire sprinkler control valves located in the Mechanical Equipment Room did not have a 5-year certificate tag or label on 3 of 4 risers. The three risers without the 5-year certificate were labeled for 1st Floor West Wing, 2nd Floor West Wing, and 3rd Floor West Wing. The vendor's inspection report stated that the gauges need replacement or calibration.


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First Floor, Hospital B:
14. On 1/13/14, at 11:34 A.M., 3 of 4 sprinklers escutcheon rings in the Medical Records office, on 1st floor, was dislodged and not flush to the ceiling. The penetrations behind the sprinkler escutcheon rings had cable cords running through them.

Based on record review, the facility failed to ensure that areas with flammable materials had warning signs to prevent fire. This was evidenced by a smoking policy that did not include provisions to prohibit smoking where flammable liquids, combustible gases and oxygen are used and stored. This could have the potential for causing fire, resulting in injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
19.7.4 Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) Smoking by patients classified as not responsible shall be prohibited.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the smoking policy was reviewed.

Hospital A:
On 1/14/2014, at 6:14 P.M., the smoking policy titled "86100-011 SMOKING, NON-SMOKING" did not contain the requirement of prohibiting smoking where flammable liquids, combustible gases and oxygen are used and stored. The facility was observed to have a portable supply of medical oxygen.

Based on observation, the facility failed to ensure that all means of egress were continuously maintained free of obstructions to full instant use in the case of fire or other emergency. This was evidenced by medication dispensing units that were not properly secured. This could result in a delay in evacuation in the event of a fire, or other emergency. This affected 1 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.2.2 There shall be no obstructions by railings, barriers, or gates that divide the open space into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment.

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the egress paths were observed.

Third Floor, Hospital A:
On 1/13/2014, at 9:54 A.M., there were two Pyxis Supply Stations in the corridor by the exit door to the Angio Room in the Imaging Department that were not anchored to prevent them from tipping over. The height of the unsecured medication dispensing units were approximately 6-feet each.

Based on observation and interview, the facility failed to ensure that soiled linen containers were not exceeding 32 gallons. This was evidenced by the oversized soiled linen container stored by the service elevators lobby area. This could posed a danger of fire with a container over the allowed capacity in the corridor during fire. This affected 2 of 4 floors in Hospital B.

Findings:

During the facility tour with the Head Engineer (ENG 81), the linen carts were observed.

Second Floor, Hospital B:
On 1/14/14 at 8:06 A.M., there was a soiled linen cart, greater than 32 gallons storage capacity, stored across from the elevator in the elevator room on the 2nd floor. The cart measured 28 inches by 47 inches, and a height of 68 inches.

Third Floor, Hospital B:
On 1/14/14 at 8:50 A.M., there was a soiled linen cart, greater than 32 gallons storage capacity, stored across from the elevator in the elevator room on the 3rd floor. The cart measured 28 inches by 47 inches, and a height of 68 inches.

Based on record review, the facility failed to maintain the emergency generator. This was evidenced by the facility failure to provide complete records for the weekly inspections on the emergency generators for 9 of 52 weeks. This could result in the failure of the emergency generator to provide power to the facility's Life Safety systems in the event of a power outage and increased the risk of injury to the patients. This affected 4 of 4 floors in Hospital B.

Findings:

During the record review with the Head Engineer (ENG 81), the weekly inspections for the two emergency generators in Hospital B were reviewed.

Hospital B:
On 1/13/14, at 2:15 P.M., the facility failed to provide records of weekly inspections for both emergency generators during the following weeks: 1/7/13, 1/14/13, 8/4/13, 10/11/13, 11/24/13 and for the month of September in 2013.

Based on observation, the facility failed to maintain electrical safety. This was evidenced by failing to properly install spliced wires and by electrical appliances equipment plugged into multi-plug surged protected power strips. This had the potential for increasing the risk of electrical fire and electrical shock that may result in the injury to patients, visitors, and staff. This affected 3 of 6 floors in Hospital A and 2 of 4 floors in Hospital B.

NFPA 72, National Fire Alarm Code, 1999 Edition
6-8.2.5.2 All conductors inside buildings shall be in conduit, electrical tubing, metal molding, or raceways. Installation shall be in accordance with NFPA 70, National Electrical Code.
6-8.2.5.3 Conductors shall have an approved insulation. The insulation or other outer covering shall be flame retardant and moisture resistant.
6-8.2.5.4 Conductors shall be installed as far as possible without joints. Splices shall be permitted only in listed junction or terminal boxes. Fire alarm circuits shall be identified by the use of red covers or doors and the words " municipal fire alarm circuit " shall be clearly marked on all terminal and junction locations to prevent unintentional interference. Wire terminals, terminal boxes, splices, and joints shall conform to NFPA 70, National Electrical Code.

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.
380-9. Provisions for Snap Switch Faceplates. (a) Position. Snap switches mounted in boxes shall have faceplates installed so as to completely cover the opening and seat against the finished surface.

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 a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with the Chief Financial Officer (CFO 72) from 1/13/2014 through 1/16/2014, the electrical equipments and devices were observed.

Sixth Floor, Hospital A:
1. On 1/13/2014, at 10:32 A.M., the fire alarm system cable conductors that were located above the ceiling tiles by Room 622 were observed to be spliced together with electrical splice screws. The cable conductors were not feed through a tubing or conduit, and the spliced cables were not in a junction or terminal box.

Third Floor, Hospital A:
2. On 1/14/2014, at 9:11 A.M., the electrical cable conductors that were connected to lights located on the Palm Trees by the Main Lobby were observed to be spliced together with electrical splice screws and were not in a junction or terminal box.


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During a tour of the facility with the Head Engineer (ENG 81), the electrical appliances were observed.

First Floor, Hospital B:
3. On 1/13/14 at 11:26 A.M., there was a microwave plugged into a multi-plug surged protected power strip, and a refrigerator and coffee pot plugged into another multi-plug surged protected power strips in the staff lounge of the Residential Treatment Center on the 1st floor.

Second Floor, Hospital B:
4. On 1/14/14 at 8:16 A.M., there was a refrigerator plugged into a multi-plug surged protected power strip in the rehab on the 2nd floor.

First Floor, Hospital A:
5. On 1/15/14 at 3:29 P.M., there was a microwave and water cooler unit plugged into a multi-plug surged protected power strip in the Engineer/Maintenance room on the 1st floor.