HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by an unsealed wall penetration. This affected one of three floors in the Dominican Campus and could result in the faster spread of fire and smoke, in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in.
(6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.

8.2.1 Construction. Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided

8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with staff on 10/16/14, the walls and ceilings were observed.

DOMINICAN CAMPUS
ENDOSCOPY:

1. On 10/16/14, at 9:45 a.m., there was an approximately 1/2 inch penetration in the wall, around a cable wire, in the Physician Dictation Room.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, by doors that were obstructed from closing, and by doors with impaired self-closing hardware. This affected five of eight floors in the Main Tower and one of four floors in the Pavilion. This could result in the inability to contain a fire and consequently cause the faster spread of smoke and fire throughout the buildings.

NFPA 101, Life Safety Code, 2000 Edition
18.3.6.3.1 Doors protecting corridor openings shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.

18.3.6.3.2 Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the doors were observed.

MAIN TOWER
SIXTH FLOOR:

1. On 10/14/14, at 2:34 p.m., the self-closing door to the housekeeping closet, Room 6039, failed to latch.

THIRD FLOOR:

2. On 10/14/14, at 3:50 p.m., the self-closing door to the Clean Equipment Room, Room 3073, failed to latch.

GROUND LEVEL:

3. On 10/15/14, at 9:06 a.m., the self-closing door to the Emergency Department Decontamination Room, Room 1067, failed to latch.


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SECOND FLOOR:

4. On 10/15/14, at 9:16 a.m., the door to Room 2030 was equipped with a self-closing device. The door failed to positively latch when fully opened and released.

5. On 10/15/14, at 9:34 a.m., the door to Room 2135 was equipped with a self-closing device. The door failed to positively latch when fully opened and released.

6. On 10/15/14, at 9:34 a.m., the double doors by the elevator lobby failed to close and latch when tested. During an interview, Facilities staff 1 stated that a work order had already been submitted to repair the doors.

GARDEN LEVEL:

7. On 10/15/14, at 10:58 a.m., the door to the Beverage Storage Room, Room 0117, was obstructed from closing by a box.

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PAVILION
FIRST FLOOR CLINICS:

8. On 10/15/14, at 11:35 a.m., the door to Storage Room 158, in Radiology, was equipped with a self-closing device. The door failed to positively latch when fully opened and released.

9. On 10/15/14, at 11:41 a.m., the door to Room 170 was equipped with a self-closing device. The door failed to positively latch when fully opened and released. The self-closing device was disconnected and failed to function.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch and by doors with impaired self-closing hardware. This affected one of one smoke compartments in the Cancer Center and one of three floors in the Dominican Campus. This could result in the inability to contain a fire and consequently cause the faster spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the doors were observed.

CANCER CENTER:

1. On 10/15/14, at 4:10 p.m., the door to a doctor's office, near the breakroom, was equipped with a self-closing device. The self-closing device was disconnected and no longer functioned.

DOMINICAN CAMPUS
PHYSICAL THERAPY:

2. On 10/16/14, at 9:21 a.m., the door to the Gym Room was equipped with a self-closing device. The door failed to positively latch when fully opened and released.

Based on observation and interview, the facility failed to ensure that access to exits were marked by readily visible signs. This was evidenced by exit signs that were oriented such that they could not be viewed from a main corridor, where the exit pathway was not readily apparent. This affected one of eight floors in the Main Tower and could result in a delay in evacuation, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
18.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

7.10.1.2 Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.4 Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, exits were observed for approved, readily visible signage.

MAIN TOWER
GROUND LEVEL:

1. On 10/16/14, at 9:15 a.m., there was an approximately 15 foot corridor coming off of the east Emergency Department (ED) corridor. At the end of the 15 foot corridor were two doors, one on each side. One door lead to an exit through the ED lobby and the other was an office door. There were two exit signs in the corridor between the two doors. The signs were directly facing the doors such that only the sides of the two exit signs were visible from the east ED corridor. There was no exit sign visible from the east ED corridor directing egress through the ED lobby door.

During an interview at 9:16 a.m., Engineering Staff 1 stated that one of the signs present directed egress from the ED lobby to the east ED corridor and the other was directing egress for persons in the office. Engineering Staff 1 confirmed that the pathway through the ED lobby was considered an emergency exit and that only the sides of the installed exit signs were visible from the east ED corridor.

Based on observation, the facility failed to maintain the rated doors in their smoke barrier separations. This was evidenced by smoke barrier doors that were obstructed from closing and by smoke barrier doors that failed to latch. This affected four of eight floors in the Main Tower, and could result in the faster spread of fire and smoke from one smoke compartment to another.

NFPA 101, Life Safety Code, 2000 Edition
18.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

4.6.12 Maintenance and Testing
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
2-4.1 Closing Devices
2-4.1.2 A closing device shall be installed on every fire door.
Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4 All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the smoke barrier doors were observed and tested.

MAIN TOWER
SEVENTH FLOOR:

1. On 10/15/14, at 2:25 p.m., Smoke Barrier Door DHW5, located across from Room 7074, released from the magnetic hold-open device upon activation of the fire alarm system. The door dragged on the floor and failed to fully close and latch.


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FOURTH FLOOR:

2. On 10/15/14, at 2:40 p.m., Smoke Barrier Door DHW5, next to Room 4021, released from the magnetic hold-open device upon activation of the fire alarm system. The door dragged on the floor immediately upon release and remained fully open.

GROUND LEVEL:

3. On 10/15/14, at 3:20 p.m., Smoke Barrier Door GLDHW4, across from Endoscopy, released from the magnetic hold-open device upon activation of the fire alarm system. The door failed to latch upon closure.

GARDEN LEVEL:

4. On 10/15/14, at 3:37 p.m., Smoke Barrier Door GDHW7, near PBX, released from the magnetic hold-open device upon activation of the fire alarm system. The door failed to latch upon closure.

Based on observation and interview, the facility failed to maintain their emergency lighting. This was evidenced by battery-powered emergency lighting units that failed to illuminate when tested. This affected one of three floors in the Dominican Campus. This deficient practice could result in the failure to have adequate lighting, in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.2.4 Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code®.

7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the emergency lights were observed.

DOMINICAN CAMPUS
ENDOSCOPY:

1. On 10/16/14, at 8:58 a.m., one of two battery-powered emergency lighting units, in the Kohler Generator enclosure, failed to illuminate when tested by Engineering Staff 2. The Kohler Generator supplies power to the Endoscopy Unit in the event of a power outage.

During an interview at 9:08 a.m., Engineering Staff 2 stated that the emergency lighting unit needed a new battery.


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PHYSICAL THERAPY:

2. On 10/16/14, at 9:16 a.m., the battery-powered emergency lighting unit, across from the reception desk in Occupational Therapy, failed to illuminate when tested.

Based on observation, the facility failed to maintain their emergency lighting units. This was evidenced by one battery-powered emergency lighting unit that failed to illuminate when tested. This affected the penthouse of the Main Tower. This deficient practice could result in the failure to have adequate lighting, in the event of a power outage and generator failure.

NFPA 101, Life Safety Code, 2000 Edition
18.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.2.4 Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code®.

7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the emergency lighting units were observed.

MAIN TOWER
PENTHOUSE:

1. On 10/14/14 at 2:11 p.m., the battery-powered emergency lighting unit, near the Elevator Machine Room, failed to illuminate when tested.

Based on document review, the facility failed to ensure that fire drills were conducted quarterly on each shift. This was evidenced by no records of a NOC shift fire drill during one of four quarters in the past 12 months. This affected all patients and staff in the Main Tower and could result in a delayed staff response to a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition
18.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
The provisions of 18.7.1.2 through 18.7.2.3 shall apply.
18.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review with staff from 10/13/14 to 10/16/14, the facility's fire drill documents were reviewed.

MAIN TOWER:

1. On 10/13/14 at 2:12 p.m., there were no records indicating that a NOC shift fire drill was conducted during the first quarter (January to March) of 2014.

Based on observation, record review, and interview, the facility failed to maintain their fire alarm system. This was evidenced by no records of annual testing of the fire alarm system at the Cancer Center and by an ongoing trouble signal at the fire alarm panel at the Dominican Campus. This affected one of one smoke compartments in the Cancer Center and three of three floors at the Dominican Campus. This could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

4.1.1 Fire and Similar Emergency. The goal of this Code is to provide an environment for the occupants that is reasonably safe from fire and similar emergencies by the following means:
(1) Protection of occupants not intimate with the initial fire development
(2) Improvement of the survivability of occupants intimate with the initial fire development.

4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-6.3 Records. A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.

7-1.6.2.1 Reacceptance testing shall be performed after any of the following:
(1) Added or deleted system components
(2) Any modification, repair, or adjustment to system hardware or wiring
(3) Any change to site-specific software.
All components, circuits, systems operations, or site-specific software functions known to be affected by the change or identified by a means that indicates the system operational changes shall be 100 percent tested. In addition, 10 percent of initiating devices that are not directly affected by the change, up to a maximum of 50 devices, also shall be tested, and correct system operation shall be verified. A revised record of completion in accordance with 1-6.2.1 shall be prepared to reflect any changes.

7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Table 7-3.2 Testing Frequencies

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the fire alarm system was observed and testing records were requested.

CANCER CENTER:

1. On 10/15/14, at 8:25 a.m., there were no records of an annual test and inspection of the fire alarm control panel and all associated components. The Cancer Center was equipped with an externally monitored fire alarm system connected to initiation devices, notification devices, and supervisory switches. There were no records of an annual test and inspection of the fire alarm system.

DOMINICAN CAMPUS:

2. On 10/16/14, at 9:30 a.m., there was trouble signal at the fire alarm control panel. The monitor on the panel stated "Card 7. Interface Part A. Abnormal."

During an interview at 9:31 a.m., Engineering Staff 1 stated that when an old telephone line was removed approximately 3 months ago, the panel went into trouble. The vendor came out last week to inspect the trouble signal and stated that the panel was missing an ethernet card.

Based on record review, the facility failed to maintain their fire alarm system. This was evidenced by no records of testing and inspection for 15 fire alarm system initiating devices at the Pavilion. This affected four of four floors in the Pavilion. This could result in a malfunctioning fire alarm system, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
18.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Table 7-3.2 Testing Frequencies

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the fire alarm system was observed and testing records were requested.

PAVILION:

On 10/16/14, at 1:53 p.m., records showed that the annual test and inspection of the fire alarm system at Pavilion was conducted over the course of several days in January and February of 2014. The records showed that not all of the initiating devices were tested.

The following devices were not tested and inspected during the annual certification of the fire alarm system:

1. Smoke Detector N04L01D012 in the fourth floor elevator shaft
2. Smoke Detector N04L01D014 in the fourth floor elevator lobby
3. Smoke Detector N02L01D003 in the second floor elevator lobby
4. Smoke Detector N02L01D018 in the second floor elevator lobby
5. Smoke Detector N02L01D005 in the second floor elevator equipment room
6. Smoke Detector N02L01D006 in the second floor elevator shaft
7. Smoke Detector N01L01D003 in the first floor elevator lobby
8. Smoke Detector N01L01D005 near Elevator 1 and Elevator 2 fire door on the first floor
9. Smoke Detector N01L01D075 in Corridor S 109 near the Elevator 3 lobby on the first floor
10. Smoke Detector N01L01D076 in the first floor Discharge Elevator lobby
11. Smoke Detector N01L01D090 in the first floor elevator equipment room
12. Smoke Detector N01L02D072 in Room 104B, inside Data Room 104, on the first floor
13. Smoke Detector N01L02D140 in the Med Gas Bottle Room on the first floor
14. Duct Detector N03L01D003 in the third floor elevator lobby
15. Duct Detector (no "address" listed on the paperwork) in the second floor elevator lobby.

No other records were provided showing when these 15 fire alarm system initiating devices were last tested and inspected.

Based on observation, record review, and interview, the facility failed to maintain their smoke detection system. This was evidenced by incomplete smoke detector sensitivity testing records for Dominican Campus, a smoke detector that was missing a cover at the Endoscopy Unit at Dominican Campus, and by no records of sensitivity testing for the smoke detector at the Cancer Center. This affected three of three floors at Dominican Campus and one of one smoke compartments at Cancer Center. This could result in a delay in the automatic detection of smoke, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.5.1 Corridors. An approved automatic smoke detection system shall be installed in all corridors of limited care facilities. Such system shall be in accordance with Section 9.6.
Exception No. 1: Where each patient sleeping room is protected by an approved smoke detection system, and a smoke detector is provided at smoke barriers and horizontal exits in accordance with Section 9.6, the
corridor smoke detection system shall not be required on the patient sleeping room floors.
Exception No. 2: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the smoke detection system was observed and maintenance records were requested.

DOMINICAN CAMPUS:

1. On 10/15/14, at 8:20 a.m., records of smoke detector sensitivity testing were provided. The records consisted of a list of detectors tested from 1/30/14 to 2/12/14 and the results of the testing. The record did not include a signature of the technician and vendor who performed the test.

During an interview at 8:21 a.m., Engineering Staff 1 stated that he could not find the signature page but he knew the vendor who conducted the testing. The complete document with the signature page was not provided during the survey.

ENDOSCOPY:

2. On 10/16/14, at 9:40 a.m., the smoke detector in the environmental services closet was missing a cover pate.

CANCER CENTER:

3. On 10/15/14, at 8:24 a.m., there were no records of smoke detector sensitivity testing provided. The Cancer Center was equipped with one smoke detector, located near the fire alarm control panel, and there were no records showing that it was tested for smoke sensitivity.

.
PAVILION:

10. On 10/15/14, at 4:47 p.m., the Inspector's Test Valve in the second floor stairwell landing was tested. The alarms inside the buildings were activated but the exterior sprinkler alarm bell, located outside the fire pump room, failed to alarm.

During an interview at 4:48 p.m., Engineering Staff 1 confirmed that the bell was designed to alarm upon activation of the sprinkler alarm valves.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinkler heads that were loaded with debris, by one sprinkler head that was missing an escutcheon ring, by the failure to maintain a minimum 18 inch clearance around one sprinkler head deflector, and by a sprinkler waterflow alarm bell that failed. These deficient practices affected three of eight floors in the Main Tower and four of four floors at the Pavilion. This could result in a malfunctioning automatic sprinkler system, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
18.3.5.1 Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.


NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition.
5-5.3.4 Minimum Distance Between Sprinklers. A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated the section for each type or style of sprinkler.

5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1:Where other standards specify greater minimums, they shall be followed.
Exception No.2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition.
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.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

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.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the automatic sprinkler system was observed and maintenance records were requested.

MAIN TOWER
GROUND LEVEL:

1. On 10/15/14, at 10:20 a.m., the electrical closet in the back of the Cath Lab, Room 1207, was observed. The sprinkler head in the closet was missing an escutcheon ring and had orange-colored plastic caps around the studs.

During an interview at 10:21 a.m., Engineering Staff 1 stated that the caps were part of the packaging designed to protect the sprinkler heads while being shipped. He stated that the caps should have been removed upon installation of the head.


31201

.
SECOND FLOOR:

2. On 10/15/14, at 9:25 a.m., there was an accumulation of dust and debris on the sprinkler head, in the Staff Locker Bathroom, Room 2075.

3. On 10/15/14, at 9:26 a.m., there was an accumulation of dust and debris on the sprinkler head, in the Staff Locker Bathroom, Room 2076.

4. On 10/15/14, at 9:30 a.m., there was an accumulation of dust and debris on the sprinkler head in Room 2101.

During an interview, Facilities Staff 1 stated that the dust on the sprinkler head accumulated due to a nearby air vent.

5. On 10/15/14, at 9:32 a.m., there was an accumulation of dust and debris on the sprinkler head in Room 2098.

GROUND FLOOR:

6. On 10/15/14, at 9:49 a.m., there was an accumulation of dust and debris on the sprinkler heard in Room 1136.

7. On 10/15/14, at 9:57 a.m., there was an accumulation of dust and debris on three of five sprinkler heads in Room 1119.

GARDEN LEVEL:

8. On 10/15/14, at 10:09 a.m., there was an accumulation of dust and debris on one of three sprinkler heads in Room 0332.

9. On 10/15/14, at 10:47 a.m., there was a box stored approximately 8 1/2 inches below the sprinkler deflector in Room 0148. The sprinkler did not have 18 inches of clearance.

Based on record review and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by no records of testing the backflow prevention assemblies in 2013 at the Main Tower, Pavilion, Dominican Campus, and Cancer Center. This was also evidenced by no sprinkler inspection records for two of four quarters at the Dominican Campus. These deficient practices affected three of three floors at the Dominican Campus and the backflow prevention assemblies at all four buildings. This could result in a delay in a malfunctioning automatic sprinkler system, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

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.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

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.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

Table 9-1 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance indicates that backflow prevention assemblies are required to be tested annually in accordance with Section 9-6.2.

9-6.2.1 All backflow preventers installed in fire protection system piping shall be tested annually in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

9-6.2.2 All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

9-6.3.1 Maintenance of all backflow prevention assemblies shall be conducted by a trained individual following the manufacturer's instructions in accordance with the procedure and policies of the authority having jurisdiction.

9-7 Fire Department Connections.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the automatic sprinkler system was observed and maintenance records were requested.

ALL BUILDINGS (MAIN TOWER, PAVILION, DOMINICAN, AND CANCER CENTER):

1. On 10/14/14, at 11:32 a.m., records provided indicated that the most recent backflow prevention assembly inspections were conducted on 3/30/12 for four of four buildings. There were no records indicating that the backflow prevention assemblies were inspected in 2013.

During an interview on 10/16/14, at 10:49 a.m., Facilities Staff 1 stated that the backflow prevention assemblies were inspected on 10/16/14 at all buildings. He stated that previous inspection records could not be provided. There were no records showing that the backflow prevention assemblies were inspected on an annual basis.

On 10/16/14, at 1:40 p.m., records provided showed that the backflow prevention assemblies were tested at all four building by the City of Merced on 10/16/14, approximately 1 year and seven months after the date of the previous 3/30/12 inspection.

DOMINICAN CAMPUS:

2. On 10/14/14, at 8:51 a.m., quarterly inspection records for the past 12 months were requested. Records provided indicated that automatic sprinkler system inspections were conducted by a vendor on 10/23/13 and 9/15/14. There were no records of tests and inspections of the automatic sprinkler system at the Dominican Campus during the first quarter (January to March) and second quarter (April to June) of 2014.

Based on observation and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by a kitchen hood that was contaminated with grease-laden deposits. This affected one of eight floors in the Main Tower and could result in the increased risk of a grease fire.

NFPA 101, Life Safety Code, 2000 Edition.
18.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
8.3.1 Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking
Systems serving solid fuel cooking operations shall be inspected monthly.
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking shall be inspected quarterly.
Systems serving moderate-volume cooking operations shall be inspected semi-annually.
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers, shall be inspected annually.

8-3.1.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

8-3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also include areas no cleaned.

Findings:

During a facility tour of the Main Tower with staff from 10/13/14 to 10/16/14, the commercial cooking equipment in the kitchen and cafeteria were observed.

MAIN TOWER
GARDEN LEVEL:

1. On 10/15/14, at 10:59 a.m., the bottom half of the filters, in the hood above the fryer and the griddle in the cafeteria, were densely covered with grease. When the filters were removed by Engineering Staff 3, the fusible links and connecting pipes in the hood were observed to be covered in grease.

The sticker on the hood in the cafeteria indicated that it was last cleaned by a vendor in May 2014.

During an interview at 11:05 a.m., Dietary Staff 1 stated that the kitchen hood in the cafeteria was scheduled to be cleaned every quarter, like the hood in the main kitchen. The hood in the main kitchen was last cleaned in September 2014 and was tagged with a sticker by the vendor. Dietary Staff 1 stated that the cafeteria hood should have been cleaned at the same time.

Based on observation, the facility failed to ensure that the capacity of soiled linen and trash did not exceed 32 gallons in a 64 square foot area that was not protected as a hazardous area. This was evidenced by more than 32 gallons of soiled linen and trash occupying less than 64 square feet in a clinical care area. This affected one of one smoke compartments at the Cancer Center and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.5.5 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the soiled linen and trash receptacles were observed.

CANCER CENTER:

1. On 10/15/14, at 4:15 p.m., there were two 20-gallon soiled linen receptacles, one 10-gallon biohazard trash receptacle, and one 10-gallon trash receptacle, behind the nurse station in the Infusion Therapy room. The receptacles were immediately adjacent to each other and there was more than 32 gallons capacity of soiled linen and trash in a location that was less than 64 square feet in area.

.
PAVILION
SECOND FLOOR SURGERY CENTER:

2. On 10/15/14, at 11:34 a.m., there was a duplex outlet in the Oxygen Storage Room, Room 219, approximately 1 foot from the floor, directly adjacent to an oxygen E cylinder in the "empty" rack.

Based on observation and interview, the facility failed to maintain their medical gas storage locations. This was evidenced by one medical gas storage location that was not provided with precautionary signage and by one electrical fixture in an oxygen storage room that was less than 5 feet from the floor. This affected the outdoor medical gas cylinder storage area at the Main Tower and one of four floors of the Pavilion. These deficient practices could result in an increased risk of a fire and damage to an electrical outlet.

NFPA 101, Life Safety Code, 2000 Edition
18.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.
12-3.8.1 Patient. Equipment shall conform to the patient equipment requirements in Chapter 8, "Gas Equipment."
12-3.8.2 Nonpatient. Equipment shall conform to the non-patient equipment requirements in Chapter 8, "Gas Equipment."

Chapter 8 Gas Equipment
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
11. Construction and Arrangement of Supply System Locations.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the medical gas storage areas were observed.

MAIN TOWER:

1. On 10/14/14, at 1:39 p.m., the outdoor medical gas storage area, located west of the Main Tower near the loading dock, was observed. The enclosure housed four argon H tanks, three helium H tanks, six nitrogen H tanks, two 180 gallon liquid nitrous oxide tanks, and more than 30 oxygen E cylinders. The enclosure was not provided with a precautionary "no smoking" sign.

Based on observation, the facility failed to maintained their piped-in medical gas system. This was evidenced by obstructed emergency shut-off valves for one operating room. This affected one of four floors in the Pavilion and could result in the faster spread of a fire in an oxygen rich environment.

NFPA 101, Life Safety Code, 2000 Edition
18.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.

4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the piped-in medical gas system was observed.

PAVILION
SECOND FLOOR SURGERY CENTER:

1. On 10/15/14, at 1:45 p.m., the emergency medical gas shut-off valves for Operating Room (OR) 2, located in the alcove of the corridor outside the room, was obstructed. The shut-off valves were enclosed in a valve box with a removable window. Approximately 4 inches of the width of the valve box was obstructed by an automated medical dispenser that was bolted to the floor and impeded access to the box.

Based on record review and interview, the facility failed to ensure that the relative humidity levels at their anesthetizing locations would be maintained at a minimum of 35% or greater. This was evidenced by the facility's policy to maintain the humidity in the anesthetizing locations at a minimum of 20% without presenting documentation of the facility's election to utilize a categorical waiver. This affected anesthetizing locations on two of eight floors of the Main Tower and could result in the increased risk of a fire due to electrostatic charges in an oxygen rich environment.

NFPA 101, Life Safety Code, 2000 Edition.
18.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During record review with staff from 10/13/14 to 10/16/14, the humidity logs for the anesthetizing locations were observed and the policy for maintaining relative humidity at those locations was reviewed. There were six operating rooms (ORs) and two labor and delivery (L&D) rooms in the Main Tower.

MAIN TOWER:

1. On 10/14/14, at 9:36 a.m., Policy SS - 394, with implementation date March 2013, for maintaining the temperature and humidity in the ORs stated that relative humidity would be maintained between 20% - 60%. Humidity and temperature logs provided for the anesthetizing locations in the main tower defined the acceptable relative humidity range as 20% - 60%. The 2000 Edition of the Life Safety Code (LSC) required that relative humidity be maintained at a minimum 35%.

During the entrance conference with facility staff, including Facilities Staff 1 and Engineering Staff 1, on 10/13/14 at 1:30 p.m., they stated that the facility had not elected to utilize any categorical waivers.

The facility did not indicate that they had elected to utilize a categorical waiver allowing the relative humidity in anesthetizing locations to be maintained between 20 to 60 percent, per the 2012 edition of NFPA 99, as outlined by CMS (Centers for Medicare & Medicaid Services) S&C (Survey & Certification) Letter 13-25-LSC.

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by the use of a surge protector as a substitute for fixed wiring. This affected one of three floors in the Dominican Campus and could result in an increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the electrical wiring was observed.

DOMINICAN BUILDING
PHYSICAL THERAPY:

1. On 10/16/14, at 9:19 a.m., there was a refrigerator and a microwave oven plugged into a four-plug surge protector in Room 2 of the Pulmonary Function Lab.

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by the use of surge protectors for appliances and medical equipment as a substitute for fixed wiring. This affected two of eight floors in the Main Tower and could result in an increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
18.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the electrical wiring was observed.

MAIN TOWER
GROUND LEVEL:

1. On 10/15/14, at 10:22 a.m., there was a medication pump plugged into a four-plug surge protector in the Cath Lab, Room 1207.


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GARDEN LEVEL:

2. On 10/15/14, at 10:19 a.m., a refrigerator was plugged into a surge protector in the Bed Repair Shop, Room 0203.

3. On 10/15/14, at 10:29 a.m., there was a refrigerator and a microwave oven were plugged into a surge protector in the Mail Room, Room 0188.

Based on record review and interview, the facility failed to provide an emergency policy stating what actions would be taken, and which authorities would be notified, in the event that the automatic sprinkler system went out of service for 4 or more hours in a 24 hour period. This affected the Main Tower, the Pavilion, the Dominican Campus, and the Cancer Center. This could result in a delayed notification of a fire emergency, in the event of a malfunctioning automatic sprinkler system.

NFPA 101, Life Safety Code, 2000 Edition.
NEW HEALTH CARE OCCUPANCIES
18.3.5.1 Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

EXISTING HEALTH CARE OCCUPANCIES
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified area where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During record review with staff from 10/13/14 to 10/16/14, an emergency policy and procedure, in the event that the automatic sprinkler system was out of service, was requested.

ALL BUILDINGS (MAIN TOWER, PAVILION, DOMINICAN, AND CANCER CENTER):

1. On 10/14/14, at 10:11 a.m., there was no emergency policy and procedure or fire watch policy provided in the event that the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period.

During an interview at 10:15 a.m., Emergency Management Staff 1 stated that in the event of a fire alarm or sprinkler outage, the facility would assign staff to do rounds of the premises. She stated that there was no policy outlining the fire watch procedures.

Based on record review and interview, the facility failed to provide an emergency policy stating what actions would be taken, and which authorities would be notified, in the event that the fire alarm system went out of service for 4 or more hours in a 24 hour period. This affected the Main Tower, the Pavilion, the Dominican Campus, and the Cancer Center. This could result in a delayed notification of a fire emergency, in the event of a malfunctioning fire alarm system.

NFPA 101, Life Safety Code, 2000 Edition.
NEW HEALTH CARE OCCUPANCIES
18.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

EXISTING HEALTH CARE OCCUPANCIES
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During record review with staff from 10/13/14 to 10/16/14, an emergency policy and procedure, in the event that the fire alarm system was out of service, was requested.

ALL BUILDINGS (MAIN TOWER, PAVILION, DOMINICAN, AND CANCER CENTER):

1. On 10/14/14, at 10:11 a.m., there was no emergency policy and procedure or fire watch policy provided in the event that the fire alarm system was out of service for more than 4 hours in a 24-hour period.

During an interview at 10:15 a.m., Emergency Management Staff 1 stated that in the event of a fire alarm or sprinkler outage, the facility would assign staff to do rounds of the premises. She stated that there was no policy outlining the fire watch procedures.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by an unsealed wall penetration. This affected one of three floors in the Dominican Campus and could result in the faster spread of fire and smoke, in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in.
(6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.

8.2.1 Construction. Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided

8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with staff on 10/16/14, the walls and ceilings were observed.

DOMINICAN CAMPUS
ENDOSCOPY:

1. On 10/16/14, at 9:45 a.m., there was an approximately 1/2 inch penetration in the wall, around a cable wire, in the Physician Dictation Room.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, by doors that were obstructed from closing, and by doors with impaired self-closing hardware. This affected five of eight floors in the Main Tower and one of four floors in the Pavilion. This could result in the inability to contain a fire and consequently cause the faster spread of smoke and fire throughout the buildings.

NFPA 101, Life Safety Code, 2000 Edition
18.3.6.3.1 Doors protecting corridor openings shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.

18.3.6.3.2 Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the doors were observed.

MAIN TOWER
SIXTH FLOOR:

1. On 10/14/14, at 2:34 p.m., the self-closing door to the housekeeping closet, Room 6039, failed to latch.

THIRD FLOOR:

2. On 10/14/14, at 3:50 p.m., the self-closing door to the Clean Equipment Room, Room 3073, failed to latch.

GROUND LEVEL:

3. On 10/15/14, at 9:06 a.m., the self-closing door to the Emergency Department Decontamination Room, Room 1067, failed to latch.


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SECOND FLOOR:

4. On 10/15/14, at 9:16 a.m., the door to Room 2030 was equipped with a self-closing device. The door failed to positively latch when fully opened and released.

5. On 10/15/14, at 9:34 a.m., the door to Room 2135 was equipped with a self-closing device. The door failed to positively latch when fully opened and released.

6. On 10/15/14, at 9:34 a.m., the double doors by the elevator lobby failed to close and latch when tested. During an interview, Facilities staff 1 stated that a work order had already been submitted to repair the doors.

GARDEN LEVEL:

7. On 10/15/14, at 10:58 a.m., the door to the Beverage Storage Room, Room 0117, was obstructed from closing by a box.

.
PAVILION
FIRST FLOOR CLINICS:

8. On 10/15/14, at 11:35 a.m., the door to Storage Room 158, in Radiology, was equipped with a self-closing device. The door failed to positively latch when fully opened and released.

9. On 10/15/14, at 11:41 a.m., the door to Room 170 was equipped with a self-closing device. The door failed to positively latch when fully opened and released. The self-closing device was disconnected and failed to function.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch and by doors with impaired self-closing hardware. This affected one of one smoke compartments in the Cancer Center and one of three floors in the Dominican Campus. This could result in the inability to contain a fire and consequently cause the faster spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the doors were observed.

CANCER CENTER:

1. On 10/15/14, at 4:10 p.m., the door to a doctor's office, near the breakroom, was equipped with a self-closing device. The self-closing device was disconnected and no longer functioned.

DOMINICAN CAMPUS
PHYSICAL THERAPY:

2. On 10/16/14, at 9:21 a.m., the door to the Gym Room was equipped with a self-closing device. The door failed to positively latch when fully opened and released.

Based on observation and interview, the facility failed to ensure that access to exits were marked by readily visible signs. This was evidenced by exit signs that were oriented such that they could not be viewed from a main corridor, where the exit pathway was not readily apparent. This affected one of eight floors in the Main Tower and could result in a delay in evacuation, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
18.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

7.10.1.2 Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.4 Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, exits were observed for approved, readily visible signage.

MAIN TOWER
GROUND LEVEL:

1. On 10/16/14, at 9:15 a.m., there was an approximately 15 foot corridor coming off of the east Emergency Department (ED) corridor. At the end of the 15 foot corridor were two doors, one on each side. One door lead to an exit through the ED lobby and the other was an office door. There were two exit signs in the corridor between the two doors. The signs were directly facing the doors such that only the sides of the two exit signs were visible from the east ED corridor. There was no exit sign visible from the east ED corridor directing egress through the ED lobby door.

During an interview at 9:16 a.m., Engineering Staff 1 stated that one of the signs present directed egress from the ED lobby to the east ED corridor and the other was directing egress for persons in the office. Engineering Staff 1 confirmed that the pathway through the ED lobby was considered an emergency exit and that only the sides of the installed exit signs were visible from the east ED corridor.

Based on observation, the facility failed to maintain the rated doors in their smoke barrier separations. This was evidenced by smoke barrier doors that were obstructed from closing and by smoke barrier doors that failed to latch. This affected four of eight floors in the Main Tower, and could result in the faster spread of fire and smoke from one smoke compartment to another.

NFPA 101, Life Safety Code, 2000 Edition
18.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

4.6.12 Maintenance and Testing
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
2-4.1 Closing Devices
2-4.1.2 A closing device shall be installed on every fire door.
Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4 All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the smoke barrier doors were observed and tested.

MAIN TOWER
SEVENTH FLOOR:

1. On 10/15/14, at 2:25 p.m., Smoke Barrier Door DHW5, located across from Room 7074, released from the magnetic hold-open device upon activation of the fire alarm system. The door dragged on the floor and failed to fully close and latch.


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FOURTH FLOOR:

2. On 10/15/14, at 2:40 p.m., Smoke Barrier Door DHW5, next to Room 4021, released from the magnetic hold-open device upon activation of the fire alarm system. The door dragged on the floor immediately upon release and remained fully open.

GROUND LEVEL:

3. On 10/15/14, at 3:20 p.m., Smoke Barrier Door GLDHW4, across from Endoscopy, released from the magnetic hold-open device upon activation of the fire alarm system. The door failed to latch upon closure.

GARDEN LEVEL:

4. On 10/15/14, at 3:37 p.m., Smoke Barrier Door GDHW7, near PBX, released from the magnetic hold-open device upon activation of the fire alarm system. The door failed to latch upon closure.

Based on observation and interview, the facility failed to maintain their emergency lighting. This was evidenced by battery-powered emergency lighting units that failed to illuminate when tested. This affected one of three floors in the Dominican Campus. This deficient practice could result in the failure to have adequate lighting, in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.2.4 Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code®.

7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the emergency lights were observed.

DOMINICAN CAMPUS
ENDOSCOPY:

1. On 10/16/14, at 8:58 a.m., one of two battery-powered emergency lighting units, in the Kohler Generator enclosure, failed to illuminate when tested by Engineering Staff 2. The Kohler Generator supplies power to the Endoscopy Unit in the event of a power outage.

During an interview at 9:08 a.m., Engineering Staff 2 stated that the emergency lighting unit needed a new battery.


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PHYSICAL THERAPY:

2. On 10/16/14, at 9:16 a.m., the battery-powered emergency lighting unit, across from the reception desk in Occupational Therapy, failed to illuminate when tested.

Based on observation, the facility failed to maintain their emergency lighting units. This was evidenced by one battery-powered emergency lighting unit that failed to illuminate when tested. This affected the penthouse of the Main Tower. This deficient practice could result in the failure to have adequate lighting, in the event of a power outage and generator failure.

NFPA 101, Life Safety Code, 2000 Edition
18.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.2.4 Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code®.

7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the emergency lighting units were observed.

MAIN TOWER
PENTHOUSE:

1. On 10/14/14 at 2:11 p.m., the battery-powered emergency lighting unit, near the Elevator Machine Room, failed to illuminate when tested.

Based on document review, the facility failed to ensure that fire drills were conducted quarterly on each shift. This was evidenced by no records of a NOC shift fire drill during one of four quarters in the past 12 months. This affected all patients and staff in the Main Tower and could result in a delayed staff response to a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition
18.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
The provisions of 18.7.1.2 through 18.7.2.3 shall apply.
18.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review with staff from 10/13/14 to 10/16/14, the facility's fire drill documents were reviewed.

MAIN TOWER:

1. On 10/13/14 at 2:12 p.m., there were no records indicating that a NOC shift fire drill was conducted during the first quarter (January to March) of 2014.

Based on observation, record review, and interview, the facility failed to maintain their fire alarm system. This was evidenced by no records of annual testing of the fire alarm system at the Cancer Center and by an ongoing trouble signal at the fire alarm panel at the Dominican Campus. This affected one of one smoke compartments in the Cancer Center and three of three floors at the Dominican Campus. This could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

4.1.1 Fire and Similar Emergency. The goal of this Code is to provide an environment for the occupants that is reasonably safe from fire and similar emergencies by the following means:
(1) Protection of occupants not intimate with the initial fire development
(2) Improvement of the survivability of occupants intimate with the initial fire development.

4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-6.3 Records. A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.

7-1.6.2.1 Reacceptance testing shall be performed after any of the following:
(1) Added or deleted system components
(2) Any modification, repair, or adjustment to system hardware or wiring
(3) Any change to site-specific software.
All components, circuits, systems operations, or site-specific software functions known to be affected by the change or identified by a means that indicates the system operational changes shall be 100 percent tested. In addition, 10 percent of initiating devices that are not directly affected by the change, up to a maximum of 50 devices, also shall be tested, and correct system operation shall be verified. A revised record of completion in accordance with 1-6.2.1 shall be prepared to reflect any changes.

7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Table 7-3.2 Testing Frequencies

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the fire alarm system was observed and testing records were requested.

CANCER CENTER:

1. On 10/15/14, at 8:25 a.m., there were no records of an annual test and inspection of the fire alarm control panel and all associated components. The Cancer Center was equipped with an externally monitored fire alarm system connected to initiation devices, notification devices, and supervisory switches. There were no records of an annual test and inspection of the fire alarm system.

DOMINICAN CAMPUS:

2. On 10/16/14, at 9:30 a.m., there was trouble signal at the fire alarm control panel. The monitor on the panel stated "Card 7. Interface Part A. Abnormal."

During an interview at 9:31 a.m., Engineering Staff 1 stated that when an old telephone line was removed approximately 3 months ago, the panel went into trouble. The vendor came out last week to inspect the trouble signal and stated that the panel was missing an ethernet card.

Based on record review, the facility failed to maintain their fire alarm system. This was evidenced by no records of testing and inspection for 15 fire alarm system initiating devices at the Pavilion. This affected four of four floors in the Pavilion. This could result in a malfunctioning fire alarm system, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
18.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Table 7-3.2 Testing Frequencies

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the fire alarm system was observed and testing records were requested.

PAVILION:

On 10/16/14, at 1:53 p.m., records showed that the annual test and inspection of the fire alarm system at Pavilion was conducted over the course of several days in January and February of 2014. The records showed that not all of the initiating devices were tested.

The following devices were not tested and inspected during the annual certification of the fire alarm system:

1. Smoke Detector N04L01D012 in the fourth floor elevator shaft
2. Smoke Detector N04L01D014 in the fourth floor elevator lobby
3. Smoke Detector N02L01D003 in the second floor elevator lobby
4. Smoke Detector N02L01D018 in the second floor elevator lobby
5. Smoke Detector N02L01D005 in the second floor elevator equipment room
6. Smoke Detector N02L01D006 in the second floor elevator shaft
7. Smoke Detector N01L01D003 in the first floor elevator lobby
8. Smoke Detector N01L01D005 near Elevator 1 and Elevator 2 fire door on the first floor
9. Smoke Detector N01L01D075 in Corridor S 109 near the Elevator 3 lobby on the first floor
10. Smoke Detector N01L01D076 in the first floor Discharge Elevator lobby
11. Smoke Detector N01L01D090 in the first floor elevator equipment room
12. Smoke Detector N01L02D072 in Room 104B, inside Data Room 104, on the first floor
13. Smoke Detector N01L02D140 in the Med Gas Bottle Room on the first floor
14. Duct Detector N03L01D003 in the third floor elevator lobby
15. Duct Detector (no "address" listed on the paperwork) in the second floor elevator lobby.

No other records were provided showing when these 15 fire alarm system initiating devices were last tested and inspected.

Based on observation, record review, and interview, the facility failed to maintain their smoke detection system. This was evidenced by incomplete smoke detector sensitivity testing records for Dominican Campus, a smoke detector that was missing a cover at the Endoscopy Unit at Dominican Campus, and by no records of sensitivity testing for the smoke detector at the Cancer Center. This affected three of three floors at Dominican Campus and one of one smoke compartments at Cancer Center. This could result in a delay in the automatic detection of smoke, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.5.1 Corridors. An approved automatic smoke detection system shall be installed in all corridors of limited care facilities. Such system shall be in accordance with Section 9.6.
Exception No. 1: Where each patient sleeping room is protected by an approved smoke detection system, and a smoke detector is provided at smoke barriers and horizontal exits in accordance with Section 9.6, the
corridor smoke detection system shall not be required on the patient sleeping room floors.
Exception No. 2: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the smoke detection system was observed and maintenance records were requested.

DOMINICAN CAMPUS:

1. On 10/15/14, at 8:20 a.m., records of smoke detector sensitivity testing were provided. The records consisted of a list of detectors tested from 1/30/14 to 2/12/14 and the results of the testing. The record did not include a signature of the technician and vendor who performed the test.

During an interview at 8:21 a.m., Engineering Staff 1 stated that he could not find the signature page but he knew the vendor who conducted the testing. The complete document with the signature page was not provided during the survey.

ENDOSCOPY:

2. On 10/16/14, at 9:40 a.m., the smoke detector in the environmental services closet was missing a cover pate.

CANCER CENTER:

3. On 10/15/14, at 8:24 a.m., there were no records of smoke detector sensitivity testing provided. The Cancer Center was equipped with one smoke detector, located near the fire alarm control panel, and there were no records showing that it was tested for smoke sensitivity.

.
PAVILION:

10. On 10/15/14, at 4:47 p.m., the Inspector's Test Valve in the second floor stairwell landing was tested. The alarms inside the buildings were activated but the exterior sprinkler alarm bell, located outside the fire pump room, failed to alarm.

During an interview at 4:48 p.m., Engineering Staff 1 confirmed that the bell was designed to alarm upon activation of the sprinkler alarm valves.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinkler heads that were loaded with debris, by one sprinkler head that was missing an escutcheon ring, by the failure to maintain a minimum 18 inch clearance around one sprinkler head deflector, and by a sprinkler waterflow alarm bell that failed. These deficient practices affected three of eight floors in the Main Tower and four of four floors at the Pavilion. This could result in a malfunctioning automatic sprinkler system, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
18.3.5.1 Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.


NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition.
5-5.3.4 Minimum Distance Between Sprinklers. A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated the section for each type or style of sprinkler.

5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1:Where other standards specify greater minimums, they shall be followed.
Exception No.2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition.
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.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

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.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the automatic sprinkler system was observed and maintenance records were requested.

MAIN TOWER
GROUND LEVEL:

1. On 10/15/14, at 10:20 a.m., the electrical closet in the back of the Cath Lab, Room 1207, was observed. The sprinkler head in the closet was missing an escutcheon ring and had orange-colored plastic caps around the studs.

During an interview at 10:21 a.m., Engineering Staff 1 stated that the caps were part of the packaging designed to protect the sprinkler heads while being shipped. He stated that the caps should have been removed upon installation of the head.


31201

.
SECOND FLOOR:

2. On 10/15/14, at 9:25 a.m., there was an accumulation of dust and debris on the sprinkler head, in the Staff Locker Bathroom, Room 2075.

3. On 10/15/14, at 9:26 a.m., there was an accumulation of dust and debris on the sprinkler head, in the Staff Locker Bathroom, Room 2076.

4. On 10/15/14, at 9:30 a.m., there was an accumulation of dust and debris on the sprinkler head in Room 2101.

During an interview, Facilities Staff 1 stated that the dust on the sprinkler head accumulated due to a nearby air vent.

5. On 10/15/14, at 9:32 a.m., there was an accumulation of dust and debris on the sprinkler head in Room 2098.

GROUND FLOOR:

6. On 10/15/14, at 9:49 a.m., there was an accumulation of dust and debris on the sprinkler heard in Room 1136.

7. On 10/15/14, at 9:57 a.m., there was an accumulation of dust and debris on three of five sprinkler heads in Room 1119.

GARDEN LEVEL:

8. On 10/15/14, at 10:09 a.m., there was an accumulation of dust and debris on one of three sprinkler heads in Room 0332.

9. On 10/15/14, at 10:47 a.m., there was a box stored approximately 8 1/2 inches below the sprinkler deflector in Room 0148. The sprinkler did not have 18 inches of clearance.

Based on record review and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by no records of testing the backflow prevention assemblies in 2013 at the Main Tower, Pavilion, Dominican Campus, and Cancer Center. This was also evidenced by no sprinkler inspection records for two of four quarters at the Dominican Campus. These deficient practices affected three of three floors at the Dominican Campus and the backflow prevention assemblies at all four buildings. This could result in a delay in a malfunctioning automatic sprinkler system, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

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.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

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.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

Table 9-1 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance indicates that backflow prevention assemblies are required to be tested annually in accordance with Section 9-6.2.

9-6.2.1 All backflow preventers installed in fire protection system piping shall be tested annually in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

9-6.2.2 All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

9-6.3.1 Maintenance of all backflow prevention assemblies shall be conducted by a trained individual following the manufacturer's instructions in accordance with the procedure and policies of the authority having jurisdiction.

9-7 Fire Department Connections.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the automatic sprinkler system was observed and maintenance records were requested.

ALL BUILDINGS (MAIN TOWER, PAVILION, DOMINICAN, AND CANCER CENTER):

1. On 10/14/14, at 11:32 a.m., records provided indicated that the most recent backflow prevention assembly inspections were conducted on 3/30/12 for four of four buildings. There were no records indicating that the backflow prevention assemblies were inspected in 2013.

During an interview on 10/16/14, at 10:49 a.m., Facilities Staff 1 stated that the backflow prevention assemblies were inspected on 10/16/14 at all buildings. He stated that previous inspection records could not be provided. There were no records showing that the backflow prevention assemblies were inspected on an annual basis.

On 10/16/14, at 1:40 p.m., records provided showed that the backflow prevention assemblies were tested at all four building by the City of Merced on 10/16/14, approximately 1 year and seven months after the date of the previous 3/30/12 inspection.

DOMINICAN CAMPUS:

2. On 10/14/14, at 8:51 a.m., quarterly inspection records for the past 12 months were requested. Records provided indicated that automatic sprinkler system inspections were conducted by a vendor on 10/23/13 and 9/15/14. There were no records of tests and inspections of the automatic sprinkler system at the Dominican Campus during the first quarter (January to March) and second quarter (April to June) of 2014.

Based on observation and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by a kitchen hood that was contaminated with grease-laden deposits. This affected one of eight floors in the Main Tower and could result in the increased risk of a grease fire.

NFPA 101, Life Safety Code, 2000 Edition.
18.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
8.3.1 Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking
Systems serving solid fuel cooking operations shall be inspected monthly.
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking shall be inspected quarterly.
Systems serving moderate-volume cooking operations shall be inspected semi-annually.
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers, shall be inspected annually.

8-3.1.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

8-3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also include areas no cleaned.

Findings:

During a facility tour of the Main Tower with staff from 10/13/14 to 10/16/14, the commercial cooking equipment in the kitchen and cafeteria were observed.

MAIN TOWER
GARDEN LEVEL:

1. On 10/15/14, at 10:59 a.m., the bottom half of the filters, in the hood above the fryer and the griddle in the cafeteria, were densely covered with grease. When the filters were removed by Engineering Staff 3, the fusible links and connecting pipes in the hood were observed to be covered in grease.

The sticker on the hood in the cafeteria indicated that it was last cleaned by a vendor in May 2014.

During an interview at 11:05 a.m., Dietary Staff 1 stated that the kitchen hood in the cafeteria was scheduled to be cleaned every quarter, like the hood in the main kitchen. The hood in the main kitchen was last cleaned in September 2014 and was tagged with a sticker by the vendor. Dietary Staff 1 stated that the cafeteria hood should have been cleaned at the same time.

Based on observation, the facility failed to ensure that the capacity of soiled linen and trash did not exceed 32 gallons in a 64 square foot area that was not protected as a hazardous area. This was evidenced by more than 32 gallons of soiled linen and trash occupying less than 64 square feet in a clinical care area. This affected one of one smoke compartments at the Cancer Center and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.5.5 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the soiled linen and trash receptacles were observed.

CANCER CENTER:

1. On 10/15/14, at 4:15 p.m., there were two 20-gallon soiled linen receptacles, one 10-gallon biohazard trash receptacle, and one 10-gallon trash receptacle, behind the nurse station in the Infusion Therapy room. The receptacles were immediately adjacent to each other and there was more than 32 gallons capacity of soiled linen and trash in a location that was less than 64 square feet in area.

.
PAVILION
SECOND FLOOR SURGERY CENTER:

2. On 10/15/14, at 11:34 a.m., there was a duplex outlet in the Oxygen Storage Room, Room 219, approximately 1 foot from the floor, directly adjacent to an oxygen E cylinder in the "empty" rack.

Based on observation and interview, the facility failed to maintain their medical gas storage locations. This was evidenced by one medical gas storage location that was not provided with precautionary signage and by one electrical fixture in an oxygen storage room that was less than 5 feet from the floor. This affected the outdoor medical gas cylinder storage area at the Main Tower and one of four floors of the Pavilion. These deficient practices could result in an increased risk of a fire and damage to an electrical outlet.

NFPA 101, Life Safety Code, 2000 Edition
18.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.
12-3.8.1 Patient. Equipment shall conform to the patient equipment requirements in Chapter 8, "Gas Equipment."
12-3.8.2 Nonpatient. Equipment shall conform to the non-patient equipment requirements in Chapter 8, "Gas Equipment."

Chapter 8 Gas Equipment
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
11. Construction and Arrangement of Supply System Locations.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the medical gas storage areas were observed.

MAIN TOWER:

1. On 10/14/14, at 1:39 p.m., the outdoor medical gas storage area, located west of the Main Tower near the loading dock, was observed. The enclosure housed four argon H tanks, three helium H tanks, six nitrogen H tanks, two 180 gallon liquid nitrous oxide tanks, and more than 30 oxygen E cylinders. The enclosure was not provided with a precautionary "no smoking" sign.

Based on observation, the facility failed to maintained their piped-in medical gas system. This was evidenced by obstructed emergency shut-off valves for one operating room. This affected one of four floors in the Pavilion and could result in the faster spread of a fire in an oxygen rich environment.

NFPA 101, Life Safety Code, 2000 Edition
18.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.

4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the piped-in medical gas system was observed.

PAVILION
SECOND FLOOR SURGERY CENTER:

1. On 10/15/14, at 1:45 p.m., the emergency medical gas shut-off valves for Operating Room (OR) 2, located in the alcove of the corridor outside the room, was obstructed. The shut-off valves were enclosed in a valve box with a removable window. Approximately 4 inches of the width of the valve box was obstructed by an automated medical dispenser that was bolted to the floor and impeded access to the box.

Based on record review and interview, the facility failed to ensure that the relative humidity levels at their anesthetizing locations would be maintained at a minimum of 35% or greater. This was evidenced by the facility's policy to maintain the humidity in the anesthetizing locations at a minimum of 20% without presenting documentation of the facility's election to utilize a categorical waiver. This affected anesthetizing locations on two of eight floors of the Main Tower and could result in the increased risk of a fire due to electrostatic charges in an oxygen rich environment.

NFPA 101, Life Safety Code, 2000 Edition.
18.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During record review with staff from 10/13/14 to 10/16/14, the humidity logs for the anesthetizing locations were observed and the policy for maintaining relative humidity at those locations was reviewed. There were six operating rooms (ORs) and two labor and delivery (L&D) rooms in the Main Tower.

MAIN TOWER:

1. On 10/14/14, at 9:36 a.m., Policy SS - 394, with implementation date March 2013, for maintaining the temperature and humidity in the ORs stated that relative humidity would be maintained between 20% - 60%. Humidity and temperature logs provided for the anesthetizing locations in the main tower defined the acceptable relative humidity range as 20% - 60%. The 2000 Edition of the Life Safety Code (LSC) required that relative humidity be maintained at a minimum 35%.

During the entrance conference with facility staff, including Facilities Staff 1 and Engineering Staff 1, on 10/13/14 at 1:30 p.m., they stated that the facility had not elected to utilize any categorical waivers.

The facility did not indicate that they had elected to utilize a categorical waiver allowing the relative humidity in anesthetizing locations to be maintained between 20 to 60 percent, per the 2012 edition of NFPA 99, as outlined by CMS (Centers for Medicare & Medicaid Services) S&C (Survey & Certification) Letter 13-25-LSC.

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by the use of a surge protector as a substitute for fixed wiring. This affected one of three floors in the Dominican Campus and could result in an increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the electrical wiring was observed.

DOMINICAN BUILDING
PHYSICAL THERAPY:

1. On 10/16/14, at 9:19 a.m., there was a refrigerator and a microwave oven plugged into a four-plug surge protector in Room 2 of the Pulmonary Function Lab.

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by the use of surge protectors for appliances and medical equipment as a substitute for fixed wiring. This affected two of eight floors in the Main Tower and could result in an increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
18.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 10/13/14 to 10/16/14, the electrical wiring was observed.

MAIN TOWER
GROUND LEVEL:

1. On 10/15/14, at 10:22 a.m., there was a medication pump plugged into a four-plug surge protector in the Cath Lab, Room 1207.


31201

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GARDEN LEVEL:

2. On 10/15/14, at 10:19 a.m., a refrigerator was plugged into a surge protector in the Bed Repair Shop, Room 0203.

3. On 10/15/14, at 10:29 a.m., there was a refrigerator and a microwave oven were plugged into a surge protector in the Mail Room, Room 0188.

Based on record review and interview, the facility failed to provide an emergency policy stating what actions would be taken, and which authorities would be notified, in the event that the automatic sprinkler system went out of service for 4 or more hours in a 24 hour period. This affected the Main Tower, the Pavilion, the Dominican Campus, and the Cancer Center. This could result in a delayed notification of a fire emergency, in the event of a malfunctioning automatic sprinkler system.

NFPA 101, Life Safety Code, 2000 Edition.
NEW HEALTH CARE OCCUPANCIES
18.3.5.1 Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

EXISTING HEALTH CARE OCCUPANCIES
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified area where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During record review with staff from 10/13/14 to 10/16/14, an emergency policy and procedure, in the event that the automatic sprinkler system was out of service, was requested.

ALL BUILDINGS (MAIN TOWER, PAVILION, DOMINICAN, AND CANCER CENTER):

1. On 10/14/14, at 10:11 a.m., there was no emergency policy and procedure or fire watch policy provided in the event that the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period.

During an interview at 10:15 a.m., Emergency Management Staff 1 stated that in the event of a fire alarm or sprinkler outage, the facility would assign staff to do rounds of the premises. She stated that there was no policy outlining the fire watch procedures.

Based on record review and interview, the facility failed to provide an emergency policy stating what actions would be taken, and which authorities would be notified, in the event that the fire alarm system went out of service for 4 or more hours in a 24 hour period. This affected the Main Tower, the Pavilion, the Dominican Campus, and the Cancer Center. This could result in a delayed notification of a fire emergency, in the event of a malfunctioning fire alarm system.

NFPA 101, Life Safety Code, 2000 Edition.
NEW HEALTH CARE OCCUPANCIES
18.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

EXISTING HEALTH CARE OCCUPANCIES
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During record review with staff from 10/13/14 to 10/16/14, an emergency policy and procedure, in the event that the fire alarm system was out of service, was requested.

ALL BUILDINGS (MAIN TOWER, PAVILION, DOMINICAN, AND CANCER CENTER):

1. On 10/14/14, at 10:11 a.m., there was no emergency policy and procedure or fire watch policy provided in the event that the fire alarm system was out of service for more than 4 hours in a 24-hour period.

During an interview at 10:15 a.m., Emergency Management Staff 1 stated that in the event of a fire alarm or sprinkler outage, the facility would assign staff to do rounds of the premises. She stated that there was no policy outlining the fire watch procedures.