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Based on observation and interview, the facility failed to maintain the integrity of the common two hour fire rated construction. This was evidenced by no separation wall. This could result in the reduction in staff ability to protect in place due to smoke and fire. This affected Suite 105, unoccupied, in 1 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
19.1.1.4.1 Additions. Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)
19.1.1.4.2 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protective's shall be as follows:
(1) 2-hour fire barrier - 1 1/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42.
8.2.2.1 Where required by Chapters 12 through 42, every building shall be divided into compartments to limit the spread of fire and restrict the movement of smoke.
8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.
Exception: A fire barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier.

Findings:

During a tour of the facility with the Bio Med Engineer Manager on 11/20/14, the fire rated construction was observed, and a staff person was interviewed.

Suite 105

1. At 9:22 a.m., there was no separation wall/door/partition between Suite 105 (on the facilities License) and Suite 109 (separate business).

2. At 9:23 a.m., the Bio Med Manager said during an interview, that there was no separation between 105 and 109.

Based on observation, the facility failed to maintain the integrity of their building construction. This was evidenced by unsealed penetrations in the facility walls. This could result in the spread of smoke or fire to other locations in the facility. This affected 2 of 7 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
8.3.1* General. Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
8.3.2* Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling,
including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14, the building construction was observed.

Main Hospital

1. At 10:32 a.m. there was an approximately 5 inch by 8 inch unsealed penetration in the south wall of Room 518.

2. At 1:36 p.m., there was an approximately 8 inch by 6 inch unsealed penetration in the wall above the lockers in the second floor Nursing Lounge.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch, and by corridor doors that were impeded from closing. This could result in a delay to contain smoke or fire to a room. This affected 3 of 7 floors in the Main Hospital and one contractual suite 13.

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.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
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.

19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

A.19.3.6.3.3 Doors should not be blocked open by furniture, door stops, chocks, tie backs, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14 through 11/19/14, the doors in the facility were observed, and a staff person was interviewed.

11/17/14, Main Hospital

1. At 10:01 a.m., the corridor door to Room 632 was impeded from closing with a trash can in front of the door.

2. At 10:23 a.m., the corridor door to Room 621 was not latching when tested.

3. At 10:53 a.m., the corridor door to EVS at the fourth floor Nursing Station was not latching when tested. The latching mechanism was sticking.

4. At 11:01 a.m., the self closing corridor door to the fourth floor Nursing Station lounge was not latching when tested.

11/18/14, Main Hospital

5. At 11:04 a.m., the self-closing corridor door to the CPD lunch room was impeded from closing with a piece of cardboard wedged under the door.

11/19/14, Suite 13

6. At 9:00 a.m., the corridor door to the Ultra Sound Room was impeded from closing with a kick stop in use.

7. At 9:07 a.m., the corridor door to mammography was impeded from closing with a rubber wedge under the door.

8. At 9:09 a.m., the Director of Facilities said during an interview, that the suite 13 personnel were responsible for maintaining their facility.

Based on observation, the facility failed to maintain their automatic closing fire doors. This was evidenced by a fire door that failed to release from the magnetic hold open device, and by a fire door that failed to positive latch when tested. This could allow the spread of smoke or flames in the event of a fire. This affected 2 of 7 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes self closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During fire alarm testing with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/18/14, the doors held open by magnetic hold-open devices were observed and tested.

11/18/14, Main Hospital

1. At 10:17 a.m., the fire door 223 was not releasing from the magnetic hold device and closing.

2. At 10:42 a.m., the fire door from EVS to the hallway was not latching when tested.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls. This was evidenced by unsealed penetrations. The penetrations could result in the reduction in staff ability to protect in place due to smoke and fire. This affected 2 of 7 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/18/14, the smoke barrier walls were observed.

11/18/14, Main Hospital

1. At 12:51 p.m., there was an approximately 3 foot by 3 foot unsealed penetration in the smoke barrier wall near Operating Room 2.

2. At 12:53 p.m., there were four approximately 3 inch round unsealed penetrations in the smoke barrier wall near Operating Room 1.

3. At 1:39 p.m., there was an approximately 2 inch by 3 inch unsealed penetration in the smoke barrier wall by 109 on the first floor.

Based on observation, document review, and interview, the facility failed to maintain their emergency lighting units. This was evidenced by the failure to perform monthly and annual test for the emergency lights in Suite 105, and by emergency lights that failed to illuminate in suite 105 and the main hospital. This could leave the rooms in darkness during a power outage. This affected 1 of 7 floors in the Main Hospital and Ambulatory Surgery Suite 105.

NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/18/14, the facility emergency lighting units were observed, tested, testing documents were requested, and a staff person was interviewed.

11/18/14 Suite 105

1. At 8:41 a.m., 3 of 3 emergency lights in the hallway were not illuminating when the test button was pressed.

2. At 8:45 a.m., 2 of 2 emergency lights in the Operating Rooms (2) were not illuminating when the test button was pressed.

3. At 8:48 a.m., there was no documented evidence of testing the 5 emergency lights monthly for 30 seconds and annually for 90 minutes for suite 105.

4. At 8:55 a.m., the emergency light in the north stairwell was not illuminating when the test button was pressed.

5. At 8:58 a.m., the Director of Facilities said during an interview, that there has not been any testing of the emergency lights for approximately 12 years, since the building was unoccupied.

11/18/14, Main Hospital

6. At 12:47 p.m., the emergency light in Operating Room 1 was not illuminating when the test button was pressed. The emergency light was last tested during the month of October 2014.

Based on observation, document review, and interview, the facility failed to maintain their exit signs in Suite 105 and Suite 13. This was evidenced by the failure to perform monthly and annual tests on their exit signs equipped with an internal emergency power supply source, and by exit signs that failed to illuminate when tested. This could result in a delay in evacuation due to limited exit sign visibility. This affected Suite 105 under the facilities License, and Suite 13 Contractual Services.

NFPA 101, Life Safety Code, 2000 Edition
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/18/14 through 11/19/14, the exit signs were tested, exit sign testing documents were requested, the contractual agreement was reviewed, and a staff member was interviewed.

11/18/14, Suites 105

1. At 8:32 a.m., the exit sign to the Main Entrance was not illuminating when the test button was pressed.

2. At 8:51 a.m., the east exit sign near the back entrance was not illuminating when the test button was pressed.

11/19/14, Suite 105, and 13

3. At 9:09 a.m., there was no documented evidence of monthly 30 second tests and an annual 90 minute test for all of the exit signs in Suite 105 and Suite 13.

4. At 9:18 a.m., the contractual agreement read in part that the Contractual Suite 13 would provide all inspection and testing documentation to the hospital's Director of Facilities.

11/20/14, Suite 105, and 13

5. At 9:03 a.m., the Director of Facilities said that there was no documented testing of the exit signs for suite 105 and suite 13.

Based on observation, the facility failed to maintained the fire alarm system. This was evidenced by expired batteries in 5 of 7 Fire Alarm Control Panels in the Main Hospital, by expired batteries in Suite 105, by no monthly testing in suite 105 and Suite 13, and by no annual certification for Suite 105 and Suite 13. This could result in the fire alarm system not functioning as designed in the event of a fire. This affected 2 of 2 buildings, the Main Hospital and Building 999.

NFPA 101, Life Safety Code, 2000 Edition
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.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2, requires sealed lead acid batteries to be replaced every four years.
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
6. Batteries - Fire Alarm Systems
d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years.)

Table 7-3.2, Testing Frequencies, Item 23 - requires the system be tested monthly with the Monitoring/Supervising Station.

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14 through 11/19/14, the Fire Alarm system components were observed, testing documents were requested, and a staff person was interviewed.

11/17/14, Main Hospital

1. At 9:49 a.m., the two batteries in the fire alarm control panel on the 7th floor were dated 3/2/10 and expired on 3/2/14.

2. At 10:38 a.m., the two batteries in the fire alarm control panel on the 5th floor were dated 3/2/10 and expired on 3/2/14.

3. At 1:19 p.m., the two batteries in the fire alarm control panel on the 3rd floor were dated 3/2/10 and expired on 3/2/14.

4. At 1:41 p.m., the two batteries in the fire alarm control panel on the 2nd floor were dated 3/2/10 and expired on 3/2/14.

5. At 2:25 p.m., the two batteries in the fire alarm control panel on the 1st floor were dated 3/2/10 and expired on 3/2/14.

11/18/14, Main Hospital

6. At 9:14 a.m., the two batteries in the Main fire alarm control panel in the Plant Operations shop were dated 3/2/10 and expired on 3/2/14.

11/19/14, Suite 13

7. At 9:12 a.m., there was no documented evidence of annual testing and maintenance of fire alarm system.

11/20/14, Suite 105

8. At 9:22 a.m., the two batteries in the fire alarm control panel in Suite 105 were undated, approximately 1/4 of the batteries were covered with green corrosion that was piled approximately 1 inch above the batteries, battery acid was leaking down the positive side of the batteries on to the control panel, and the battery wires were covered with corrosion.

9. At 8:57 a.m., there was no documented evidence on monthly testing of the fire alarm system in Suite 105 and Suite 13.

10. At 8:59 a.m., there was no documented evidence of an annual certification of the fire alarm control panel in suite 105 and suite 13.

11. At 9:38 a.m., the Director of Facilities said during an interview, that there was no annual testing and certification of the fire alarm system in suite 105 and that the facility was not responsible for suite 13.

Based on document review, and interview, the facility failed to ensure that the smoke detectors were maintained. This was evidenced by no documentation of sensitivity testing. The smoke detectors could fail in the event of a fire emergency. This affected Suite 105, unoccupied, in 1 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
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.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-7.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

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 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.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-5.2.2 A permanent record of all inspections, testing and maintenance shall be provided that includes the 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 the 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/success-fully retested, device abandoned in place)

Findings:

During a tour of the facility with the Bio Med Engineer Manager on 11/20/14, the smoke detectors maintenance records were requested, and a staff person was interviewed.

11/20/14, Suite 105

1. At 9:20 a.m., there was no documented evidence of sensitivity testing of the 2 smoke detectors in Suite 105.

2. At 9:39 a.m., the Director of Facilities said during an interview, that the building had not maintained the smoke detectors since the building was unoccupied approximately 12 years ago.

Based on document review and interview, the facility failed to maintain their automatic sprinkler system and enforce the contractual agreement with suite 13. This was evidenced by the 5 year certification that failed in the main hospital, by no quarterly testing of suite 105, and by no quarterly testing of suite 13 per contractual agreement. This could result in the failure of the sprinkler system in the event of a fire. This affected 7 of 7 floors in the Main Hospital, Suite 105, and Suite 13.

NFPA 101, Life Safety Code, 2000 Edition
19.7.6 Maintenance and Testing. (See 4.6.12.)
4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

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
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

Findings:

During document review with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/19/14 through 11/20/14, the sprinkler system certification and testing documents were reviewed, and a staff person was interviewed.

11/19/14, Suite 105, Suite 13

1. At 9:12 a.m., there was no documented evidence of quarterly testing of the sprinkler system in suite 105 under the facilities license, and Suite 13 contracted services.

2. At 9:14 a.m., the contractual agreement read in part on page A number 3, Group is required to provide fire sprinkler testing.

11/19/14, Main Hospital

3. At 1:43 p.m., the facilities documented evidence of the 5 year certification indicated that it failed during testing on 12/31/13. The test indicated that the dry pipe was leaking and failed. The dry pipe allows for water to be pumped to each floor by the fire department during a fire emergency.

11/20/14

4. At 2:11 p.m., the Safety Officer said during an interview, that the facility was in the process of securing a contract to have the dry pipe replaced. The job was being evaluated by a few companies for bid. The facility was informed of the waiver process during the exit interview.

Based on observation, document review, and interview, the facility failed to maintain their fire extinguishers. This was evidenced by an expired fire extinguisher, by fire extinguishers that were missing safety seals, by fire extinguishers with the gauge in the red, by an unsecured fire extinguisher, and by fire extinguishers that were not inspected on a monthly basis. The fire extinguishers could fail and delay extinguishing a fire in the event of a fire emergency. This affected 2 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14 through 11/19/14, the fire extinguishers were observed, and a staff person was interviewed.

11/17/14, Main Hospital

1. At 9:44 a.m., the fire extinguisher gauge was in the red, indicating that the extinguisher needed to be recharged near Room 702.

2. At 1:49 p.m., the fire extinguisher gauge was in the red near C-Section, Room 3.

11/18/14, Main Hospital

3. At 10:42 a.m., the fire extinguisher in the Kitchen near Catering was missing a safety seal on the pin.

11/19/14, Suite 13

4. At 9:04 a.m., the blue and white fire extinguisher was sitting on the floor unsecured, the date on the label was 8/13/13, expired 8/13/14, with no monthly inspections.

5. At 9:05 a.m., there were 3 fire extinguishers that were installed on 6/16/14 with no monthly inspections since the installation.

6. At 9:11 a.m., the Director of Facilities said during an interview, that the personnel in suite 13 were responsible for the inspections and maintenance of their suite.

11/19/14, Main Hospital

7. At 2:59 p.m., the fire extinguisher near the street exit in the Boiler Room was missing a safety seal on the pin.

Based on document review and interview, the facility failed to maintain the humidity in their surgery rooms. This was evidenced by no documented maintenance of one building and by documented evidence of the surgery suite below 30 percent humidity. This could result in a fire. This affected 2 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.3 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 document review with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/19/14 through 11/20/14, the facility humidity logs were reviewed, and a staff person was interviewed.

11/19/14, Main Hospital

1. At 2:16 p.m., the facilities operating room humidity log indicated the acceptable range for humidity was 30% to 60%.

2. At 2:30 p.m., the humidity log for the month of November indicated that the humidity (H) was out of compliance for the following dates and operating rooms (OR):
OR 1 11/6 H 24%, 11/8 H 28%, 11/12 H 12%,
OR 2 11/6 H 24%, 11/17 H 10%, 11/18 H 20%,
OR 3 11/6 H 26%, 11/17 H 12%, 11/18 H 20%,
OR 4 11/6 H 23%, 11/17 H 10%, 11/18 H 20%,
OR 5 11/6 H 24%, 11/8 H 26%, 11/17 H 10%, 11/18 H 20%,
OR 6 11/6 H 23%, 11/8 H 25%, 11/17 H 12%, 11/18 H 20%,
OR 7 11/6 H 24%, 11/8 H 28%, 11/17 H 12%, 11/18 H 20%,
OR 8 11/6 H 22%, 11/8 H 25%, 11/17 H 10%, 11/18 H 20%,
OR 9 11/6 H 24%, 11/17 H 10%, 11/18 H 20%,
OR 10 11/6 H 22%, 11/8 H 24%, 11/17 H 10%, 11/18 H 18%,
OR 11 11/6 H 23%, 11/17 H 10%, 11/18 H 20%,
Storeroom 11/6 H 20%, 11/7 H 22%, 11/8 H 21%, 11/17 H 19%, 11/18 H 20%

3. At 2:30 p.m., the RN director said during an interview, that the operating rooms with the humidity below 30% were used.

4. At 2:43 p.m., there was no documented evidence of a policy or procedure in place for the operating rooms with the humidity below the facilities acceptable range (30% - 60%).

11/20/14, Suite 105, unoccupied
5. At 8:48 a.m., there was no documented evidence that the humidity within the 2 operating rooms in suite 105 were maintained for the last 12 of 12 months.

6. At 8:49 a.m., the Director of Facilities said during an interview, that humidity in the operating rooms in suite 105 were not maintained for the past 12 months.

Based on observation, the facility failed to maintain penetrating items through the smoke walls. This was evidenced by unsealed pipes through a wall and a ceiling. This could result in the spread of smoke or fire to other smoke compartments. This affected 2 of 7 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke 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 smoke barrier, the sleeve shall be solidly set in the smoke 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 smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14, the smoke barrier walls were observed.

11/17/14, Main Hospital

1. At 12:53 p.m., there was an approximately 2 inch unsealed pipe through the ceiling of the fourth floor Nurse Call Closet.

2. At 2:12 p.m., there was an approximately 6 inch pipe with 3 inches unsealed in the first floor shaft Room near Room 126.

Based on document review and interview, the facility failed to provide written documentation of weekly visual inspections of the emergency generator for 52 of 52 weeks for Suite 105 and 1 of 52 weeks for the Main Hospital. This could result in loss of power in the event of a power failure. This affected 2 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 99, Health Care Facilities, 1999 Edition
3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time one or more transfer switches. One transfer switch shall practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days .Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, be installed and connected to the alternate power source Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the
machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer The date and time of day for required testing shall be decided by the owner, based on facility operations.

Findings:

During document review with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/19/14, the generator maintenance records were reviewed, and staff was interviewed.

Main Hospital

1. At 1:12 p.m., there was no documented evidence of weekly inspections since 11/5/14. There was no record for the week of 11/12/14.

11/20/14, Suite 105

2. At 8:52 a.m., there was no documented evidence of testing the EPS system in suite 105 for 12 of 12 months and weekly inspections for 52 of 52 weeks.

3. At 8:54 a.m., the Director of Facilities said during an interview, that they do not have records for the EPS system in suite 105 since it has been unoccupied for the past several years.

Based on document review, and interview, the facility failed to maintain their emergency generator. This was evidenced by no EPS system connected to the facility in Suite 105. The building was unoccupied. This affected 1 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.2.2.2 Emergency System. 6. Blood, bone, and tissue banks
(a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c).
+All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5)

Findings:

During document review with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/20/14, the facility's emergency EPS system was examined, and a staff person was interviewed.

11/20/14, Suite 105
1. At 8:51 a.m., the batteries to the EPS system were disconnected and did not provide emergency power in the event of a power failure.

2. At 8:54 a.m., the Director of Facilities said during an interview, that they did not have records for the EPS system in suite 105, since it has been unoccupied for the past several years.

Based on observation and interview, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances that were plugged into multi-outlet extension cords, by utilizing extension cords as permanent wiring, by a multi-outlet extension cord that was plugged into an extension cord, and by uncovered electrical boxes. This could result in an electrical fire. This affected 4 of 7 floors in the Main Hospital and Suite 13.

NFPA 101, Life Safety Code, 2000 Edition
SECTION 9.1 UTILITIES
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
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(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

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14 through 11/19/14, the electrical system and components were observed, and staff was interviewed.

11/17/14, Main Hospital

1. At 9:24 a.m., there was a yellow extension cord in use in the elevator equipment room on the roof.

2. At 9:32 a.m., outside of the elevator equipment room, there was an uncovered electrical box near the door.

3. At 9:55 a.m., there was a microwave that was plugged into a multi-outlet power strip at the 7th floor Nursing Station.

4. At 10:48 a.m., there was a brown extension in use in the Med Surge Directors Office.

5. At 10:50 a.m., there was a refrigerator that was plugged into a multi-plug power strip in the 4th floor Charge Nurse Office.

6. At 1:02 p.m., there was an orange extension cord in use in Room 308.

7. At 2:29 p.m., there was a refrigerator that was plugged into a multi-plug power strip in the Director of Paranatal Services Office.

11/18/14, Main Hospital

8. At 11:06 a.m., there was a microwave in the CPD lunch room that was plugged into a multi-plug power strip.

11/19/14, Suite 13

9. At 9:02 a.m., there was a four plug extension cord in use in the CT Scan Room.

10. At 9:03 a.m., the Safety Officer said during an interview, that the four plug extension cords do not meet the UL waiver requirements.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of two alcohol based hand rub dispensers over ignition sources. could result in an alcohol based hand rub ignited fire. This affected 2 of 7 floors in the Main Hospital.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/18/14, the alcohol based hand rub dispensers in the facility were observed.

11/18/14, Main Hospital

1. At 12:42 p.m., there was an alcohol based hand rub dispenser in the emergency waiting Room, that was mounted over a light switch.

2. At 2:44 p.m., there was an alcohol based hand rub dispenser in the Trauma Services Room, that was mounted over a light switch.

Based on observation and interview, the facility failed to maintain the integrity of the common two hour fire rated construction. This was evidenced by no separation wall. This could result in the reduction in staff ability to protect in place due to smoke and fire. This affected Suite 105, unoccupied, in 1 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
19.1.1.4.1 Additions. Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)
19.1.1.4.2 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protective's shall be as follows:
(1) 2-hour fire barrier - 1 1/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42.
8.2.2.1 Where required by Chapters 12 through 42, every building shall be divided into compartments to limit the spread of fire and restrict the movement of smoke.
8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.
Exception: A fire barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier.

Findings:

During a tour of the facility with the Bio Med Engineer Manager on 11/20/14, the fire rated construction was observed, and a staff person was interviewed.

Suite 105

1. At 9:22 a.m., there was no separation wall/door/partition between Suite 105 (on the facilities License) and Suite 109 (separate business).

2. At 9:23 a.m., the Bio Med Manager said during an interview, that there was no separation between 105 and 109.

Based on observation, the facility failed to maintain the integrity of their building construction. This was evidenced by unsealed penetrations in the facility walls. This could result in the spread of smoke or fire to other locations in the facility. This affected 2 of 7 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
8.3.1* General. Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
8.3.2* Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling,
including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14, the building construction was observed.

Main Hospital

1. At 10:32 a.m. there was an approximately 5 inch by 8 inch unsealed penetration in the south wall of Room 518.

2. At 1:36 p.m., there was an approximately 8 inch by 6 inch unsealed penetration in the wall above the lockers in the second floor Nursing Lounge.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch, and by corridor doors that were impeded from closing. This could result in a delay to contain smoke or fire to a room. This affected 3 of 7 floors in the Main Hospital and one contractual suite 13.

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.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
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.

19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

A.19.3.6.3.3 Doors should not be blocked open by furniture, door stops, chocks, tie backs, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14 through 11/19/14, the doors in the facility were observed, and a staff person was interviewed.

11/17/14, Main Hospital

1. At 10:01 a.m., the corridor door to Room 632 was impeded from closing with a trash can in front of the door.

2. At 10:23 a.m., the corridor door to Room 621 was not latching when tested.

3. At 10:53 a.m., the corridor door to EVS at the fourth floor Nursing Station was not latching when tested. The latching mechanism was sticking.

4. At 11:01 a.m., the self closing corridor door to the fourth floor Nursing Station lounge was not latching when tested.

11/18/14, Main Hospital

5. At 11:04 a.m., the self-closing corridor door to the CPD lunch room was impeded from closing with a piece of cardboard wedged under the door.

11/19/14, Suite 13

6. At 9:00 a.m., the corridor door to the Ultra Sound Room was impeded from closing with a kick stop in use.

7. At 9:07 a.m., the corridor door to mammography was impeded from closing with a rubber wedge under the door.

8. At 9:09 a.m., the Director of Facilities said during an interview, that the suite 13 personnel were responsible for maintaining their facility.

Based on observation, the facility failed to maintain their automatic closing fire doors. This was evidenced by a fire door that failed to release from the magnetic hold open device, and by a fire door that failed to positive latch when tested. This could allow the spread of smoke or flames in the event of a fire. This affected 2 of 7 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes self closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During fire alarm testing with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/18/14, the doors held open by magnetic hold-open devices were observed and tested.

11/18/14, Main Hospital

1. At 10:17 a.m., the fire door 223 was not releasing from the magnetic hold device and closing.

2. At 10:42 a.m., the fire door from EVS to the hallway was not latching when tested.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls. This was evidenced by unsealed penetrations. The penetrations could result in the reduction in staff ability to protect in place due to smoke and fire. This affected 2 of 7 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/18/14, the smoke barrier walls were observed.

11/18/14, Main Hospital

1. At 12:51 p.m., there was an approximately 3 foot by 3 foot unsealed penetration in the smoke barrier wall near Operating Room 2.

2. At 12:53 p.m., there were four approximately 3 inch round unsealed penetrations in the smoke barrier wall near Operating Room 1.

3. At 1:39 p.m., there was an approximately 2 inch by 3 inch unsealed penetration in the smoke barrier wall by 109 on the first floor.

Based on observation, document review, and interview, the facility failed to maintain their emergency lighting units. This was evidenced by the failure to perform monthly and annual test for the emergency lights in Suite 105, and by emergency lights that failed to illuminate in suite 105 and the main hospital. This could leave the rooms in darkness during a power outage. This affected 1 of 7 floors in the Main Hospital and Ambulatory Surgery Suite 105.

NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/18/14, the facility emergency lighting units were observed, tested, testing documents were requested, and a staff person was interviewed.

11/18/14 Suite 105

1. At 8:41 a.m., 3 of 3 emergency lights in the hallway were not illuminating when the test button was pressed.

2. At 8:45 a.m., 2 of 2 emergency lights in the Operating Rooms (2) were not illuminating when the test button was pressed.

3. At 8:48 a.m., there was no documented evidence of testing the 5 emergency lights monthly for 30 seconds and annually for 90 minutes for suite 105.

4. At 8:55 a.m., the emergency light in the north stairwell was not illuminating when the test button was pressed.

5. At 8:58 a.m., the Director of Facilities said during an interview, that there has not been any testing of the emergency lights for approximately 12 years, since the building was unoccupied.

11/18/14, Main Hospital

6. At 12:47 p.m., the emergency light in Operating Room 1 was not illuminating when the test button was pressed. The emergency light was last tested during the month of October 2014.

Based on observation, document review, and interview, the facility failed to maintain their exit signs in Suite 105 and Suite 13. This was evidenced by the failure to perform monthly and annual tests on their exit signs equipped with an internal emergency power supply source, and by exit signs that failed to illuminate when tested. This could result in a delay in evacuation due to limited exit sign visibility. This affected Suite 105 under the facilities License, and Suite 13 Contractual Services.

NFPA 101, Life Safety Code, 2000 Edition
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/18/14 through 11/19/14, the exit signs were tested, exit sign testing documents were requested, the contractual agreement was reviewed, and a staff member was interviewed.

11/18/14, Suites 105

1. At 8:32 a.m., the exit sign to the Main Entrance was not illuminating when the test button was pressed.

2. At 8:51 a.m., the east exit sign near the back entrance was not illuminating when the test button was pressed.

11/19/14, Suite 105, and 13

3. At 9:09 a.m., there was no documented evidence of monthly 30 second tests and an annual 90 minute test for all of the exit signs in Suite 105 and Suite 13.

4. At 9:18 a.m., the contractual agreement read in part that the Contractual Suite 13 would provide all inspection and testing documentation to the hospital's Director of Facilities.

11/20/14, Suite 105, and 13

5. At 9:03 a.m., the Director of Facilities said that there was no documented testing of the exit signs for suite 105 and suite 13.

Based on observation, the facility failed to maintained the fire alarm system. This was evidenced by expired batteries in 5 of 7 Fire Alarm Control Panels in the Main Hospital, by expired batteries in Suite 105, by no monthly testing in suite 105 and Suite 13, and by no annual certification for Suite 105 and Suite 13. This could result in the fire alarm system not functioning as designed in the event of a fire. This affected 2 of 2 buildings, the Main Hospital and Building 999.

NFPA 101, Life Safety Code, 2000 Edition
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.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2, requires sealed lead acid batteries to be replaced every four years.
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
6. Batteries - Fire Alarm Systems
d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years.)

Table 7-3.2, Testing Frequencies, Item 23 - requires the system be tested monthly with the Monitoring/Supervising Station.

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14 through 11/19/14, the Fire Alarm system components were observed, testing documents were requested, and a staff person was interviewed.

11/17/14, Main Hospital

1. At 9:49 a.m., the two batteries in the fire alarm control panel on the 7th floor were dated 3/2/10 and expired on 3/2/14.

2. At 10:38 a.m., the two batteries in the fire alarm control panel on the 5th floor were dated 3/2/10 and expired on 3/2/14.

3. At 1:19 p.m., the two batteries in the fire alarm control panel on the 3rd floor were dated 3/2/10 and expired on 3/2/14.

4. At 1:41 p.m., the two batteries in the fire alarm control panel on the 2nd floor were dated 3/2/10 and expired on 3/2/14.

5. At 2:25 p.m., the two batteries in the fire alarm control panel on the 1st floor were dated 3/2/10 and expired on 3/2/14.

11/18/14, Main Hospital

6. At 9:14 a.m., the two batteries in the Main fire alarm control panel in the Plant Operations shop were dated 3/2/10 and expired on 3/2/14.

11/19/14, Suite 13

7. At 9:12 a.m., there was no documented evidence of annual testing and maintenance of fire alarm system.

11/20/14, Suite 105

8. At 9:22 a.m., the two batteries in the fire alarm control panel in Suite 105 were undated, approximately 1/4 of the batteries were covered with green corrosion that was piled approximately 1 inch above the batteries, battery acid was leaking down the positive side of the batteries on to the control panel, and the battery wires were covered with corrosion.

9. At 8:57 a.m., there was no documented evidence on monthly testing of the fire alarm system in Suite 105 and Suite 13.

10. At 8:59 a.m., there was no documented evidence of an annual certification of the fire alarm control panel in suite 105 and suite 13.

11. At 9:38 a.m., the Director of Facilities said during an interview, that there was no annual testing and certification of the fire alarm system in suite 105 and that the facility was not responsible for suite 13.

Based on document review, and interview, the facility failed to ensure that the smoke detectors were maintained. This was evidenced by no documentation of sensitivity testing. The smoke detectors could fail in the event of a fire emergency. This affected Suite 105, unoccupied, in 1 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
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.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-7.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

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 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.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-5.2.2 A permanent record of all inspections, testing and maintenance shall be provided that includes the 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 the 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/success-fully retested, device abandoned in place)

Findings:

During a tour of the facility with the Bio Med Engineer Manager on 11/20/14, the smoke detectors maintenance records were requested, and a staff person was interviewed.

11/20/14, Suite 105

1. At 9:20 a.m., there was no documented evidence of sensitivity testing of the 2 smoke detectors in Suite 105.

2. At 9:39 a.m., the Director of Facilities said during an interview, that the building had not maintained the smoke detectors since the building was unoccupied approximately 12 years ago.

Based on document review and interview, the facility failed to maintain their automatic sprinkler system and enforce the contractual agreement with suite 13. This was evidenced by the 5 year certification that failed in the main hospital, by no quarterly testing of suite 105, and by no quarterly testing of suite 13 per contractual agreement. This could result in the failure of the sprinkler system in the event of a fire. This affected 7 of 7 floors in the Main Hospital, Suite 105, and Suite 13.

NFPA 101, Life Safety Code, 2000 Edition
19.7.6 Maintenance and Testing. (See 4.6.12.)
4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

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
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

Findings:

During document review with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/19/14 through 11/20/14, the sprinkler system certification and testing documents were reviewed, and a staff person was interviewed.

11/19/14, Suite 105, Suite 13

1. At 9:12 a.m., there was no documented evidence of quarterly testing of the sprinkler system in suite 105 under the facilities license, and Suite 13 contracted services.

2. At 9:14 a.m., the contractual agreement read in part on page A number 3, Group is required to provide fire sprinkler testing.

11/19/14, Main Hospital

3. At 1:43 p.m., the facilities documented evidence of the 5 year certification indicated that it failed during testing on 12/31/13. The test indicated that the dry pipe was leaking and failed. The dry pipe allows for water to be pumped to each floor by the fire department during a fire emergency.

11/20/14

4. At 2:11 p.m., the Safety Officer said during an interview, that the facility was in the process of securing a contract to have the dry pipe replaced. The job was being evaluated by a few companies for bid. The facility was informed of the waiver process during the exit interview.

Based on observation, document review, and interview, the facility failed to maintain their fire extinguishers. This was evidenced by an expired fire extinguisher, by fire extinguishers that were missing safety seals, by fire extinguishers with the gauge in the red, by an unsecured fire extinguisher, and by fire extinguishers that were not inspected on a monthly basis. The fire extinguishers could fail and delay extinguishing a fire in the event of a fire emergency. This affected 2 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14 through 11/19/14, the fire extinguishers were observed, and a staff person was interviewed.

11/17/14, Main Hospital

1. At 9:44 a.m., the fire extinguisher gauge was in the red, indicating that the extinguisher needed to be recharged near Room 702.

2. At 1:49 p.m., the fire extinguisher gauge was in the red near C-Section, Room 3.

11/18/14, Main Hospital

3. At 10:42 a.m., the fire extinguisher in the Kitchen near Catering was missing a safety seal on the pin.

11/19/14, Suite 13

4. At 9:04 a.m., the blue and white fire extinguisher was sitting on the floor unsecured, the date on the label was 8/13/13, expired 8/13/14, with no monthly inspections.

5. At 9:05 a.m., there were 3 fire extinguishers that were installed on 6/16/14 with no monthly inspections since the installation.

6. At 9:11 a.m., the Director of Facilities said during an interview, that the personnel in suite 13 were responsible for the inspections and maintenance of their suite.

11/19/14, Main Hospital

7. At 2:59 p.m., the fire extinguisher near the street exit in the Boiler Room was missing a safety seal on the pin.

Based on document review and interview, the facility failed to maintain the humidity in their surgery rooms. This was evidenced by no documented maintenance of one building and by documented evidence of the surgery suite below 30 percent humidity. This could result in a fire. This affected 2 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.3 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 document review with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/19/14 through 11/20/14, the facility humidity logs were reviewed, and a staff person was interviewed.

11/19/14, Main Hospital

1. At 2:16 p.m., the facilities operating room humidity log indicated the acceptable range for humidity was 30% to 60%.

2. At 2:30 p.m., the humidity log for the month of November indicated that the humidity (H) was out of compliance for the following dates and operating rooms (OR):
OR 1 11/6 H 24%, 11/8 H 28%, 11/12 H 12%,
OR 2 11/6 H 24%, 11/17 H 10%, 11/18 H 20%,
OR 3 11/6 H 26%, 11/17 H 12%, 11/18 H 20%,
OR 4 11/6 H 23%, 11/17 H 10%, 11/18 H 20%,
OR 5 11/6 H 24%, 11/8 H 26%, 11/17 H 10%, 11/18 H 20%,
OR 6 11/6 H 23%, 11/8 H 25%, 11/17 H 12%, 11/18 H 20%,
OR 7 11/6 H 24%, 11/8 H 28%, 11/17 H 12%, 11/18 H 20%,
OR 8 11/6 H 22%, 11/8 H 25%, 11/17 H 10%, 11/18 H 20%,
OR 9 11/6 H 24%, 11/17 H 10%, 11/18 H 20%,
OR 10 11/6 H 22%, 11/8 H 24%, 11/17 H 10%, 11/18 H 18%,
OR 11 11/6 H 23%, 11/17 H 10%, 11/18 H 20%,
Storeroom 11/6 H 20%, 11/7 H 22%, 11/8 H 21%, 11/17 H 19%, 11/18 H 20%

3. At 2:30 p.m., the RN director said during an interview, that the operating rooms with the humidity below 30% were used.

4. At 2:43 p.m., there was no documented evidence of a policy or procedure in place for the operating rooms with the humidity below the facilities acceptable range (30% - 60%).

11/20/14, Suite 105, unoccupied
5. At 8:48 a.m., there was no documented evidence that the humidity within the 2 operating rooms in suite 105 were maintained for the last 12 of 12 months.

6. At 8:49 a.m., the Director of Facilities said during an interview, that humidity in the operating rooms in suite 105 were not maintained for the past 12 months.

Based on observation, the facility failed to maintain penetrating items through the smoke walls. This was evidenced by unsealed pipes through a wall and a ceiling. This could result in the spread of smoke or fire to other smoke compartments. This affected 2 of 7 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke 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 smoke barrier, the sleeve shall be solidly set in the smoke 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 smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14, the smoke barrier walls were observed.

11/17/14, Main Hospital

1. At 12:53 p.m., there was an approximately 2 inch unsealed pipe through the ceiling of the fourth floor Nurse Call Closet.

2. At 2:12 p.m., there was an approximately 6 inch pipe with 3 inches unsealed in the first floor shaft Room near Room 126.

Based on document review and interview, the facility failed to provide written documentation of weekly visual inspections of the emergency generator for 52 of 52 weeks for Suite 105 and 1 of 52 weeks for the Main Hospital. This could result in loss of power in the event of a power failure. This affected 2 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 99, Health Care Facilities, 1999 Edition
3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time one or more transfer switches. One transfer switch shall practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days .Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, be installed and connected to the alternate power source Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the
machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer The date and time of day for required testing shall be decided by the owner, based on facility operations.

Findings:

During document review with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/19/14, the generator maintenance records were reviewed, and staff was interviewed.

Main Hospital

1. At 1:12 p.m., there was no documented evidence of weekly inspections since 11/5/14. There was no record for the week of 11/12/14.

11/20/14, Suite 105

2. At 8:52 a.m., there was no documented evidence of testing the EPS system in suite 105 for 12 of 12 months and weekly inspections for 52 of 52 weeks.

3. At 8:54 a.m., the Director of Facilities said during an interview, that they do not have records for the EPS system in suite 105 since it has been unoccupied for the past several years.

Based on document review, and interview, the facility failed to maintain their emergency generator. This was evidenced by no EPS system connected to the facility in Suite 105. The building was unoccupied. This affected 1 of 2 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.2.2.2 Emergency System. 6. Blood, bone, and tissue banks
(a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c).
+All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5)

Findings:

During document review with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/20/14, the facility's emergency EPS system was examined, and a staff person was interviewed.

11/20/14, Suite 105
1. At 8:51 a.m., the batteries to the EPS system were disconnected and did not provide emergency power in the event of a power failure.

2. At 8:54 a.m., the Director of Facilities said during an interview, that they did not have records for the EPS system in suite 105, since it has been unoccupied for the past several years.

Based on observation and interview, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances that were plugged into multi-outlet extension cords, by utilizing extension cords as permanent wiring, by a multi-outlet extension cord that was plugged into an extension cord, and by uncovered electrical boxes. This could result in an electrical fire. This affected 4 of 7 floors in the Main Hospital and Suite 13.

NFPA 101, Life Safety Code, 2000 Edition
SECTION 9.1 UTILITIES
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
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(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

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with the Director of Facilities, the Safety Officer, and the Bio Med Engineer Manager on 11/17/14 through 11/19/14, the electrical system and components were observed, and staff was interviewed.

11/17/14, Main Hospital

1. At 9:24 a.m., there was a yellow extension cord in use in the elevator equipment room on the roof.

2. At 9:32 a.m., outside of the elevator equipment room, there was an uncovered electrical box near the door.

3. At 9:55 a.m., there was a microwave that was plugged into a multi-outlet power strip at the 7th floor Nursing Station.

4. At 10:48 a.m., there was a brown extension in use in the Med Surge Directors Office.

5. At 10:50 a.m., there was a refrigerator that was plugged into a multi-plug power strip in the 4th floor Charge Nurse Office.

6. At 1:02 p.m., there was an orange extension cord in use in Room 308.

7. At 2:29 p.m., there was a refrigerator that was plugged into a multi-plug power strip in the Director of Paranatal Services Office.

11/18/14, Main Hospital

8. At 11:06 a.m., there was a microwave in the CPD lunch room that was plugged into a multi-plug power strip.

11/19/14, Suite 13

9. At 9:02 a.m., there was a four plug extension cord in use in the CT Scan Room.

10. At 9:03 a.m., the Safety Officer said during an interview, that the four plug extension cords do not meet the UL waiver requirements.