HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by an unsealed ceiling and wall penetrations. This affected two of three floors at the Outpatient Services building, and could result in the passage of smoke in the event of a fire.

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

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

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

Findings:

During a tour of the facility with the Staff on 4/14/15, the ceilings and walls were observed.

Outpatient Services Building, Medical Therapy Center - Second Floor

1. At 2:36 p.m., there were 21 ceiling penetrations that measured approximately 1/4 inch to 3/4 inch around metal conduit pipes, in the Electrical Closet. When interviewed, the Chief Stationary Engineer stated that he will inform the owner of the building of the penetrations.

Ground Floor

2. At 2:40 p.m., there was an approximately 1/2 inch penetration around a water pipe, in the Closet near the Electrical Panel Room. When interviewed, the Chief Stationary Engineer stated that he will inform the owner of the building of the penetration.

Based on observation and interview, the facility failed to maintain its corridor doors. This was evidenced by a corridor door that failed to close and positive latch, and by a corridor door that was obstructed from closing. This could result in the passage of smoke in the event of a fire, and affected one of three floors at the Outpatient Services building, and one of six floors at the Main Hospital.

Findings:

During a tour of the facility with the Staff on 4/14/15 and 4/15/15, the corridor doors were observed.

Outpatient Services Building, Medical Therapy Center
4/14/15 - Second Floor

1. At 2:39 p.m., the door latch to the Staff Lounge obstructed the door from closing. When interviewed, the Chief Stationary Engineer stated that he will inform the owner of the building.


Main Hospital
4/15/15 - Third Floor

2. At 2 p.m., the door to Room 314 was equipped with a self-closuring device. The door failed to latch when manually tested. When interviewed, the Chief Stationary Engineer stated that the self-closure needed adjustment.

Based on observation and interview, the facility failed to maintain their hazardous areas. This was evidenced by a door to a hazardous area that was not equipped with a self-closing device. This affected one of six floors at the Main Hospital, and could result in the passage of smoke in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded
by a fire barrier having a 1-hour fire resistance rating
or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies
and equipment in quantities deemed hazardous by the
authority having jurisdiction
(8) Laboratories employing flammable or combustible materials
in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more
than 48 in. (122 cm) above the bottom of the door.

Findings:

During a tour of the facility with the Staff on 4/15/15, the hazardous areas were observed.

At 2:30 p.m., the door to Soiled Linen Room 245 located on the second floor, was not equipped with a self-closing device. When interviewed, the Chief Stationary Engineer confirmed the finding, and stated that the self-closing device is currently being repaired.

Based on observation, document review and interview, the facility failed to maintain its battery-powered emergency lighting. This was evidenced by an emergency light that failed to illuminate when tested, and by the lack of documentation of monthly and annual testing for the battery-powered emergency light. This affected one of three floors at the Outpatient Services Building, and could result in a failure to provide backup lighting at the generator in the event of an emergency.

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 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During document review, testing, and a tour of the facility with the Staff on 4/14/15, the documents for the battery-powered emergency lighting were requested, and the emergency light was tested.

Outpatient Services Building

1. At 2:56 p.m., the battery-powered emergency lighting in the X-Ray Room located in the basement failed to illuminate when tested. When interviewed, the Chief Stationary Engineer confirmed the finding and stated that he will inform the owner of the building.

2. At 3 p.m., the facility failed to provide documentation for the monthly and annual test of the emergency lighting. When interviewed, the Director of Facilities stated that the 1 1/2 hour annual and the 30 second monthly tests were not conducted.

Based on interview and document review, the facility failed to conduct fire drills at least quarterly, on each shift, as evidenced by 3 of 4 missing fire drills during a twelve month period. This could lead to staff not understanding the evacuation procedures in the event of an emergency and affected the Outpatient Services building.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review with Director of Facilities and Chief Stationary Engineer on 4/13/15, the fire drill records were requested.

At 9:45 a.m., the fire drill records for the Outpatient Services building was reviewed. The facility conducted one of four fire drills in the past twelve months. When interviewed, the Director of Facilities stated that they thought fire drills for clinics were only required once per year in an business occupancy.

Based on interview, document review and observation, the facility failed to maintain their Automatic Sprinkler System, as evidenced by the failure to provide quarterly/annual testing of the automatic sprinkler system, and by the inability to test the Inspector's Test Valve and Main Drain. This could lead to a malfunction of the automatic sprinkler system in the event of an emergency, and affected the Outpatient Services building.

NFPA 101 Life Safety Code, 2000 edition
19.7.6 Maintenance and Testing. (See 4.6.12.)
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

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 authority having jurisdiction.

9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, waterflow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

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.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6 Sprinkler Waterflow Alarm -Initiating Devices.
2-6.1 The provisions of Section 2-6 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.
2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

Outpatient Services Building

During fire alarm system testing with the Chief Stationary Engineer and Director of Facilities on 4/15/15, the automatic sprinkler system was observed and documentation was reviewed.

At 1:15 p.m., the main drain was tested. The Engineer opened the main drain valve and water began to leak from the drain connection piping. The main drain valve was immediately closed. During document review, the last test of sprinkler system conducted on 2/13/13 by the vendor failed. The deficiencies on the report titled, " Inspection, Testing, and Maintenance Fire Sprinkler System " dated 2/13/13 stated that the "Main Drain test can not be performed because of leak in drain connection piping and floor sink can not handle water being discharged". When interviewed, the Chief Stationary Engineer and Director of Facilities stated that they thought the building owner was conducting the necessary testing/maintenance. Both stated that the hospital has a new vendor coming in to take over the maintenance/testing of the fire alarm systems and sprinkler systems, and that this location will be handled by the new vendor also.

At 1:30 p.m., the Inspector's Test Valve was requested to be tested. The Inspector's Test Valve could not be tested. The alarm technician onsite stated that he did not know the location of the Inspector's Test Valve and did not have any keys with him. During document review of the sprinkler system vendor report titled "Inspection, Testing, and Maintenance Fire Sprinkler System", dated 2/15/13, the vendor stated "Cannot perform inspection's test because of leak in drain connection and floor sink can not handle water being discharged". The facility did not provide any additional paperwork documenting the testing and/or repair of the Inspector's Test Valve after the vendor report dated 2/15/13.

Based on observation and interview, the facility failed to maintain its portable fire extinguishers. This was evidenced by a portable fire extinguisher that was obstructed from immediate access. This affected one of six floors in the Main Hospital, and could result in a delay in access to the fire extinguishers, resulting in the spread of smoke and/or fire.

NFPA 101, Life Safety Code, 2000 Edition
9.7.4 Manual Extinguishing Equipment.
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
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
Chapter 4 Inspection, Maintenance and Recharging
4-3.4 Inspection Recordkeeping.
4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.
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.
4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.
4-4 Maintenance.
4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.
4-4.4 Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Findings:

During a tour of the facility with the Staff on 4/15/15, the portable fire extinguishers were observed.

Main Hospital
At 10 a.m., the fire extinguisher in Operating Room 2 located on the 5th floor, was obstructed from immediate access by medical equipment. A staff in the OR 2 moved the medical equipment away from the fire extinguisher.

Based on document review and interview, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity levels in 2 of 2 operating rooms between 30 % and 60%, per the facility's policy. This affected 2 of 2 operating rooms, and could result in a fire emergency due to electrostatic charges in an oxygen rich environment.

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 Engineering Staff on 4/14/15, the facility's humidity logs were reviewed.

At 1:30 p.m., the humidity logs were reviewed. The "Daily Relative Humidity/Temperature Record" noted the temperature and humidity levels for Operating Rooms 1 and 2. The relative humidity levels in December 2014, January 2015 and February 2015 were below 20%, and the relative humidity levels in July 2014, August 2014, September 2014 and November 2014 were above 60%. The Policy and Procedure indicated that the humidity would be maintained between 30% to 60%.

Operating Room 1:
1. On 2/23/15, the humidity level was at 4%. In the "Engineer Actions" column of the "Relative Humidity/Temperature Action Log Sheet", stated "verified humidity, OR1-4%, OR2-27%. Advised OR staff of fire precaution. Have bowl of water available. Advised OR Mgr to inform surgeon, anesthesiologist regarding oxygen use, and correct grounding".
2. On 1/2/15, the humidity level was at 27%.
3. On 12/31/14, the humidity level was at 13%.
4. On 11/13/14, the humidity level was at 61%. In the "Engineer Actions" column of the "Relative Humidity/Temperature Action Log Sheet", stated "verified humidity. Advised OR staff of fire precaution. Have bowl of water available. Advised OR Mgr to inform surgeon, anesthesiologist regarding oxygen use, and correct grounding".
5. On 9/25/14, the humidity level was at 67%.
6. On 9/10/14, the humidity level was at 61%.
7. On 8/6/14, the humidity level was at 61%.
8. On 8/5/14, the humidity level was at 61%.
9. On 8/4/14, the humidity level was at 61%.
10. On 7/29/14, the humidity level was at 62%.
11. On 7/23/14, the humidity level was at 65%.
12. On 7/16/14, the humidity level was at 64%.

Operating Room 2:
13. On 2/23/15, the humidity level was 12%. In the "Engineer Actions" column of the "Relative Humidity/Temperature Action Log Sheet", stated "verified humidity, OR1-4%, OR2-27%. Advised OR staff of fire precaution. Have bowl of water available. Advised OR Mgr to inform surgeon, anesthesiologist regarding oxygen use, and correct grounding".
14. On 1/2/15, the humidity level was 23%.
15. On 12/30/14, the humidity level was at 25%.
16. On 12/31/14, the humidity level was at 13%.
17. On 9/25/14, the humidity level was at 61%.
18. On 7/23/14, the humidity level was at 62%.
19. On 7/22/14, the humidity level was at 61%.
20. On 7/16/14, the humidity level was at 61%.

At 9:09 a.m. on 4/15/15, the Director of Facilities was interviewed. The Director of Facilities stated that there is an air handler issue in the existing operating rooms. The air handlers are scheduled to be replaced in 2016 after the move to the new hospital tower.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by an unsealed ceiling and wall penetrations. This affected two of three floors at the Outpatient Services building, and could result in the passage of smoke in the event of a fire.

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

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

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

Findings:

During a tour of the facility with the Staff on 4/14/15, the ceilings and walls were observed.

Outpatient Services Building, Medical Therapy Center - Second Floor

1. At 2:36 p.m., there were 21 ceiling penetrations that measured approximately 1/4 inch to 3/4 inch around metal conduit pipes, in the Electrical Closet. When interviewed, the Chief Stationary Engineer stated that he will inform the owner of the building of the penetrations.

Ground Floor

2. At 2:40 p.m., there was an approximately 1/2 inch penetration around a water pipe, in the Closet near the Electrical Panel Room. When interviewed, the Chief Stationary Engineer stated that he will inform the owner of the building of the penetration.

Based on observation and interview, the facility failed to maintain its corridor doors. This was evidenced by a corridor door that failed to close and positive latch, and by a corridor door that was obstructed from closing. This could result in the passage of smoke in the event of a fire, and affected one of three floors at the Outpatient Services building, and one of six floors at the Main Hospital.

Findings:

During a tour of the facility with the Staff on 4/14/15 and 4/15/15, the corridor doors were observed.

Outpatient Services Building, Medical Therapy Center
4/14/15 - Second Floor

1. At 2:39 p.m., the door latch to the Staff Lounge obstructed the door from closing. When interviewed, the Chief Stationary Engineer stated that he will inform the owner of the building.


Main Hospital
4/15/15 - Third Floor

2. At 2 p.m., the door to Room 314 was equipped with a self-closuring device. The door failed to latch when manually tested. When interviewed, the Chief Stationary Engineer stated that the self-closure needed adjustment.

Based on observation and interview, the facility failed to maintain their hazardous areas. This was evidenced by a door to a hazardous area that was not equipped with a self-closing device. This affected one of six floors at the Main Hospital, and could result in the passage of smoke in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded
by a fire barrier having a 1-hour fire resistance rating
or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies
and equipment in quantities deemed hazardous by the
authority having jurisdiction
(8) Laboratories employing flammable or combustible materials
in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more
than 48 in. (122 cm) above the bottom of the door.

Findings:

During a tour of the facility with the Staff on 4/15/15, the hazardous areas were observed.

At 2:30 p.m., the door to Soiled Linen Room 245 located on the second floor, was not equipped with a self-closing device. When interviewed, the Chief Stationary Engineer confirmed the finding, and stated that the self-closing device is currently being repaired.

Based on observation, document review and interview, the facility failed to maintain its battery-powered emergency lighting. This was evidenced by an emergency light that failed to illuminate when tested, and by the lack of documentation of monthly and annual testing for the battery-powered emergency light. This affected one of three floors at the Outpatient Services Building, and could result in a failure to provide backup lighting at the generator in the event of an emergency.

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 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During document review, testing, and a tour of the facility with the Staff on 4/14/15, the documents for the battery-powered emergency lighting were requested, and the emergency light was tested.

Outpatient Services Building

1. At 2:56 p.m., the battery-powered emergency lighting in the X-Ray Room located in the basement failed to illuminate when tested. When interviewed, the Chief Stationary Engineer confirmed the finding and stated that he will inform the owner of the building.

2. At 3 p.m., the facility failed to provide documentation for the monthly and annual test of the emergency lighting. When interviewed, the Director of Facilities stated that the 1 1/2 hour annual and the 30 second monthly tests were not conducted.

Based on interview and document review, the facility failed to conduct fire drills at least quarterly, on each shift, as evidenced by 3 of 4 missing fire drills during a twelve month period. This could lead to staff not understanding the evacuation procedures in the event of an emergency and affected the Outpatient Services building.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review with Director of Facilities and Chief Stationary Engineer on 4/13/15, the fire drill records were requested.

At 9:45 a.m., the fire drill records for the Outpatient Services building was reviewed. The facility conducted one of four fire drills in the past twelve months. When interviewed, the Director of Facilities stated that they thought fire drills for clinics were only required once per year in an business occupancy.

Based on interview, document review and observation, the facility failed to maintain their Automatic Sprinkler System, as evidenced by the failure to provide quarterly/annual testing of the automatic sprinkler system, and by the inability to test the Inspector's Test Valve and Main Drain. This could lead to a malfunction of the automatic sprinkler system in the event of an emergency, and affected the Outpatient Services building.

NFPA 101 Life Safety Code, 2000 edition
19.7.6 Maintenance and Testing. (See 4.6.12.)
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

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 authority having jurisdiction.

9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, waterflow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

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.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6 Sprinkler Waterflow Alarm -Initiating Devices.
2-6.1 The provisions of Section 2-6 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.
2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

Outpatient Services Building

During fire alarm system testing with the Chief Stationary Engineer and Director of Facilities on 4/15/15, the automatic sprinkler system was observed and documentation was reviewed.

At 1:15 p.m., the main drain was tested. The Engineer opened the main drain valve and water began to leak from the drain connection piping. The main drain valve was immediately closed. During document review, the last test of sprinkler system conducted on 2/13/13 by the vendor failed. The deficiencies on the report titled, " Inspection, Testing, and Maintenance Fire Sprinkler System " dated 2/13/13 stated that the "Main Drain test can not be performed because of leak in drain connection piping and floor sink can not handle water being discharged". When interviewed, the Chief Stationary Engineer and Director of Facilities stated that they thought the building owner was conducting the necessary testing/maintenance. Both stated that the hospital has a new vendor coming in to take over the maintenance/testing of the fire alarm systems and sprinkler systems, and that this location will be handled by the new vendor also.

At 1:30 p.m., the Inspector's Test Valve was requested to be tested. The Inspector's Test Valve could not be tested. The alarm technician onsite stated that he did not know the location of the Inspector's Test Valve and did not have any keys with him. During document review of the sprinkler system vendor report titled "Inspection, Testing, and Maintenance Fire Sprinkler System", dated 2/15/13, the vendor stated "Cannot perform inspection's test because of leak in drain connection and floor sink can not handle water being discharged". The facility did not provide any additional paperwork documenting the testing and/or repair of the Inspector's Test Valve after the vendor report dated 2/15/13.

Based on observation and interview, the facility failed to maintain its portable fire extinguishers. This was evidenced by a portable fire extinguisher that was obstructed from immediate access. This affected one of six floors in the Main Hospital, and could result in a delay in access to the fire extinguishers, resulting in the spread of smoke and/or fire.

NFPA 101, Life Safety Code, 2000 Edition
9.7.4 Manual Extinguishing Equipment.
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
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
Chapter 4 Inspection, Maintenance and Recharging
4-3.4 Inspection Recordkeeping.
4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.
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.
4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.
4-4 Maintenance.
4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.
4-4.4 Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Findings:

During a tour of the facility with the Staff on 4/15/15, the portable fire extinguishers were observed.

Main Hospital
At 10 a.m., the fire extinguisher in Operating Room 2 located on the 5th floor, was obstructed from immediate access by medical equipment. A staff in the OR 2 moved the medical equipment away from the fire extinguisher.

Based on document review and interview, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity levels in 2 of 2 operating rooms between 30 % and 60%, per the facility's policy. This affected 2 of 2 operating rooms, and could result in a fire emergency due to electrostatic charges in an oxygen rich environment.

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 Engineering Staff on 4/14/15, the facility's humidity logs were reviewed.

At 1:30 p.m., the humidity logs were reviewed. The "Daily Relative Humidity/Temperature Record" noted the temperature and humidity levels for Operating Rooms 1 and 2. The relative humidity levels in December 2014, January 2015 and February 2015 were below 20%, and the relative humidity levels in July 2014, August 2014, September 2014 and November 2014 were above 60%. The Policy and Procedure indicated that the humidity would be maintained between 30% to 60%.

Operating Room 1:
1. On 2/23/15, the humidity level was at 4%. In the "Engineer Actions" column of the "Relative Humidity/Temperature Action Log Sheet", stated "verified humidity, OR1-4%, OR2-27%. Advised OR staff of fire precaution. Have bowl of water available. Advised OR Mgr to inform surgeon, anesthesiologist regarding oxygen use, and correct grounding".
2. On 1/2/15, the humidity level was at 27%.
3. On 12/31/14, the humidity level was at 13%.
4. On 11/13/14, the humidity level was at 61%. In the "Engineer Actions" column of the "Relative Humidity/Temperature Action Log Sheet", stated "verified humidity. Advised OR staff of fire precaution. Have bowl of water available. Advised OR Mgr to inform surgeon, anesthesiologist regarding oxygen use, and correct grounding".
5. On 9/25/14, the humidity level was at 67%.
6. On 9/10/14, the humidity level was at 61%.
7. On 8/6/14, the humidity level was at 61%.
8. On 8/5/14, the humidity level was at 61%.
9. On 8/4/14, the humidity level was at 61%.
10. On 7/29/14, the humidity level was at 62%.
11. On 7/23/14, the humidity level was at 65%.
12. On 7/16/14, the humidity level was at 64%.

Operating Room 2:
13. On 2/23/15, the humidity level was 12%. In the "Engineer Actions" column of the "Relative Humidity/Temperature Action Log Sheet", stated "verified humidity, OR1-4%, OR2-27%. Advised OR staff of fire precaution. Have bowl of water available. Advised OR Mgr to inform surgeon, anesthesiologist regarding oxygen use, and correct grounding".
14. On 1/2/15, the humidity level was 23%.
15. On 12/30/14, the humidity level was at 25%.
16. On 12/31/14, the humidity level was at 13%.
17. On 9/25/14, the humidity level was at 61%.
18. On 7/23/14, the humidity level was at 62%.
19. On 7/22/14, the humidity level was at 61%.
20. On 7/16/14, the humidity level was at 61%.

At 9:09 a.m. on 4/15/15, the Director of Facilities was interviewed. The Director of Facilities stated that there is an air handler issue in the existing operating rooms. The air handlers are scheduled to be replaced in 2016 after the move to the new hospital tower.