HospitalInspections.org

Based on observation and document review, the facility failed to maintain fire rated occupancy separations in accordance with NFPA 101, 2000 Edition. This was evidenced by failing to provide a 90-minute (1 1/2 hour) fire rated door at an occupancy separation. This reduced the appropriate fire protection that could result in injury to the patients during a fire. This affected the occupancy separation on 1 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.1.2.1 Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
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 protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating

NFPA 80, Standard for Fire Doors and Fire Windows 1999 Edition.
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the facility's occupancy separation barriers were observed with the Emergency Preparedness Manager (MNG 75) and the Supervisor of Plant Operations (SUP 73).

Hospital A, First Floor:
On 10/27/15, at 9:08 a.m., the occupancy separation that was observed on the 1st Floor between Hospital A and the Medical Office Building (MOB) did not have the appropriate fire protection rating to include 90-minutes (1.5 hours) fire rated doors. The Life Safety floor plans identified the separation between the two buildings. The double fire doors had a label on each door that rated them for 20-minutes each.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations on the wall. This could result in the spread of fire and smoke, increasing the risk of injury to patients. This affected 3 of 6 floors in Hospital A and 2 of 4 floors in Hospital B.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the facility's walls and ceilings were observed with the Emergency Preparedness Manager (MNG 75) and the Director of Plant Operations (DPO).

Hospital A:
1. On 10/28/15, at 8:44 a.m., the wall to the staff locker room, located in Obstetric Care Unit on the 4th Floor, was observed to have an opening through the wall. The opening was located underneath the sink and it measured approximately 12-inches by 16-inches. The opening exposed the wooden stud frame.

2. At 8:48 a.m., the wall to the doctor's dictation room, located in Obstetric Care Unit on the 4th Floor, was observed to have an opening through the wall. The opening was located underneath the sink and it measured approximately 16-inches by 24-inches. The opening exposed the wooden stud frame.

3. At 10:25 a.m., the wall to Conference Room C, located in the lobby area on the 3rd Floor, was observed to have a penetration through the wall. The penetration measured approximately 3-inches by 4-inches.

4. At 11:19 a.m., the wall to passageway between Rooms 357 and 364, located in the Admin Holding Unit on the 3rd Floor, was observed to have two penetrations through the wall. The penetrations measured approximately 1/2-inch each.

Hospital B:
5. On 10/29/15, at 3:11 p.m., the wall behind the door to the Med Room, located in the North side on the 2nd Floor, was observed to have a penetration through the wall. The penetration measured approximately 1/2-inch.

6. At 4 p.m., the wall to the Room labeled as Nurse Station 13, located in the North side on the Basement Floor, was observed to have a penetration through the wall. The penetration measured approximately 2-inches diameter.



21101


Hospital A:
7. On 10/29/15, at 9:08 a.m., there were 3 holes in the wall located above the sink in the respiratory break room, located on the 1st Floor. This was acknowledged by the DPO during the survey.

Based on observation, the facility failed to maintain their door to prevent the passage of smoke during fire. This was evidenced by a door that failed to positive latch. This had the potential to allow the migration of smoke and result in injury to patients. This affected the Cottage of Hospital B.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the doors were observed with the Emergency Preparedness Manager (MNG 75).

Cottage of Hospital B:
On 10/29/15, at 4:06 p.m., the door to the closet, located next to Room 14L on the 1st Floor, failed to positive latch.

Based on observation, the facility failed to maintain their smoke barrier doors in accordance with NFPA 101, 2000 Edition. This was evidenced by smoke barrier doors that failed to close and positive latch. This could result in the spread of smoke and fire, increasing the risk of injury to patients. This affected 4 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.
1-6.1 Only labeled fire doors shall be used.
3-1.4 Operation of Doors. The doors shall swing easily and freely on their hinges. The latches shall operate freely.
3-4.3.2 Components. Fire door hardware shall include hinge brackets, hinges, latches, latch keepers, and operating handle mechanisms; hardware for inactive door or pairs of doors includes top and bottom bolts and keepers.
15-1.4 Repairs. Repairs shall be made and defects that could interfere with operation shall be corrected immediately.
15-2.1 Inspections.
15-2.1.1 Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately.
15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the fire doors were observed with the Director of Plant Operations (DPO), the Supervisor of Plant Operations (SUP 73), the Emergency Preparedness Manager (MNG 75), and the Public Safety Manager (MNG 74).

Hospital A:
1. On 10/27/15, at 10:13 a.m., the fire door to the North Stairwell, located by the Information System Room on the 2nd Floor, had its fire rating label covered with paint.

2. On 10/28/15, at 9:27 a.m., the fire door to the middle elevator on the 4th floor failed positive latch when it was manually closed.

3. At 9:29 a.m., the fire door to the right elevator on the 4th floor failed positive latch when it was manually closed.

4. On 10/29/15, at 9:03 a.m., the fire door that seperates the doctors dictation room and the Angio Room, located in the Radiology Department on 3rd floor, failed positive latch when it was manually closed.

5. At 1:05 p.m., 1 of 2 cross corridor fire doors, located by the gift shop on the 3rd floor failed positive latch when a smoke detector was activated in the area.

6. At 1:14 p.m., 2 of 2 cross corridor fire doors, located by the door labeled as Anesthesia Office on the 3rd floor, failed positive latch when a smoke detector was activated in the area.

7. At 1:24 p.m., 2 of 2 cross corridor fire doors, located by the door labeled as CT Scan on the 3rd floor, failed positive latch when a smoke detector was activated in the area.


21101


Hospital A:
8. On 10/29/15, at 10:44 a.m., the fire door leaf near Room 544 on the 5th Floor, failed to close and latch upon activation of the fire alarm system.

9. At 11:08 a.m., the fire door leaf entering the Spine and Joint unit on the 4th Floor, failed to close and latch upon activation of the fire alarm system.

10. At 11:12 a.m., the fire door leaf near Room 352 entering Admit Holding Unit on the 3rd Floor, failed to close and latch upon activation of the fire alarm system.

Based on observation, the facility failed to maintain a safe means of egress in accordance with NFPA 101, 2000 Edition. This was evidenced by a walking surface in the exit discharge that contained a slope with abrupt changes in elevation, its pathway width was less than 4-feet, its pathway was non-slip resistant, no handrails or guards provided, and the pathway to the public way was not evident. This had the potential of interfering with safe egress during an emergency evacuation, resulting in injury to patients, visitors, and staff. This affected 1 of 4 emergency exit routes on the 3rd Floor East portion of Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.2.3.3* Any required aisle, corridor, or ramp shall be not less than 4 ft (1.2 m) in clear width where serving as means of egress from patient sleeping rooms. The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with
Chapter 7.
7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (0.6 cm). Changes in elevation exceeding 1/4 in. (0.6 cm), but not exceeding 1/2 in. (1.3 cm), shall be beveled 1 to 2. Changes in elevation exceeding 1/2 in. (1.3 cm) shall be considered a change in level and shall be subject to the requirements of 7.1.7.
7.1.6.3 Level. Walking surfaces shall be nominally level. The slope of a walking surface in the direction of travel shall not exceed 1 in 20 unless the ramp requirements of 7.2.5 are met. The slope perpendicular to the direction of travel shall not exceed 1 in 48.
7.1.6.4 Slip Resistance. Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.
7.1.7.1 Changes in level in means of egress shall be achieved either by a ramp or a stair where the elevation difference
exceeds 21 in. (53.3 cm).
7.2.12.2.2 Required portions of an area of refuge shall have
access to a public way, without requiring return to the building spaces through which travel to the area of refuge occurred, via an exit or an elevator.
7.2.5.2 Dimensional Criteria. Ramps shall be in accordance with the following:
(1) New ramps shall be in accordance with Table 7.2.5.2(a).
Table 7.2.5.2(a) New Ramps
Minimum width clear of all obstructions, except projections not more than 31/2 in. (8.9 cm) at or below handrail
height on each side 44 in. (112 cm)
Maximum slope 1 in 12
Maximum cross slope 1 in 48
Maximum rise for a single ramp run 30 in. (76 cm)
7.2.5.4 Guards and Handrails. Guards complying with 7.2.2.4 shall be provided for ramps. Handrails complying with 7.2.2.4 shall be provided along both sides of a ramp run with a rise greater than 6 in. (15.2 cm). The height of handrails and guards shall be measured vertically to the top of the guard or rail from the walking surface adjacent thereto.
7.2.12.2.3* Where the exit providing egress from an area of refuge to a public way that is in accordance with 7.2.12.2.2 includes stairs, the clear width of landings and stair flights, measured between handrails and at all points below handrail height, shall not be less than 48 in. (122 cm).
7.7.1* Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other
portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the exits, exit access, and exit discharges were observed with the Emergency Preparedness Manager (MNG 75).

Hospital A:
On 10/27/15, at 10:13 a.m., the exit discharge by the Electrical Room, located on the East portion of the building on the 3rd Floor between Same Day Surgery and the Behavioral Health Unit, had a pathway not safe for patients. The evacuation plans posted in the corridor by the Same Day Surgery and in the corridor in the Behavioral Health Unit highlighted evacuation routes to this exit discharge and exit signs were installed above the door. The concrete slab by the door decreased its walking surface to less than 4-feet as it curved to the left and ended into a dirt trail. Towards the South and West portion of the discharge there was a vertical drop that exceeded 21-inches and with no handrail or guard protection. The walking surface to the dirt trail could become slippery during wet conditions. The pathway to the public way was not clearly identified or visible.

Based on observation, the facility failed to maintain battery powered emergency lights. This was evidenced by battery powered emergency lights that failed to illuminate when tested. This could result in injury during a power outage. This affected the Cottage of Hospital B.

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

Findings:

During the facility tour on 10/27/15 through 10/30/15, the battery powered emergency lights were observed with the Emergency Preparedness Manager (MNG 75).

Cottage of Hospital B:
On 10/29/15, at 4:12 p.m., the battery powered emergency lighting unit in the Main Group Room, located on the 1st Floor, failed to illuminate when pushing down on the test button.

Based on document review and interview, the facility failed to hold fire drills at least quarterly for each shift, as evidenced by no documentation for 4 of 12 required fire drills for the past 12 months. This failure could result in staff not familiar with the fire evacuation procedures and affected 3 of 3 floors in Hospital B..

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.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During records review with the DPO (Director of Plant Operations) on 10/27/15 through 10/29/15, the fire drill reports were observed.

Hospital B:
On 10/28/15, at 10:36 a.m., the facility failed to provide documentation of conducting fire drills in Hospital B for the second quarter AM shift and PM shift (April, May, June during 2015), for the third quarter NOC shift (July, August September during 2015) and for the fourth quarter NOC shift (October, November, December during 2015/2014). During interview, the DPO stated some of the drills were held in another location on the same campus. The DPO was asked if Hospital B staff participated in fire drills held in other areas located on campus, the DPO stated "no" the staff from Hospital B do not participate in the fire drills.

Based on observation and interview, the facility failed to ensure that the fire alarm system was maintained in accordance with NFPA 101, 2000 edition. This was evidenced by the fire alarm not heard throughout all occupied spaces and evidenced by keys that failed to activate the fire alarm system. This had the potential for the occupants not be notified of a fire in the building and could delay the evacuation of patients. This affected 1 of 6 floors at Hospital A and 1 of 3 floors in Hospital B.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
9.6.3 Occupant Notification.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.
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.

Findings:

During the facility tour with the DPO, SUP 73, MNG 74 and MNG 75, on 10/27/15 through 10/30/15, the fire alarm system was tested by staff and observed.

Hospital A, First Floor:
1. On 10/29/15, at 1:50 p.m., the fire alarm was not heard throughout the doctors staff dining room and dictation room during activation of the fire alarm system. There was no audible or visual notification device installed in the area that could be heard. This was acknowledged by DPO during the testing of the fire alarm system.

Hospital B, Second Floor:
2. At 3:10 p.m., the manual fire alarms that required a key to activate the alarm were tested. Three staff members were asked to use their key to activate the manual fire alarm located across from the second floor nurse station. The Keys to the first and second staff failed to activate the manual fire alarm, a third staff was asked to use her key. The third staff key worked and activated the fire alarm. The two keys that failed to activate the manual fire alarm were taken by the DPO and MNG 74 and were tested at another manual fire alarm, where they also failed. The DPO stated one of the keys was bent and did not know why the second key would not work.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system, as evidenced by the sprinkler control valve failure to transmit a visual supervisory trouble signal at the fire alarm control panel when the valve was closed. This had the potential for the sprinkler valve to be tampered with and no visual signal to notify facility staff of a system failure. This affected the Cottage of Hospital B.

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

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire Alarms, Supervisory signals, and trouble signals shall be distinctively and descriptively annunciated .
1-5.4.6.1 Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Control unit (central equipment) for protected premises fire alarm systems
(2) Building fire command center for emergency voice/alarm communications service
(3) Central station or remote station location for systems installed in compliance with Chapter 5
3-8.3.3.1.3 Signals shall distinctively indicate the particular function (e.g., valve position, temperature, or pressure) of the system that is off-normal and also indicate its restoration to normal.
3-8.3.4.2 The integrity of each fire suppression system actuating device and its circuit shall be supervised in accordance with 1-5.8.1 and with other applicable NFPA standards.
Table 7-2.2
10. Remote Annunciators The correct operation and identification of annunciators shall be verified. If provided, the correct operation of annunciator under a fault condition shall be verified.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

Findings:

During the testing of the automatic sprinkler system with the DPO, SUP 73, MNG 74, MNG 75 and Maintenance Staff 1 and Staff 2, on 10/30/15, the sprinkler valves were observed and tested.

The Cottage at Hospital B:
At 10:05 a.m., on 10/30/15, the tamper valve was closed by the Maintenance Staff. The fire alarm control panel did not have a visual signal indicating a supervisory trouble when the valve was in the closed position. The tamper valve was tested three times by the Maintenance Staff and failed to transmit a visual trouble signal to the fire alarm control panel. The DPO stated he was not aware the tamper alarm was not transmitting a visual trouble signal to the fire alarm control panel.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinkler heads with debri and were obstructed. This affected the operation of the sprinkler head that could cause delay and inefficient coverage during a fire, resulting in injury to patients. This affected 2 of 6 floors in Hospital A and the Cottage of Hospital B.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
7-3.4.1* System Piping and Fittings. System piping and fittings shall be inspected for the following:
(b) External conditions (e.g., missing or damaged paint or coatings, rust, and corrosion)

Findings:

During the facility tour on 10/27/15 through 10/30/15, the sprinkler system was observed with the Emergency Preparedness Manager (MNG 75).

Hospital A:
1. On 10/28/15, at 9:46 a.m., the sprinkler head in Patient Room 321, located in 3East on the 3rd Floor, had toilet paper around the fusible link.

2. On 10/29/15, at 9:45 a.m., the two upright type sprinkler heads in the Receiving Area, located on the 2nd Floor, were covered by cloth towels.

3. At 9:59 a.m., the pendant type sprinkler head inside the Pharmacy Storage Supply Room, located on the 2nd Floor, had a damaged deflector. The deflector's teeth were bent upward.

The Cottage at Hospital B:
4. At 4:05 p.m., the exterior pipes on the West side of the building contained rust throughout the pipe line.

Based on observation, the facility failed to maintain their kitchen's fire extinguishing system. This was evidenced by the a nozzle in the kitchen hood fire suppression system that did not have cap. This could increase the chance of not extinguishing fire in the kitchen due to accumulation of grease inside the nozzles. This affected 1 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and and Fire Protection of Commercial Cooking Equipment, 1998 Edition
10-6.4 The entire hood plenum and the blower section shall be cleaned a minimum of once every 3 months.
7-2.2.1 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable.
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 1998 Edition
2-3.1.4 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping. The protection device shall blow off, open, or blow out upon agent discharge.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the kitchen fire-suppression system was observed with the Emergency Preparedness Manager (MNG 75).

On 10/29/15, at 9:37 a.m., the kitchen hood fire suppression system, located in the cafe on the 2nd Floor, was observed to be missing cap on 1 of 2 nozzles pointing directly into the fryer.

Based on document review and interview, the facility failed to maintain the emergency generator, as evidence by incomplete documentation for the weekly inspections for 2 of 2 emergency generators. This could result in the failure of the emergency generator to provide power to the facility's Life Safety systems in the event of a power outage and had the potential to increased the risk of injury to patients. This affected 6 of 6 floors in Hospital A.

Findings:

During the records review with DPO and MNG 74, on 10/27/15, the weekly inspections for the two (550KW and 1050KW) emergency generators in Hospital A were reviewed.

Hospital A:
On 10/27/15, at 9:58 a.m., the facility failed to provide records of weekly inspections for the 550 KW emergency generator during the following weeks: 5/9/15, 5/4/15, 3/7/15, 4/4/15, 4/25/15, 12/6/14 and for 12/13/15. The facility failed to provide records of weekly inspections for the 1050 KW emergency generator during the week of 5/9/15 and 4/4/15. This was acknowledged by the Director of Plant Operations "DPO" during survey.

Based on observation and interview, the facility failed to maintain electrical safety in accordance with NFPA 70, 1999 Edition as evidenced by an appliance plugged into a multi-outlet power strip and power strips plugged into another power strips. This had the potential to overload the power strips with a high load appliance and could result in an increased risk of an electrical fire. This affected 1 of 1 smoke compartments at the Senior Health Center, 1 of 3 floors in Hospital B, and 2 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code (1999) Edition
110-12(c) Integrity of Electrical Equipment and Connections.
Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.
110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.
400-8. Uses not permitted.
Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with DPO, on 10/27/15 through 10/30/15, the electrical components were observed.

Outpatient services at the Senior Health Center:
1. On 10/27/15, at 3:14 p.m., there was a refrigerator plugged into a multiple outlet power strip in the office. This was acknowledged by the DPO during the survey.

Hospital B, Third Floor:
2. On 10/28/15, at 12:01 p.m., the microwave and refrigerator were plugged into a multiple outlet power strip in the Social Worker office. In addition the multiple outlet power strip was plugged into an other multiple outlet power strip. The power strips were in use. This was confirmed by the DPO at the time of survey.

3. On 10/28/15, at 12:08 p.m., the electrical outlet located above the dryer in the third floor laundry room was damage. This was confirmed by the DPO during the survey.

Hospital A, First Floor:
4. On 10/29/15, at 8:54 a.m., there was a microwave and refrigerator plugged into a multiple outlet power strip in the engineering storage room.

5. On 10/29 15, at 9:21 a.m., there was a multiple outlet power strip plugged into a multiple outlet power strip in the engineering office. The office is located across from the volunteer department. This was acknowledged by the DPO during the survey.


29626


Hospital A:
6. On 10/27/15, at 3:11 p.m., the light socket in the bathroom to Room 634, located on the 6th Floor, was unprotected and exposed its energized parts.

7. On 10/28/15, at 11:10 a.m., the outlet cover plate in the Critical Care Conference Room, located in the Intensive Care Unit North on the 3rd Floor, was loose and exposed a 1/2-inch gap between the plate and the wall surface.

Based on observation and interview, the facility failed to ensure the Alcohol Based Hand Rub (ABHR) dispensers were not installed above an ignition source, as evidenced by ABHR dispenser that was installed above an electrical outlet. This could increase the risk of an electrical fire and affected 1 of 3 floors in Hospital B.

Findings:

During a tour of the facility with the DPO on 10/27/15 through 10/30/15, the Alcohol Based Hand Rub (ABHR) dispensers were observed.

Hospital B, Basement Level:
On 10/29/15, at 3:48 p.m., the ABHR was mounted above the light switch in the room identified as Office Coordinator 28. This was acknowledged by the DPO during the survey.

Based on observation and document review, the facility failed to maintain fire rated occupancy separations in accordance with NFPA 101, 2000 Edition. This was evidenced by failing to provide a 90-minute (1 1/2 hour) fire rated door at an occupancy separation. This reduced the appropriate fire protection that could result in injury to the patients during a fire. This affected the occupancy separation on 1 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.1.2.1 Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
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 protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating

NFPA 80, Standard for Fire Doors and Fire Windows 1999 Edition.
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the facility's occupancy separation barriers were observed with the Emergency Preparedness Manager (MNG 75) and the Supervisor of Plant Operations (SUP 73).

Hospital A, First Floor:
On 10/27/15, at 9:08 a.m., the occupancy separation that was observed on the 1st Floor between Hospital A and the Medical Office Building (MOB) did not have the appropriate fire protection rating to include 90-minutes (1.5 hours) fire rated doors. The Life Safety floor plans identified the separation between the two buildings. The double fire doors had a label on each door that rated them for 20-minutes each.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations on the wall. This could result in the spread of fire and smoke, increasing the risk of injury to patients. This affected 3 of 6 floors in Hospital A and 2 of 4 floors in Hospital B.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the facility's walls and ceilings were observed with the Emergency Preparedness Manager (MNG 75) and the Director of Plant Operations (DPO).

Hospital A:
1. On 10/28/15, at 8:44 a.m., the wall to the staff locker room, located in Obstetric Care Unit on the 4th Floor, was observed to have an opening through the wall. The opening was located underneath the sink and it measured approximately 12-inches by 16-inches. The opening exposed the wooden stud frame.

2. At 8:48 a.m., the wall to the doctor's dictation room, located in Obstetric Care Unit on the 4th Floor, was observed to have an opening through the wall. The opening was located underneath the sink and it measured approximately 16-inches by 24-inches. The opening exposed the wooden stud frame.

3. At 10:25 a.m., the wall to Conference Room C, located in the lobby area on the 3rd Floor, was observed to have a penetration through the wall. The penetration measured approximately 3-inches by 4-inches.

4. At 11:19 a.m., the wall to passageway between Rooms 357 and 364, located in the Admin Holding Unit on the 3rd Floor, was observed to have two penetrations through the wall. The penetrations measured approximately 1/2-inch each.

Hospital B:
5. On 10/29/15, at 3:11 p.m., the wall behind the door to the Med Room, located in the North side on the 2nd Floor, was observed to have a penetration through the wall. The penetration measured approximately 1/2-inch.

6. At 4 p.m., the wall to the Room labeled as Nurse Station 13, located in the North side on the Basement Floor, was observed to have a penetration through the wall. The penetration measured approximately 2-inches diameter.



21101


Hospital A:
7. On 10/29/15, at 9:08 a.m., there were 3 holes in the wall located above the sink in the respiratory break room, located on the 1st Floor. This was acknowledged by the DPO during the survey.

Based on observation, the facility failed to maintain their door to prevent the passage of smoke during fire. This was evidenced by a door that failed to positive latch. This had the potential to allow the migration of smoke and result in injury to patients. This affected the Cottage of Hospital B.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the doors were observed with the Emergency Preparedness Manager (MNG 75).

Cottage of Hospital B:
On 10/29/15, at 4:06 p.m., the door to the closet, located next to Room 14L on the 1st Floor, failed to positive latch.

Based on observation, the facility failed to maintain their smoke barrier doors in accordance with NFPA 101, 2000 Edition. This was evidenced by smoke barrier doors that failed to close and positive latch. This could result in the spread of smoke and fire, increasing the risk of injury to patients. This affected 4 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.
1-6.1 Only labeled fire doors shall be used.
3-1.4 Operation of Doors. The doors shall swing easily and freely on their hinges. The latches shall operate freely.
3-4.3.2 Components. Fire door hardware shall include hinge brackets, hinges, latches, latch keepers, and operating handle mechanisms; hardware for inactive door or pairs of doors includes top and bottom bolts and keepers.
15-1.4 Repairs. Repairs shall be made and defects that could interfere with operation shall be corrected immediately.
15-2.1 Inspections.
15-2.1.1 Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately.
15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the fire doors were observed with the Director of Plant Operations (DPO), the Supervisor of Plant Operations (SUP 73), the Emergency Preparedness Manager (MNG 75), and the Public Safety Manager (MNG 74).

Hospital A:
1. On 10/27/15, at 10:13 a.m., the fire door to the North Stairwell, located by the Information System Room on the 2nd Floor, had its fire rating label covered with paint.

2. On 10/28/15, at 9:27 a.m., the fire door to the middle elevator on the 4th floor failed positive latch when it was manually closed.

3. At 9:29 a.m., the fire door to the right elevator on the 4th floor failed positive latch when it was manually closed.

4. On 10/29/15, at 9:03 a.m., the fire door that seperates the doctors dictation room and the Angio Room, located in the Radiology Department on 3rd floor, failed positive latch when it was manually closed.

5. At 1:05 p.m., 1 of 2 cross corridor fire doors, located by the gift shop on the 3rd floor failed positive latch when a smoke detector was activated in the area.

6. At 1:14 p.m., 2 of 2 cross corridor fire doors, located by the door labeled as Anesthesia Office on the 3rd floor, failed positive latch when a smoke detector was activated in the area.

7. At 1:24 p.m., 2 of 2 cross corridor fire doors, located by the door labeled as CT Scan on the 3rd floor, failed positive latch when a smoke detector was activated in the area.


21101


Hospital A:
8. On 10/29/15, at 10:44 a.m., the fire door leaf near Room 544 on the 5th Floor, failed to close and latch upon activation of the fire alarm system.

9. At 11:08 a.m., the fire door leaf entering the Spine and Joint unit on the 4th Floor, failed to close and latch upon activation of the fire alarm system.

10. At 11:12 a.m., the fire door leaf near Room 352 entering Admit Holding Unit on the 3rd Floor, failed to close and latch upon activation of the fire alarm system.

Based on observation, the facility failed to maintain a safe means of egress in accordance with NFPA 101, 2000 Edition. This was evidenced by a walking surface in the exit discharge that contained a slope with abrupt changes in elevation, its pathway width was less than 4-feet, its pathway was non-slip resistant, no handrails or guards provided, and the pathway to the public way was not evident. This had the potential of interfering with safe egress during an emergency evacuation, resulting in injury to patients, visitors, and staff. This affected 1 of 4 emergency exit routes on the 3rd Floor East portion of Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.2.3.3* Any required aisle, corridor, or ramp shall be not less than 4 ft (1.2 m) in clear width where serving as means of egress from patient sleeping rooms. The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with
Chapter 7.
7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (0.6 cm). Changes in elevation exceeding 1/4 in. (0.6 cm), but not exceeding 1/2 in. (1.3 cm), shall be beveled 1 to 2. Changes in elevation exceeding 1/2 in. (1.3 cm) shall be considered a change in level and shall be subject to the requirements of 7.1.7.
7.1.6.3 Level. Walking surfaces shall be nominally level. The slope of a walking surface in the direction of travel shall not exceed 1 in 20 unless the ramp requirements of 7.2.5 are met. The slope perpendicular to the direction of travel shall not exceed 1 in 48.
7.1.6.4 Slip Resistance. Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.
7.1.7.1 Changes in level in means of egress shall be achieved either by a ramp or a stair where the elevation difference
exceeds 21 in. (53.3 cm).
7.2.12.2.2 Required portions of an area of refuge shall have
access to a public way, without requiring return to the building spaces through which travel to the area of refuge occurred, via an exit or an elevator.
7.2.5.2 Dimensional Criteria. Ramps shall be in accordance with the following:
(1) New ramps shall be in accordance with Table 7.2.5.2(a).
Table 7.2.5.2(a) New Ramps
Minimum width clear of all obstructions, except projections not more than 31/2 in. (8.9 cm) at or below handrail
height on each side 44 in. (112 cm)
Maximum slope 1 in 12
Maximum cross slope 1 in 48
Maximum rise for a single ramp run 30 in. (76 cm)
7.2.5.4 Guards and Handrails. Guards complying with 7.2.2.4 shall be provided for ramps. Handrails complying with 7.2.2.4 shall be provided along both sides of a ramp run with a rise greater than 6 in. (15.2 cm). The height of handrails and guards shall be measured vertically to the top of the guard or rail from the walking surface adjacent thereto.
7.2.12.2.3* Where the exit providing egress from an area of refuge to a public way that is in accordance with 7.2.12.2.2 includes stairs, the clear width of landings and stair flights, measured between handrails and at all points below handrail height, shall not be less than 48 in. (122 cm).
7.7.1* Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other
portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the exits, exit access, and exit discharges were observed with the Emergency Preparedness Manager (MNG 75).

Hospital A:
On 10/27/15, at 10:13 a.m., the exit discharge by the Electrical Room, located on the East portion of the building on the 3rd Floor between Same Day Surgery and the Behavioral Health Unit, had a pathway not safe for patients. The evacuation plans posted in the corridor by the Same Day Surgery and in the corridor in the Behavioral Health Unit highlighted evacuation routes to this exit discharge and exit signs were installed above the door. The concrete slab by the door decreased its walking surface to less than 4-feet as it curved to the left and ended into a dirt trail. Towards the South and West portion of the discharge there was a vertical drop that exceeded 21-inches and with no handrail or guard protection. The walking surface to the dirt trail could become slippery during wet conditions. The pathway to the public way was not clearly identified or visible.

Based on observation, the facility failed to maintain battery powered emergency lights. This was evidenced by battery powered emergency lights that failed to illuminate when tested. This could result in injury during a power outage. This affected the Cottage of Hospital B.

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

Findings:

During the facility tour on 10/27/15 through 10/30/15, the battery powered emergency lights were observed with the Emergency Preparedness Manager (MNG 75).

Cottage of Hospital B:
On 10/29/15, at 4:12 p.m., the battery powered emergency lighting unit in the Main Group Room, located on the 1st Floor, failed to illuminate when pushing down on the test button.

Based on document review and interview, the facility failed to hold fire drills at least quarterly for each shift, as evidenced by no documentation for 4 of 12 required fire drills for the past 12 months. This failure could result in staff not familiar with the fire evacuation procedures and affected 3 of 3 floors in Hospital B..

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.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During records review with the DPO (Director of Plant Operations) on 10/27/15 through 10/29/15, the fire drill reports were observed.

Hospital B:
On 10/28/15, at 10:36 a.m., the facility failed to provide documentation of conducting fire drills in Hospital B for the second quarter AM shift and PM shift (April, May, June during 2015), for the third quarter NOC shift (July, August September during 2015) and for the fourth quarter NOC shift (October, November, December during 2015/2014). During interview, the DPO stated some of the drills were held in another location on the same campus. The DPO was asked if Hospital B staff participated in fire drills held in other areas located on campus, the DPO stated "no" the staff from Hospital B do not participate in the fire drills.

Based on observation and interview, the facility failed to ensure that the fire alarm system was maintained in accordance with NFPA 101, 2000 edition. This was evidenced by the fire alarm not heard throughout all occupied spaces and evidenced by keys that failed to activate the fire alarm system. This had the potential for the occupants not be notified of a fire in the building and could delay the evacuation of patients. This affected 1 of 6 floors at Hospital A and 1 of 3 floors in Hospital B.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
9.6.3 Occupant Notification.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.
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.

Findings:

During the facility tour with the DPO, SUP 73, MNG 74 and MNG 75, on 10/27/15 through 10/30/15, the fire alarm system was tested by staff and observed.

Hospital A, First Floor:
1. On 10/29/15, at 1:50 p.m., the fire alarm was not heard throughout the doctors staff dining room and dictation room during activation of the fire alarm system. There was no audible or visual notification device installed in the area that could be heard. This was acknowledged by DPO during the testing of the fire alarm system.

Hospital B, Second Floor:
2. At 3:10 p.m., the manual fire alarms that required a key to activate the alarm were tested. Three staff members were asked to use their key to activate the manual fire alarm located across from the second floor nurse station. The Keys to the first and second staff failed to activate the manual fire alarm, a third staff was asked to use her key. The third staff key worked and activated the fire alarm. The two keys that failed to activate the manual fire alarm were taken by the DPO and MNG 74 and were tested at another manual fire alarm, where they also failed. The DPO stated one of the keys was bent and did not know why the second key would not work.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system, as evidenced by the sprinkler control valve failure to transmit a visual supervisory trouble signal at the fire alarm control panel when the valve was closed. This had the potential for the sprinkler valve to be tampered with and no visual signal to notify facility staff of a system failure. This affected the Cottage of Hospital B.

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

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire Alarms, Supervisory signals, and trouble signals shall be distinctively and descriptively annunciated .
1-5.4.6.1 Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Control unit (central equipment) for protected premises fire alarm systems
(2) Building fire command center for emergency voice/alarm communications service
(3) Central station or remote station location for systems installed in compliance with Chapter 5
3-8.3.3.1.3 Signals shall distinctively indicate the particular function (e.g., valve position, temperature, or pressure) of the system that is off-normal and also indicate its restoration to normal.
3-8.3.4.2 The integrity of each fire suppression system actuating device and its circuit shall be supervised in accordance with 1-5.8.1 and with other applicable NFPA standards.
Table 7-2.2
10. Remote Annunciators The correct operation and identification of annunciators shall be verified. If provided, the correct operation of annunciator under a fault condition shall be verified.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

Findings:

During the testing of the automatic sprinkler system with the DPO, SUP 73, MNG 74, MNG 75 and Maintenance Staff 1 and Staff 2, on 10/30/15, the sprinkler valves were observed and tested.

The Cottage at Hospital B:
At 10:05 a.m., on 10/30/15, the tamper valve was closed by the Maintenance Staff. The fire alarm control panel did not have a visual signal indicating a supervisory trouble when the valve was in the closed position. The tamper valve was tested three times by the Maintenance Staff and failed to transmit a visual trouble signal to the fire alarm control panel. The DPO stated he was not aware the tamper alarm was not transmitting a visual trouble signal to the fire alarm control panel.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinkler heads with debri and were obstructed. This affected the operation of the sprinkler head that could cause delay and inefficient coverage during a fire, resulting in injury to patients. This affected 2 of 6 floors in Hospital A and the Cottage of Hospital B.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
7-3.4.1* System Piping and Fittings. System piping and fittings shall be inspected for the following:
(b) External conditions (e.g., missing or damaged paint or coatings, rust, and corrosion)

Findings:

During the facility tour on 10/27/15 through 10/30/15, the sprinkler system was observed with the Emergency Preparedness Manager (MNG 75).

Hospital A:
1. On 10/28/15, at 9:46 a.m., the sprinkler head in Patient Room 321, located in 3East on the 3rd Floor, had toilet paper around the fusible link.

2. On 10/29/15, at 9:45 a.m., the two upright type sprinkler heads in the Receiving Area, located on the 2nd Floor, were covered by cloth towels.

3. At 9:59 a.m., the pendant type sprinkler head inside the Pharmacy Storage Supply Room, located on the 2nd Floor, had a damaged deflector. The deflector's teeth were bent upward.

The Cottage at Hospital B:
4. At 4:05 p.m., the exterior pipes on the West side of the building contained rust throughout the pipe line.

Based on observation, the facility failed to maintain their kitchen's fire extinguishing system. This was evidenced by the a nozzle in the kitchen hood fire suppression system that did not have cap. This could increase the chance of not extinguishing fire in the kitchen due to accumulation of grease inside the nozzles. This affected 1 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and and Fire Protection of Commercial Cooking Equipment, 1998 Edition
10-6.4 The entire hood plenum and the blower section shall be cleaned a minimum of once every 3 months.
7-2.2.1 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable.
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 1998 Edition
2-3.1.4 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping. The protection device shall blow off, open, or blow out upon agent discharge.

Findings:

During the facility tour on 10/27/15 through 10/30/15, the kitchen fire-suppression system was observed with the Emergency Preparedness Manager (MNG 75).

On 10/29/15, at 9:37 a.m., the kitchen hood fire suppression system, located in the cafe on the 2nd Floor, was observed to be missing cap on 1 of 2 nozzles pointing directly into the fryer.

Based on document review and interview, the facility failed to maintain the emergency generator, as evidence by incomplete documentation for the weekly inspections for 2 of 2 emergency generators. This could result in the failure of the emergency generator to provide power to the facility's Life Safety systems in the event of a power outage and had the potential to increased the risk of injury to patients. This affected 6 of 6 floors in Hospital A.

Findings:

During the records review with DPO and MNG 74, on 10/27/15, the weekly inspections for the two (550KW and 1050KW) emergency generators in Hospital A were reviewed.

Hospital A:
On 10/27/15, at 9:58 a.m., the facility failed to provide records of weekly inspections for the 550 KW emergency generator during the following weeks: 5/9/15, 5/4/15, 3/7/15, 4/4/15, 4/25/15, 12/6/14 and for 12/13/15. The facility failed to provide records of weekly inspections for the 1050 KW emergency generator during the week of 5/9/15 and 4/4/15. This was acknowledged by the Director of Plant Operations "DPO" during survey.

Based on observation and interview, the facility failed to maintain electrical safety in accordance with NFPA 70, 1999 Edition as evidenced by an appliance plugged into a multi-outlet power strip and power strips plugged into another power strips. This had the potential to overload the power strips with a high load appliance and could result in an increased risk of an electrical fire. This affected 1 of 1 smoke compartments at the Senior Health Center, 1 of 3 floors in Hospital B, and 2 of 6 floors in Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code (1999) Edition
110-12(c) Integrity of Electrical Equipment and Connections.
Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.
110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.
400-8. Uses not permitted.
Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with DPO, on 10/27/15 through 10/30/15, the electrical components were observed.

Outpatient services at the Senior Health Center:
1. On 10/27/15, at 3:14 p.m., there was a refrigerator plugged into a multiple outlet power strip in the office. This was acknowledged by the DPO during the survey.

Hospital B, Third Floor:
2. On 10/28/15, at 12:01 p.m., the microwave and refrigerator were plugged into a multiple outlet power strip in the Social Worker office. In addition the multiple outlet power strip was plugged into an other multiple outlet power strip. The power strips were in use. This was confirmed by the DPO at the time of survey.

3. On 10/28/15, at 12:08 p.m., the electrical outlet located above the dryer in the third floor laundry room was damage. This was confirmed by the DPO during the survey.

Hospital A, First Floor:
4. On 10/29/15, at 8:54 a.m., there was a microwave and refrigerator plugged into a multiple outlet power strip in the engineering storage room.

5. On 10/29 15, at 9:21 a.m., there was a multiple outlet power strip plugged into a multiple outlet power strip in the engineering office. The office is located across from the volunteer department. This was acknowledged by the DPO during the survey.


29626


Hospital A:
6. On 10/27/15, at 3:11 p.m., the light socket in the bathroom to Room 634, located on the 6th Floor, was unprotected and exposed its energized parts.

7. On 10/28/15, at 11:10 a.m., the outlet cover plate in the Critical Care Conference Room, located in the Intensive Care Unit North on the 3rd Floor, was loose and exposed a 1/2-inch gap between the plate and the wall surface.