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Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the walls and ceilings. This affected 9 of 15 floors in the Main Hospital, and could result in the increased potential for the spread of fire and smoke to other areas of the facility.

Findings:

During a tour of the facility with staff, the walls and ceilings were observed.

Main Hospital
1. On 12/17/12 at 10:15 a.m., a sprinkler escutcheon ring was not flush against the ceiling. There was an approximately 1/2 inch penetration exposed in the ceiling, in Room 12812-Staff lounge.

2. On 12/17/12 at 10:25 a.m., 1 of 3 sprinkler escutcheon rings were not flush against the ceiling. There was an approximately 1/8 inch penetration exposed in the ceiling, in Room 10781.

3. On 12/17/12 at 10:40 a.m., a sprinkler escutcheon ring was not flush against the ceiling. There was an approximately 1/8 inch penetration exposed in the ceiling, in Room 10731-Clean utility.

4. On 12/17/12 at 11:02 a.m., there was an approximately 1/8 inch penetration exposed in the ceiling, in Room 8811-Nourishment.

5. On 12/17/12 at 1:16 p.m., there were two approximately 1/4 inch penetrations exposed in the left wall, in Room 7792.

6. On 12/17/12 at 1:26 p.m., there were five approximately 1/4 inch penetrations in the left wall and seven approximately 1/4 inch penetrations in the back wall, in Room 7818.

7. On 12/17/12 at 1:49 p.m., a sprinkler was shifted to one side. There was an approximately 1/8 inch penetration exposed in the ceiling, in Room 6818.

8. On 12/17/12 at 2:01 p.m., there were four approximately 1/4 inch penetrations exposed in the left wall, in Room 6701-Tower 6 satellite pharmacy.

9. On 12/17/12 at 2:36 p.m., there were two approximately 1/4 inch penetrations, four approximately 1/2 inch penetrations, and four approximately 1/8 inch penetrations exposed in the left wall, in Room 5705.

10. On 12/18/12 at 11:01 a.m., there were nine approximately 1/2 inch penetrations and ten approximately 1/4 inch penetrations exposed in the wall, in Room 2512-GI lab clerical supplies.

11. On 12/18/12 at 2:16 p.m., a sprinkler was shifted to one side. There was an approximately 1/2 inch penetration exposed in the ceiling, in Room 1722-Fire command room.

12. On 12/18/12 at 4 p.m., five of eight sprinklers shifted to one side. There were five approximately 1/2 inch to 1/4 inch penetrations exposed in the ceiling, in Room 0523-Physical Medicine and Rehabilitation (PM&R).










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13. On 12/18/12 at 1:55 p.m., there were three approximately one-half inch unsealed penetrations in the wall in Room 1303. This wall was a fire-rated wall separating Room 1303 from a mechanical room on the other side of the wall.

Based on observation and interview, the facility failed to maintain the corridor construction with a one-half hour fire rating as evidenced by unsealed penetrations in the corridor walls. This deficient practice affected 5 of 15 floors in the Main Hospital and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with staff, corridor walls and ceilings were observed.

Main Hospital
1. On 12/18/12 at 9:30 a.m., there were four one-quarter inch holes in the corridor doors to Rooms 3312, 3310, and 3308. Administrative Staff 3 stated that it looked like the door hardware had been removed.

2. On 12/18/12 at 10:57 a.m., the corridor wall near Room 2231 had three unsealed penetrations. These penetrations were located approximately 24 inches up from the floor and were areas where the gypsum board had been pushed in. The vinyl wall still partially concealed the damaged area.

3. On 12/18/12, between 11:15 a.m. and 11:45 a.m., there was two unsealed penetrations in the wall in Room 2144. One penetration was approximately one inch wide by eight feet long and the other one was approximately one inch wide by three feet long. Both penetrations were located approximately four feet up from the floor. This wall also separated Room 2144 from Corridor 2160. Room 2144 was part of a decommissioned portion of the building.





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4. On 12/17/12 at 10:06 a.m., a sprinkler was missing an escutcheon ring, in the corridor by Room 12759B. There was an approximately 1/8 inch penetration exposed.

5. On 12/17/12 at 11:10 a.m., there were twenty approximately 1/8 inch to 1/4 inch penetrations above the smoke barrier door 8700 header, by Room 8609 corridor.

6. On 12/17/12 at 3:20 p.m., there was an approximately 3 inch by 2 inch penetration in the wall, by Room 0783 corridor.

Based on observation and interview, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This affected staff and patients in 10 of 15 floors of the Main Hospital.

NFPA 101, 19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

Findings:
During a tour of the facility with the staff, doors were observed.

Main Hospital
1. On 12/17/12 at 2:32 p.m., the door to Room 5209 was impeded from closing by a door wedge. There was also a trash can that was located in the travel area of the door preventing the door from closing.

2. On 12/17/12 at 2:55 p.m., the roll down door to Room 5308 was impeded from closing by a plastic stand placed in the travel area of the door.

3. On 12/17/12 at 3:20 p.m., the door to Patient Room 5133 was impeded from closing by a scale and an isolation cart that were in front of the door.

4. On 12/17/12 at 3:24 p.m., the door to Patient Room 5113 did not close when released from a fully open position. This door was being held open by a device designed to release upon activation of the fire alarm system.

5. On 12/18/12 at 8:59 a.m., the door to Waiting Room 3220 was being held open by a trash can. Staff stated that when the door closes, it automatically locks. Administrative Staff stated that the door latching mechanism could be changed.

6. On 12/18/12 at 10:00 a.m., the door to Report Room 3684A did not positive latch when tested by releasing the door from an open position.

7. On 12/18/12 at 10:05 a.m., the door to Patient Room 3675 did not positive latch when tested by releasing the door from an open position.

8. On 12/18/12 at 2:15 p.m., the fire-rated door to Sub-Sterile Room 1346A was being held open by a door wedge.

9. On 12/18//12 at 3:16 p.m., the corridor door to the Room 0343 did not positive latch when tested by releasing it from an open position. This door was being held open by a device designed to release upon activation of the fire alarm system.

10. On 12/18/12 at 4:00 p.m., the door to Room 0204 did not positive latch when tested by releasing the door from an open position. This door was being held open by a device designed to release upon activation of the fire alarm system.


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11. On 12/17/12 at 10:24 a.m., the self closing door in Room 10716 failed to latch.

12. On 12/17/12 at 11:13 a.m., the door to Room 8603 was obstructed by a portable X-ray machine.

13. On 12/17/12 at 1:12 p.m., the self closing door to Room 7705 was obstructed by two garbage bins.

14. On 12/17/12 at 1:25 p.m., the self closing door to Room 7812 failed to latch.

15. On 12/17/12 at 1:36 p.m., the door handle to Room 6789 was tied open by a blue rubber band.

16. On 12/17/12 at 1:40 p.m., the door to Room 6763 was obstruct by a work station cart cord that prevented the door from closing.

17. On 12/17/12 at 1:48 p.m., the self closing door to Room 6812 failed to latch.

18. On 12/17/12 at 2:50 p.m., the self closing door to Room 4120 was obstructed by a wood stopper.

19. On 12/17/12 at 2:51 p.m., the self closing door to Room 4132B was obstructed by a metal stopper.

20. On 12/17/12 at 3:15 p.m., the self closing door to Room 4654 was obstructed by a propaq cart.

21. On 12/17/12 at 3:26 p.m., the self closing door to Room 4671 failed to latch.

22. On 12/18/12 at 9 a.m., the self closing door to Room 3P504 failed to latch. A tape was used to covered the latching hardware.

23. On 12/18/12 at 9:18 a.m., the self closing door to Storage room 3P892C inside Operating room (OR) 4 was obstructed by a IV pole.

24. On 12/18/12 at 10:02 a.m., the self closing door to Room 2P175 was obstructed by a metal stopper.

25. On 12/18/12 at 10:20 a.m., the door to Room 2P649 was obstructed by a garbage bin.

26. On 12/18/12 at 11 a.m., the self closing door to Room 2510A was obstructed by boxes.

27. On 12/18/12 at 2:13 p.m., the self closing door to Room 1P522 was obstructed by a round concrete block.

28. On 12/18/12 at 3:15 p.m., the self closing door to Room 00719 was obstructed by a chair.

29. On 12/18/12 at 3:21 p.m., the self closing door to Room 0767 was tied open by a plastic bag.

30. On 12/18/12 at 3:32 p.m., the self closing door to Room 0762C was obstructed by a rubber stopper.

31. On 12/18/12 at 3:36 p.m., the self closing door to Room 0762 was obstructed by a wooden wedge.

32. On 12/18/12 at 3:37 p.m., the self closing door to Room 0711B was held open by a kick stand.

33. On 12/18/12 at 3:38 p.m., the self closing door to Room 0711A was held open by a kick stand.

34. On 12/18/12 at 3:46 p.m., the self closing door to Room 0624 was obstructed by a coat stand.



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35. During a facility tour with staff, on 12/19/12 at 8:37 a.m., a roll down fire door near Room 7710A was obstructed from closing by a basket positioned directly in the roll down path of the door.

Based on observation, the facility failed to maintain its stairways. This was evidenced by penetrations in stairwell walls. This affected 2 of 15 floors in the Main Hospital and 1 of 4 floors in the Outpatient building, and could result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with staff, stairway walls and fire-rated self-closing doors were observed.

Radiation Oncology
1. On 12/19/12 at 9:10 a.m., the two-hour fire-rated Stairwell Wall 1 had two approximately one inch diameter unsealed penetrations in the wall. One penetration did not go completely through the sheeting.


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Main Hospital:
2. At 2:34 p.m., on 12/19/2012, the fire doors near the 8th floor Davis Wing elevators (Room 8712) were equipped with self-closing devices and magnetic hold-open devices. The fire alarm system was tested and activated at that time. The fire doors did not release from the magnetic hold-open devices.

3. At 3:15 p.m., the fire door 6730A near the 6th floor Davis Wing elevators was equipped with a self-closing device and a magnetic hold-open device. The fire alarm system was tested and activated at that time. The fire door released from the magnetic hold-open device but did not close. The door failed to close due to the door leaf dragging on the floor.

Based on observation and testing, the facility failed to maintain its fire alarm system to function as necessary to make the building safer for its occupants. This was evidenced by fire doors that failed to release from their magnetic hold open devices per smoke compartment during activation of the fire alarm system. This affected 3 of 15 floors in the Main Hospital, and could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

2000 NFPA 101
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

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

NFPA 101, 9.6.5.1. A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

Findings:

During the testing with staff, the smoke barrier doors were observed.

Main Hospital

1. On 12/19/12 at 2:35 p.m., the smoke barrier doors 8700A in the link area failed to release from the magnetic hold device (device N15L1D68).

2. On 12/19/12 at 3:46 p.m., the right leaf smoke barrier door in Post Anesthesia Care Unit (PACU) 3P530 failed to release from the magnetic hold device (device N33L02M56).

3. On 12/19/12 at 4:14 p.m., the right leaf smoke barrier door 0810 failed to release from the magnetic hold device (device N11L1D18).

Based on observation, the facility failed to maintain their fire-rated smoke barrier walls. This was evidenced by unsealed penetrations in four fire-rated smoke barrier walls throughout the facility. This affected 3 of 15 floors in the Main Hospital and 1 of 4 floors in the Outpatient building, and could result in the spread of smoke or fire to other smoke compartments.

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

Findings:

During a facility tour with staff, the facility's fire-rated smoke barrier walls were observed.

Main Hospital
1. On 12/18/12 at 3:55 p.m., there was an approximately 5 inch diameter pipe conduit penetrating the fire-rated smoke barrier wall near Room 10781. There was nothing sealing the opening of the pipe conduit.

2. On 12/18/12 at 4:00 p.m., there were two approximately 5 inch diameter pipe conduits penetrating the fire-rated smoke barrier wall near Room 10716. There was nothing sealing the openings of the pipe conduits.

3. On 12/19/12 at 8:55 a.m., there was an approximately 14 inch by 5 inch unsealed penetration in the fire-rated smoke barrier wall by Door 6140

4. On 12/19/12 at 10:00 a.m., there was an approximately 4 inch by 3 inch unsealed penetration in the fire-rated smoke barrier wall by Door 2200.


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Radiation Oncology
5. On 12/19/12 at 9:15 a.m., the one-hour fire-rated wall separating Room 0161 from 0165 had a 4 inch pipe sleeve with data cables in it that was not sealed with a fire-rated material.

Based on observation, the facility failed to maintain its fire doors to continuously serve as a barrier to prevent the spread of smoke and/or fire. This was evidenced by cross-corridor fire doors that were equipped with latching hardware that failed to latch when tested. This deficient practice affected all staff and patients on 5 of 15 floors at the Main Hospital and one of 1 of 4 floors in Outpatient buildings. It could potentially result in the spread of smoke and/or fire.

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

Findings:

During a tour of the facility with Staff, fire doors were inspected throughout the facility.

Main Hospital
1. On 12/17/12 at 1:40 p.m., on the sixth floor, one-half hour fire-rated door number 58216 did not close and latch when tested by releasing the door from an open position. There was an approximately six inch gap along the latch edge of the door.

2. On 12/18/12 at 9:36 a.m., the fire barrier doors to the Three South GI Procedure Room were rubbing at the top preventing the door from latching when tested by releasing the door from an open position.

3. On 12/18/12 at 2:30 p.m., the right leaf facing west of the fire barrier doors to the first floor Children's Surgery Recovery Room was damaged at the bottom preventing it from closing completely.

4. On 12/18/12 at 3:20 p.m., the double doors near Class Room 0343 did not close, leaving an approximately three inch gap at the latching edge of the door. A strong air flow could be detected holding the door open.

5. On 12/18/12 at 3:32 p.m., 90 minute fire door 58022 did not positive latch when tested, leaving an approximately three inch gap at the latching edge of the door.

6. On 12/19/12 at 1:35 p.m., the right leaf facing east of the cross corridor doors near Room 14763 did not close completely and latch.

7. On 12/19/12 at 1:52 p.m., the left leaf of the fire door 11730A facing the elevators did not coordinate properly, leaving an approximately three inch gap at the latching edge of the door.

Radiation Oncology
8. On 12/19/12 at 9:34 a.m., the 60 minute fire-rated smoke barrier doors to the Clinic Nursing Unit adjacent to Room G113J did not close completely and latch.
















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Main Hospital
9. On 12/19/12 at 1:53 p.m., the left leaf smoke barrier door 11720A failed to latch when released from the magnetic hold device.

10. On 12/19/12 at 3:28 p.m., the left leaf smoke barrier 5680 failed to close all the way. The door was dragging on the floor.

11. On 12/19/12 at 4:15 p.m., the right leaf smoke barrier door 0811 failed to close and latch.

12. On 12/19/12 at 4:30 p.m., the right leaf smoke barrier door 3500 failed to close and latch.

Based on observation, the facility failed to maintain their emergency exit door. This was evidenced by items that were stored in front of the emergency exit door. This affected 1 of 15 floors in the Main Hospital, and could result in a delay egress in the event of an emergency.

Findings:

During a tour of the facility with staff, the emergency exit doors were observed.

Main Hospital
On 12/18/12 at 3:59 p.m., the emergency exit door by 0665 in the Lower level Central processing room had a stepping stool that was stationed in front of the door.

Based on observation and record review, the facility failed to maintain their battery back-up emergency lighting units. This was evidenced by the facility's failure to document testing of monthly and annual tests on their battery back-up emergency lighting units and a failed emergency unit. This affected all patients in the Main Hospital, 2 of 3 outpatient facilities and could result in a delayed notification of a malfunctioning emergency lighting unit.

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

Findings:

During record review with staff, on 12/18/12 at 11:45 a.m., the facility's test records for their battery back-up emergency lighting units were reviewed. The facility policy indicated that the battery back-up emergency lighting units are tested monthly for thirty seconds and annually for ninety minutes. The following was noted when reviewing the test records for the emergency lighting units:

Main Hospital:
1. There were no test records for the battery back-up emergency lighting units located in the Davis Wing. The Davis Wing contains two C-Section operating rooms which are equipped with battery back-up emergency lighting units. There were no records that indicated the battery back-up emergency lighting units were tested monthly for thirty seconds or annually for ninety minutes.

2. The test records for the battery back-up emergency lighting units located in the University Wing were reviewed. There were no records of monthly thirty second testing for five of the past twelve months. There were no test records for the months of January 2012, March 2012, June 2012, August 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency lighting units during the past twelve months.

3. There were no records that indicated an annual ninety minute test had been completed on the battery back-up emergency lighting units located in the North/South/East Wing (Building 01/1). The North/South/East Wing contains four Children's Surgery operating rooms which are equipped with battery back-up emergency lighting units.

4. The test records for the battery back-up emergency lighting units located in the Pavilion Wing were reviewed. The Pavilion Wing contains twenty-four operating rooms which are equipped with battery back-up emergency lighting units. There were no records of monthly thirty second testing for five of the past twelve months. There were no test records for the months of February 2012, July 2012, September 2012, November 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency lighting units during the past twelve months.

Surgery at the Same Day
5. The test records for the battery back-up emergency lighting units located in the Same Day Surgery Center were reviewed. The Same Day Surgery Center contains four operating rooms which are equipped with battery back-up emergency lighting units. There were no records of monthly thirty second testing for two of the past twelve months. There were no test records for the months of February 2012 or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency lighting units during the past twelve months.

Surgery
6. The test records for the battery back-up emergency lighting units located in the Surgery Clinic were reviewed. There were no records of monthly thirty second testing for three of the past twelve months. There were no test records for the months of January 2012, June 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency lighting units during the past twelve months.


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7. On 12/19/12 at 11:20 a.m., one of two emergency lighting units in the Waiting Room did not function when tested by pressing the test button. Staff agreed that the light was not working.

Based on observation and record review, the facility failed to maintain their battery back-up emergency exit signs. This was evidenced by the facility's failure to document testing of monthly and annual tests on their battery back-up emergency exit signs and failed exit signs. This affected all patients in the Main Hospital and 2 of 3 outpatient facilities and could result in a delayed notification of a malfunctioning emergency exit sign.

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

Findings:

During record review with staff, on 12/18/12 at 11:32 a.m., the facility's test records for their battery back-up emergency exit signs were reviewed. The facility policy indicated that the battery back-up emergency exit signs are tested monthly for thirty seconds and annually for ninety minutes. The following was noted when reviewing the test records for the emergency exit signs:

Main Hospital:
1. The test records for the battery back-up emergency exit signs located in the Davis Wing were reviewed. There were no records of monthly thirty second testing for seven of the past twelve months. There were no test records for the months of January 2012, February 2012, July 2012, August 2012, September 2012, October 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency exit signs during the past twelve months.

2. The test records for the battery back-up emergency exit signs located in the University Wing were reviewed. There were no records of monthly thirty second testing for eight of the past twelve months. There were no test records for the months of January 2012, February 2012, April 2012, June 2012, July 2012, August 2012, September 2012, or November 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency exit signs during the past twelve months.

3. The test records for the battery back-up emergency exit signs located in the North/South/East Wing were reviewed. There were no records of monthly thirty second testing for seven of the past twelve months. There were no test records for the months of January 2012, February 2012, April 2012, July 2012, August 2012, September 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency exit signs during the past twelve months.

Surgery at Same Day
4. The test records for the battery back-up emergency exit signs located in the Same Day Surgery Center were reviewed. There were no records of monthly thirty second testing for three of the past twelve months. There were no test records for the months of February 2012, October 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency exit signs during the past twelve months.

Surgery
5. The test records for the battery back-up emergency exit signs located in the Surgery Clinic were reviewed. There were no records of monthly thirty second testing for four of the past twelve months. There were no test records for the months of January 2012, March 2012, August 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency exit signs during the past twelve months.



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Main Hospital
6. On 12/17/12, at 2:40 p.m., the exit sign at the end of the corridor near door 58190 was not illuminated.

7. On 12/18/12 at 2:45 p.m., the exit sign located near the first floor Clinical Nurse Specialist (CNS) Room was illuminated with one of two bulbs.

Radiation Oncology
8. On 12/19/12 at 8:45 a.m., the exit sign located in the Lobby near the elevator was not illuminated.

Outpatient Surgery
9. On 12/19/12 between 10:20 and 11:10 a.m., the exit signs located near rooms 1900, 1900 A, 1908, 1890, and 1875 were tested by pressing the test button. The light on the side of the exit sign flashed green and red indicating that the sign had insufficient charge. All exit signs did stay illuminated when tested. When asked, Fire Inspector 2 stated that it might mean that the sign would not hold a charge for the full 90 minutes.

Based on record review, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by the facility's failure to conduct one of two semi-annual emergency preparedness drills during the past twelve months. This affected all patients in the Main Hospital and three of three outpatient facilities and could result in staff being unprepared to respond to emergency situations.

NFPA 99, 1999 edition
11-5.3.9 Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During record review with staff, on 12/18/12 at 8:10 a.m., the facility's emergency preparedness drill records were requested. The facility had conducted an emergency preparedness drill in October 2012 and November 2012. There was no documentation that indicated the facility had conducted an emergency preparedness drill during the months of January 2012 to September 2012.

Based on interview, the facility failed to ensure that all staff respond properly in the event of a fire emergency. This was evidenced by two staff that were not familiar with what actions to take in the event of a fire and had not yet received training. This deficient practice affected all staff and patients on 1 of 15 floors in the Main Hospital and could potentially result in a delay in staff or first responders' responses in the event of a fire.

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

19.7.2 Procedure in Case of Fire.
19.7.2.1* For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During fire alarm testing, staff were being interview for fire and life safety procedures.

Main Hospital
1. On 12/19/12 at 3:22 p.m., in an interview with Staff, Staff 6 and 7 at the Nurses' Station near Room 6783 were asked at the same time what they would do if there were a fire in a patient's room. Both staff did not answer with the acronym RACE or PASS. Staff stated that they were not sure what to do. When asked if they had received any fire drill training, both said that they had not. When asked how long they had worked at the facility Staff 6 stated three years and Staff 7 stated six months.



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2. On 12/19/12 at 4:25 p.m., Staff 2 in the Radiology department was interviewed and was asked what she would do in the event of a large fire. Staff 2 responded that she would call the fire department. She failed to state the use of the fire alarm devices including the manual pull alarms to notify the staff and visitors of a fire in the area.

Based on observation, documentation, and interview, the facility failed to maintain their fire alarm system components. This was evidenced by manual pull alarms that were obstructed, a alarm notification device that did not emit sound, and by the lack of a trouble signal when a smoke detector was removed from service. This affected 4 of 15 floors in the Main Hospital and 1 of 3 floors in the Outpatient building, and could result in staff inability to readily access the pull alarm and the component in the event of a fire.

NFPA 101 (2000 Edition)
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

NFPA 72, 1999
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a facility tour with staff, the fire alarm system and components were observed.

Main Hospital
1. On 12/17/12 at 10:54 a.m., a fire alarm notifier was obscured from view and access by a pyxis machine, in Nurse station 1 on the 8th floor (Davis Tower).

2. On 12/17/12 at 1:28 p.m., a manual pull alarm was obstructed from access by a carefusion cart, in Nurse station 2 of 7th floor (Davis Tower).

3. On 12/17/12 at 1:29 p.m., a manual pull alarm was obstructed from access by a carefusion cart, in Nurse station 1 of 7th floor (Davis Tower).

4. On 12/17/12 at 1:30 p.m., a manual pull alarm was obstructed from access by a carefusion cart, in Nurse station 4 of 7th floor (Davis Tower).

5. On 12/17/12 at 1:37 p.m., a fire alarm notifier was obscured from view and access by a pyxis machine, in Nurse station 4 on the 6th floor (Davis Tower).

6. On 12/17/12 at 1:39 p.m., a fire alarm notifier was obscured from view and access by a pyxis machine, in Nurse station 3 on the 6th floor (Davis Tower).

7. On 12/17/12 at 1:43 p.m., a fire alarm notifier was obscured from view and access by a pyxis machine, in Nurse station 2 on the 6th floor (Davis Tower).

8. On 12/17/12 at 1:47 p.m., a fire alarm notifier was obscured from view and access by a pyxis machine, in Nurse station 1 on the 6th floor (Davis Tower).














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Surgery
9. On 12/19/12 at 10:26 a.m., the smoke detector in Room 1919 was missing. This surveyor noted that there was no audible fire alarm trouble signal at the fire alarm control panel (FACP). At 11:03 a.m., when this surveyor asked Staff to remove the smoke detector to simulate a missing detector, the FACP audible could be heard. During an interview on 12/20/12, between 11:15 a.m. and 11:45 a.m., When asked why the FACP was not producing an audible alarm, Fire Officer 1 stated that he thought that the detector had been removed and someone had silenced the FACP. When asked how long the detector had been missing, Fire Officer 1 stated that he was unsure. During record review at 11:50 a.m., documentation provided titled "System Event Report" indicated that there was a system trouble logged during the timer test on 12/18/12.







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Main Hospital:
10. During a facility tour with staff, on 12/19/12 at 4:42 p.m., the facility's fire alarm system was tested. The fire alarm chime/strobe device located in the corridor by Room 3306 was observed. The chime/strobe device failed to emit an audible alarm when the fire alarm system was activated.

Based on record review and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the facility's waterflow alarm valves that failed to alarm within ninety seconds, one automatic fire sprinkler system riser that was not equipped with a hydraulic nameplate, sprinkler heads with debris, paint, less than 18 inches of clearances, and no identification sign of test valves . This affected all patients in the Main Hospital and one of three outpatient facilities. This could result in a delayed notification of a sprinkler activation.

NFPA 72, 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.

NFPA 13, 1999 edition
10-5 Hydraulic Design Information Sign. The installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other approved means. Such signs shall be placed at the alarm valve, dry pipe valve, preaction valve, or deluge valve supplying the corresponding hydraulically designed area. the sign shall include the following information:
(1) Location of the design area or areas
(2) Discharge densities over the design area or areas
(3) Required flow and residual pressure demand at the base of the riser
(4) Occupancy classification or commodity classification and maximum permitted storage height and configuration
(5) Hose stream demand included in addition to the sprinkler demand

NFPA 25, 1998 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.

NFPA 13, 3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. This sign shall be secured with corrosion-resistant wire, chain or other approved means.

Findings:

During record review with staff, on 12/18/12 at 10:14 a.m., the facility's quarterly automatic fire sprinkler system test and inspection records were reviewed. The following waterflow alarm valve tests did not indicate alarm activation within ninety seconds:

Main Hospital:
1. The waterflow alarm valve near room 2615 was tested on 2/28/12. The recorded alarm time was 100 seconds.

2. The waterflow alarm valve in the Davis Wing near the 14th north stairwell was tested on 3/1/12. The recorded alarm time was 111 seconds.

3. The waterflow alarm valve in the Davis Wing near the 14th north stairwell was tested on 5/14/12. The recorded alarm time was 98 seconds.

4. The waterflow alarm valve in the Davis Wing near the 2nd floor Stair B was tested on 8/9/12. The recorded alarm time was 97 seconds.

5. The waterflow alarm valve in the Pavilion Wing near the 3rd floor Stair H was tested on 8/10/12. The recorded alarm time was 113 seconds.

6. The waterflow alarm valve in the Davis Wing near the lower level loading dock was tested on 11/21/12. No alarm time was recorded.
There was no documentation that indicated the waterflow alarm valves were repaired or replaced.

Surgery at the Same Day
7. During record review with staff, on 12/18/12 at 1:15 p.m., the 5-year certification report for the automatic fire sprinkler system was reviewed. The certification report was dated 10/12/12. The certification report indicated that the automatic fire sprinkler system riser was missing a hydraulic nameplate. On 12/20/12 at 7:45 a.m., a repair report from the inspection vendor was reviewed. The repair report indicated that the automatic fire sprinkler system riser was not equipped with a hydraulic nameplate. There was no other records that indicated the automatic fire sprinkler system riser was equipped with a hydraulic nameplate.


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Main Hospital
8. On 12/17/12 at 2:05 p.m., the sprinkler head in Storage closet 1 across from Cardiac Intensive Care Unit (CICU) did not have 18 inches of clearance around the deflector plate. The sprinkler was obstructed by a letter paper that was stationed at 12 inches of clearance.
9. On 12/17/12 at 2:06 p.m., the sprinkler head in Storage closet 2 across from Cardiac Intensive Care Unit (CICU) did not have 18 inches of clearance around the deflector plate. The sprinkler was obstructed by papers that was stationed at 12 inches of clearance.
10. On 12/17/12 at 2:43 p.m., a corridor sprinkler head by Room 5609 had paint on the strut and deflector plate.
11. On 12/17/12 at 2:47 p.m., a corridor sprinkler head by Service Intensive Care Unit (SICU) corridor had paint on the strut.
12. On 12/17/12 at 3:25 p.m., a sprinkler head outside of South stairwell exit 58176 has lint build-up around the head.
13. On 12/18/12 at 9:15 a.m., a sprinkler in Room 3P648 has a rubber band around the head.
14. On 12/18/12 at 10:50 a.m., a sprinkler head by Room 2162D has black lint build-up around the head.
15. On 12/18/12 at 2:05 p.m., the sprinkler head in Room 1P541 did not have 18 inches of clearance around the deflector plate. The sprinkler was obstructed by a box that was stationed at 10 inches of clearance.
16. On 12/18/12 at 2:47 p.m., 4 of 6 sprinkler heads in the University tower lobby, next to the Information service desk, has paints on the heads and the struts.
17. On 12/18/12 at 3:16 p.m., a corridor sprinkler deflector spoke was bent upward, by Room 0P711.
18. On 12/18/12 at 3:20 p.m., 1 of 2 sprinkler escutcheon rings was missing, in Room 0783.
19. On 12/18/12 at 3:45 p.m., a corridor sprinkler head by Room 0625 has paint on the strut and head.
20. On 12/19/12 at 3:02 p.m., a corridor sprinkler by University tower 7 elevator has paint on the strut.
All sprinkler heads with paint added on thier deflectors must be replaced.
Surgery at Same Day
20. On 12/19/12 at 9:29 a.m., an Inspector Test Valve (ITV) in Room 1155 did not have a visible identification sign posted that indicated this valve is the Inspector Test Valve.
21. On 12/19/12 at 9:32 a.m., the Riser sprinkler in Room 1140 did not have a visible identification sign posted that indicated this valve is the Main Drain.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by portable fire extinguishers that were obstructed. This affected 4 of 15 floors in the Main Hospital, and could result in a delay in accessing the fire extinguisher in the event of an emergency.

NFPA 10, 1998.1-6.6* Fire extinguishers shall not be obstructed or obscured from view. Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means all be provided to indicate the location.
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.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with staff, the portable fire extinguishers were observed.

Main Hospital
1. On 12/17/12 at 11:05 a.m., a recessed portable ABC fire extinguisher by Room 8705 was missing an identification sign that indicated a portable fire extinguisher was available at that location.

2. On 12/17/12 at 2:10 p.m., a recessed portable ABC fire extinguisher in Cardiac Intensive Care (CICU) 6th floor was obstructed from access by a ventilator.

3. On 12/17/12 at 3:30 p.m., a recessed portable ABC fire extinguisher by Restroom 4709 was missing an identification sign that indicated a portable fire extinguisher was available at that location.

4. On 12/18/12 at 9:16 a.m., a recessed portable ABC fire extinguisher by Operation room (OR) 4 and 3P745A corridor was obstructed from access by a microscope.









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5. On 12/17/12 at 11:14 a.m., the fire extinguisher located in the University Tower 8 Waiting Room was blocked by three attached chairs. The door to the extinguisher cabinet could not be opened unless the chairs were moved. In an interview with staff, Fire Officer 2 stated that sometimes people in the waiting room move the chairs.

Based on record review and interview, the facility failed to maintain their fire/smoke dampers. This was evidenced by fire/smoke dampers that had not been inspected within the past four years. This affected two of three outpatient facilities and could result in the spread of smoke or fire to other locations of the facility due to a malfunctioning fire/smoke damper.

NFPA 90A, 1999 edition
3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review with staff, on 12/17/12 at 1:29 p.m., the facility's fire/smoke damper inspection records were requested.

Radiation Oncology
1. There were no records that indicated the fire/smoke dampers in the Cancer Center had been tested, inspected, cleaned, and lubricated within the past four years. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that the facility's fire/smoke damper test and inspection was currently in progress. Fire Officer 1 indicated that the testing and inspection for the Cancer Center has not been completed.

Surgery
2. There were no records that indicated the fire/smoke dampers in the Surgery Clinic had been tested, inspected, cleaned, and lubricated within the past four years. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that the facility's fire/smoke damper test and inspection was currently in progress. Fire Officer 1 indicated that the testing and inspection for the Surgery Clinic has not been completed.

Based on observation, the facility failed to maintain their kitchen suppression system. This was evidenced by accumulation of greasy deposits on pipes inside the kitchen exhaust hoods and an ansul pull alarm that was obstructed. This affected 1 of 15 floors in the Main Hospital, and could result in an increased risk of a grease fire to ignite in the kitchen and delay access of pull alarm in the event of an emergency.

NFPA 96, 1998
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1-System serving moderate-volume cooking operations-semi-annually.

8.3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing the company. It shall also indicate areas not cleaned.

Findings:

During a tour of the facility with staff, the Kitchen system were observed.

Main Hospital
1. On 12/18/12 at 2:34 p.m., an ansul pull alarm in the Pizza oven area was obstructed by a tall pizza cart that was stationed in front of the pull alarm.

2. On 12/20/12 at 8:31 a.m., the Cafe Wok area hood exhaust was observed with thick accumulation of greasy deposits on pipes running through the interior kitchen exhaust hood.
The sticker on the hood indicated it was cleaned on 11/2011. Plant Operation 1 presented a cleaning certificated documentation that indicated the hood was cleaned on 8/2012. There was a gap in cleaning the hood over six months between cleanings.

3. On 12/20/12 at 9 a.m., the Cafe Pizza oven area hood exhaust was observed with thick accumulation of greasy deposits running through the interior kitchen exhaust hood. There was no sticker on the hood. Plant Operation 1 presented a cleaning certificated documentation that indicated the hood was lasted cleaned on 8/2012.

Based on observation, the facility failed to comply with the regulations regarding portable space heating devices. This was evidenced by an unapproved portable heater in a non-sleeping staff area. This affected all staff and residents in 1 of 15 floors in the Main Hospital and could potentially result in the ignition of fire.

1999 NFPA 99
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.

9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator ' s, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

1999 NFPA 70
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a tour of the facility with staff, electrical equipment was observed.

Main Hospital
On 12/17/12 at 1:55 p.m., there was a heater under a desk in Office Room 6304 that was plugged into a power strip. This heater had a label warning, "high temperature three feet of clearance required". There was no tag on the heater and no documentation was provided indicating that this heater had been inspected by the facility.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency. This was evidenced by items stored in the exit corridor. This deficient practice affected all staff and patients in 3 of 15 floors at the Main Hospital and could potentially result in injury or a delayed evacuation in the event of an emergency.

7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

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

7.10.8 Special Signs.
7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Findings:

During a tour of the facility with staff, exit corridors were observed.

Main Hospital
1. On 12/17/12 at 10:35 a.m., there were nine charting computers against the wall near Room 11818. On the opposite side of the corridor was a vital signs monitor. Two of the charting computers had signs on them that read "do not move". There also were four charting computers around the corner from Room 11818. These charting computers were located near Room 11802 B. These charting computers were also located against the corridor wall.
During a return visit with Administrative Staff 3 at 1:13 p.m., the above charting computers were still in the same location.

2. On 12/17/12 at 10:46 a.m., there were tinsel decorations attached to the handrails on both sides of the corridor outside the Family Waiting Room. The handrail on the Family Waiting Room side of the corridor had tinsel attached for approximately eight feet. The handrail on the opposite side of the corridor had tinsel attached for approximately 15 feet.

3. On 12/17/12 at 2:58 p.m., The corridor doors to the four Sleep Disorder Rooms in Suite 5305 could not be opened without special knowledge from the egress side. Each of these rooms did have a second door that was used as an exit door. In an interview with staff, Fire Inspector 2 stated that the corridor doors were not used as exits. These doors could be mistaken for exit doors from the sleep rooms in an emergency.







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4. On 12/17/12 at 10:10 a.m., a Stryker bed was stored in the path of egress in front of the smoke barrier door right leaf, next to Room 12701.

Based on observation and interview, the facility failed to regulate the placement of potentially combustible decorations as evidenced by a decorated cut conifer-type tree and other cut decorations located in a corridor. This was also evidenced by artificial decorations with no documentation for flame retardant. This deficient practice could increase the potential for the spread of smoke and/or fire and affected 1 of 15 floors at the Main Hospital.

19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.

Exception: Combustible decorations, such as photographs and paintings,
in such limited quantities that a hazard of fire development or spread is not present.

Findings:

During a tour of the facility with staff, the potentially combustible decorations were observed.

Main Hospital
At 1:59 p.m., there were two approximately 18 inch diameter fir tree wreaths with cones and other decorations hanging on the corridor doors leading into the 10th Floor PICU Nurses' Station 2. Behind Nurses' Stations 2 there was paper on the wall with cedar bows bordering its edges. This area was approximately four feet wide and five feet long. To the left of the Nurses' Station was an approximately seven foot tall fir-type Christmas tree. This tree had a UC Davis tag attached to it that stated that it was treated with a flame retardant. In an interview with staff, Staff agreed that they were live cut decorations. Administrative Staff had the decorations removed at that time.

Based on observation and interview, the facility failed to maintain their oxygen and gas cylinders. This was evidenced by cylinders that were not safely secured. This affected 4 of 15 floors in the Main Hospital and 1 of 1 floor in the Outpatient building, and could result in a fallen med gas cylinder turning into a projectile and causing harm to patients and staff or by persons smoking near med gas storage rooms where there were no signs on the door.

NFPA 99, 1999
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.5.2.1 (27) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m) shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum: Caution: Oxidizing Gas(es) Within, No Smoking.

Findings:

During a tour of the facility with staff, the oxygen cylinders were observed.

Main Hospital
1. On 12/17/12 at 3:18 p.m., an E cylinder was unsecured, in Room 5662.

2. On 12/17/12 at 3:33 p.m., there were six E cylinders that was unsecured, in Room 4465. Four cylinders were freestanding and two cylinders were laying on the floor.

3. On 12/18/12 at 10 a.m., an E cylinder was unsecured underneath a babytherm cart, in Room 3777. In an interview, Staff 9 stated the rack underneath the babytherm cart is not for storing a cylinder.

Surgery at Same Day
4. On 12/19/12 at 8:55 a.m., the cylinder storage room 1159 door did not have an identification sign that indicated it was an oxygen storage location. There were 16 H cylinders in the room.









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Main Hospital
5. On 12/18/12 at 4:05 p.m., Room 0226 had an approximately three foot tall compressed nitrogen gas cylinder that was sitting unsecured on the floor.

Based on document review, the facility failed to maintain their piped-in medical gas system. This was evidenced by the facility's failure to correct discrepancies noted on their most recent piped-in medical gas system inspection report. This affected one of fourteen floors in the Main Hospital and could result in a piped-in medical gas system breach or malfunction.

Findings:

During record review, on 12/17/12 at 2:02 p.m., the facility's most recent piped-in medical gas system inspection report was reviewed. The inspection was conducted in May 2012. Repairs were conducted in June 2012. The repair report indicated that outlets in four patient rooms had leaks that could not be repaired. The repair report indicated that a zone shut down is required to repair the leaking outlets in the four patient rooms.

The leaking outlets were located in patient rooms 8653, 8661, 8667, and 8677. There were no records that indicated the leaking outlets in the four patient rooms had been repaired.

Based on record review and interview, the facility failed to maintain the relative humidity levels at their anesthetizing locations. This was evidenced by the facility's failure to maintain relative humidity levels at 35 percent or greater. This affected all facility operating rooms and anesthetizing locations and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review with staff, on 12/18/12 at 2:12 p.m., the facility's policy for anesthetizing location humidity levels was reviewed. The policy indicated that the facility would maintain relative humidity levels in their anesthetizing locations between 35-60%. The facility has twenty-four operating rooms, four children's surgery rooms, two C-section rooms, and four same day surgery rooms. The relative humidity records for the facility's anesthetizing locations were requested. The relative humidity records indicated that humidity had fallen below 35% on multiple instances in the anesthetizing locations.

The facility remotely monitors the relative humidity levels for their anesthetizing locations. The humidity monitoring system would trigger an alarm at the monitoring station whenever humidity fell outside of the alarm parameters. The offsite monitoring station was observed at that time. Staff at the monitoring station was asked to display the alarm parameters for the anesthetizing locations. The following alarm parameters were noted:

1. Surgery at Same Day Operating Rooms had alarm parameters of either 20-60% or 20-65% relative humidity.

2. Main Operating Rooms had alarm parameters of 25-60% relative humidity.

3. Children's Surgery Rooms had alarm parameters of either 22-60%, 22-65%, or 20-80% relative humidity.
4. C-section Rooms had alarm parameters of either 20-60% and 25-65% relative humidity.

Staff at the monitoring station was interviewed at that time. Staff did not know why the alarm parameters were not consistent throughout the anesthetizing locations. Staff did not know why the alarm parameters were not consistent with the facility policy of 35-60% relative humidity.

Based on record review, interview, and observation, the facility failed to maintain a Halon fire extinguishing system. This was evidenced by one Halon fire extinguishing system that was not certified in past six months. This affected one of fourteen floors in the Main Hospital and could result in a malfunctioning Halon fire extinguishing system.

NFPA 101, 2000 edition
9.7.3 Other Automatic Extinguishing Equipment.

9.7.3.1 In any occupancy where the character of the potential fuel for fire is such that extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as water mist, carbon dioxide, dry chemical, foam, Halon 1301, water spray, or a standard extinguishing system of another type, that system shall be permitted to be installed in lieu of an automatic sprinkler system. Such systems shall be installed, inspected, and maintained in accordance with appropriate NFPA standards.

19.3.5.4 Isolated hazardous areas shall be permitted to be protected in accordance with 9.7.1.2. For new installations in existing health care occupancies, where more than two sprinklers are installed in a single area, waterflow detection shall be provided to sound the building fire alarm, or to notify by a signal, any constantly attended location, such as PBX, security, or emergency room, at which the necessary corrective action shall be taken.

NFPA 12A, 1997 edition
4-1 Inspection and Tests.
4-1.1 At least semiannually, all systems shall be thoroughly inspected, tested, and documented for proper operation by trained competent personnel. Tests shall be in accordance with the appropriate NFPA or Canadian standards.
4-1.2 The documented report with recommendations shall be filed with the owner.

Findings:

During record review with staff, on 12/18/12 at 9:47 a.m., the facility's Halon fire extinguishing system inspection records were reviewed. The facility has a Halon fire extinguishing system protecting the MRI Computer Room 1355. The Halon fire extinguishing system was last inspected on 6/22/12. The inspection report indicated that the system did not pass inspection. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that the repairs had been made on the Halon fire extinguishing system. There was no record that indicated the inspection vendor had returned to re-inspect and certify the Halon fire extinguishing system after the repairs had been completed. The Halon fire extinguishing system was observed at 8:35 a.m. on 12/20/12. The Halon fire extinguishing system had a certification tag on it dated 12/29/11.

Based on observation and interview, the facility failed to maintain its area alarm panel. This was evidenced by an area alarm panel screen that did not display any reading. This affected 1 of 15 floors in the Main Hospital and could result in staff not being notified in the event the line pressure for the medical air increases/decreases from the normal operating pressure.

NFPA 99, 1999
4-3.1.2.2 Gas Warning Systems.
2. Local, master, and area alarms shall indicate visually and audibly if:
(a) the monitored condition occurs (b) the wiring to the sensor or switch is disconnected
C (3) Area alarms shall indicate if the pressure in the local line increases 20 percent or decreases 20 percent from normal line pressure.

Findings:

During a tour of the facility with staff, the area alarm panels were observed.

Main Hospital
On 12/18/12 at 1:45 p.m., the area alarm panel in the Pediatric Emergency Department (ED) in the Nurse station failed to display line pressure reading. The power icon was blinking and the screen was blank. The area alarm panel supply rooms 1P762, 1P763, 1P764, 1P766, 1P779, 1P777, 1P778, 1P776, 1P775, 1P774, 1P773. There was a patient in Room 1P773 at the time.

In an interview, Staff 8 stated she did not know how long the area alarm panel screen was not working.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, the permanent use of extension cords, improper clearance in front of electrical panels, fixtures missing covers, and damaged electrical equipment. This deficient practice affected all staff and patients in 10 of 15 floors and could potentially result in electrical shock or the ignition of fire.

NFPA 70, 1999
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.
110-12 requires that electrical equipment be installed in a neat and workman like manner.
110-26 (a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less
370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.
110-12 requires that electrical equipment be installed in a neat and workmanlike manner. 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.
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.
400-8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.
110-26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in.
(762 mm), whichever is greater.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During a tour of the facility with staff, electrical wiring and equipment were observed.

Main Hospital
1. On 12/17/12 at 1:49 p.m. there was a water cooler, a microwave oven, and a half size refrigerator plugged into a power strip in Room 6302.

2. On 12/17/12 at 1:50 p.m. in Room 6312 C, there was a coffee pot plugged into a white, unapproved, approximately 16 gauge extension cord that had a multiple outlet end with no over-current protection.

3. On 12/17/12 at 1:59 p.m., there was a receptacle plate cover missing in Utility Room 6307.

4. On 12/17/12 at 2:15 p.m., there was a refrigerator in Room 6212 that had tape wrapped around the cord near the plug end. The cord was stretched tightly creating tension to the joint and terminals.

5. On 12/17/12 at 2:32 p.m., there was a toaster oven plugged into a power strip in Room 5209.

6. On 12/18/12 at 8:37 a.m., there was a power strip plugged into a power strip in Room 3211.

7. On 12/18/12 at 8:55 a.m., there was an extension cord with a multiple outlet end and no over-current protection with a coffee pot plugged into it in Room 3219.

8. On 12/18/12 at 9:06 a.m., there was an unapproved extension cord under a desk in Room 3012 B.

9. On 12/18/12 at 9:13 a.m., there was a power strip under a desk in the third floor Student Sleep Room 3302 that had the top cover disconnected exposing un-insulated wires. The power strip was plugged in. Administrative Staff 3 unplugged the power strip and had it removed at that time.

10. On 12/18/12 at 9:55 a.m., there was a receptacle outlet that was missing a plate cover in Room 3125.

11. On 12/18/12 at 11:07 a.m., there was a power strip suspended above the floor in Office 2304.

12. On 12/18/12 at 11:35 a.m., there was a power strip plugged into another power strip in Laboratory Office 2P323.

13. On 12/18/12 at 2:03 p.m., there was a half size refrigerator plugged into a power strip in Room 1525.

14. On 12/18/12 at 3:20 p.m., Equipment Storage Room 0322 had three electrical panels with boxes and equipment stored in front of the panels.

15. On 12/18/12 at 3:30 p.m., the was an extension cord in Room 0317 that was wrapped around a pipe and traveled across the wall, behind a bulletin board, and down to the floor. This extension cord had a multiple outlet end with no over-current protection.

16. On 12/18/12 at 4:28 p.m., the Lower Level Optical Biopsy Research Laboratory had four power strips chained together under a large table.




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17. On 12/17/12 at 10:16 a.m., a surge protector was hanging suspended from the receptacle transmitting tension to the joint and terminals, with items plugged into it, in the Nurse station by Room 12710.

18. On 12/17/12 at 10:30 a.m., a junction box was missing a cover plate, in Room 10778.

19. On 12/17/12 at 11:11 a.m., two 8 inch by 8 inch openings in the ceiling were missing cover plates, in Room 8608.

20. On 12/17/12 at 1:45 p.m., an electrical panel C6LA2-91229 in Room 6742 was obstructed by tool cart that was stationed within inches of the electrical panel.

21. On 12/17/12 at 1:56 p.m., four battery chargers were plugged into a non hospital grade surge protector that was connected to a two plugs wall receptacle, in Room 6752. The manufacture specification on the back of the battery machine indicated, "to be connected to a hospital grade power outlet.

22. On 12/17/12 at 2:11 p.m., two electrical panels 6A section 1 and 2 in Room 6652 were obstructed by boxes and oxygen tanks. The sign on the electrical panel read: Area in front of this electrical panel must be keep clear for 36 inches.

23. On 12/17/12 at 2:13 p.m., an electrical box was missing a cover plate, in Room 6606.

24. On 12/17/12 at 3:02 p.m., a white refrigerator was plugged into a surge protector, in Room 4210 north.

25. On 12/17/12 at 3:16 p.m., a cover plate shifted to one side and exposed opening junction box, in Room 4656.

26. On 12/18/12 at 8:52 a.m., a phone charger was plugged into a white extension cord, in Room 3P609-CRD/THO Fellow room.

27. On 12/18/12 at 8:54 a.m., an electrical panel N3YL2 in Room 3P606 were obstructed by a 6 foot and 8 foot ladders that were stationed within inches of the electrical panel.

28. On 12/18/12 at 8:55 a.m., an electrical panel C3XL2 in Room 3P344 were obstructed by a 6 foot and 8 foot ladders that were stationed within inches of the electrical panel.

29. On 12/18/12 at 10:30 a.m., a surge protector was hanging suspended from the receptacle transmitting tension to the joint and terminals, with items plugged into it, in Room 2P518.

30. On 12/18/12 at 10:58 a.m., a junction box was missing a cover plate. The box exposed blue and white IT wires, in Room 2303.

31. On 12/18/12 at 1:39 p.m., a surge protector was plugged into another surge protector, in Room 1P934 cubicle 4.

Based on observation, the facility failed to maintain the installation of the alcohol based hand rub dispensers (ABHR). This was evidenced by the mounting a ABHR over or adjacent to an ignition source. This affected 3 of 15 floors in the Main Hospital, and could result in an increased potential for an alcohol based hand rub to ignite a fire.

Findings:

During a tour of the facility with staff, the alcohol based hand rub dispensers were observed.

Main Hospital
1. On 12/17/12 at 10:03 a.m., a ABHR was mounted directly above an outlet, in Room 12771.

2. On 12/17/12 at 10:13 a.m., a ABHR was mounted 4 1/2 inches adjacent to a light switch, in Room 12710A.

















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3. On 12/17/12 at 2:26 p.m., there was an ABHR dispenser attached to a charting stand near Room 6112. The dispenser was above the computer that was mounted on its side.

4. On 12/17/12 at 2:27 p.m., there was a ABHR dispenser mounted above a wall receptacle near Room 6116.

5. On 12/17/12 at 3:16 p.m., the Five East Nurses' Station had an ABHR dispenser mounted above battery charging units.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the walls and ceilings. This affected 9 of 15 floors in the Main Hospital, and could result in the increased potential for the spread of fire and smoke to other areas of the facility.

Findings:

During a tour of the facility with staff, the walls and ceilings were observed.

Main Hospital
1. On 12/17/12 at 10:15 a.m., a sprinkler escutcheon ring was not flush against the ceiling. There was an approximately 1/2 inch penetration exposed in the ceiling, in Room 12812-Staff lounge.

2. On 12/17/12 at 10:25 a.m., 1 of 3 sprinkler escutcheon rings were not flush against the ceiling. There was an approximately 1/8 inch penetration exposed in the ceiling, in Room 10781.

3. On 12/17/12 at 10:40 a.m., a sprinkler escutcheon ring was not flush against the ceiling. There was an approximately 1/8 inch penetration exposed in the ceiling, in Room 10731-Clean utility.

4. On 12/17/12 at 11:02 a.m., there was an approximately 1/8 inch penetration exposed in the ceiling, in Room 8811-Nourishment.

5. On 12/17/12 at 1:16 p.m., there were two approximately 1/4 inch penetrations exposed in the left wall, in Room 7792.

6. On 12/17/12 at 1:26 p.m., there were five approximately 1/4 inch penetrations in the left wall and seven approximately 1/4 inch penetrations in the back wall, in Room 7818.

7. On 12/17/12 at 1:49 p.m., a sprinkler was shifted to one side. There was an approximately 1/8 inch penetration exposed in the ceiling, in Room 6818.

8. On 12/17/12 at 2:01 p.m., there were four approximately 1/4 inch penetrations exposed in the left wall, in Room 6701-Tower 6 satellite pharmacy.

9. On 12/17/12 at 2:36 p.m., there were two approximately 1/4 inch penetrations, four approximately 1/2 inch penetrations, and four approximately 1/8 inch penetrations exposed in the left wall, in Room 5705.

10. On 12/18/12 at 11:01 a.m., there were nine approximately 1/2 inch penetrations and ten approximately 1/4 inch penetrations exposed in the wall, in Room 2512-GI lab clerical supplies.

11. On 12/18/12 at 2:16 p.m., a sprinkler was shifted to one side. There was an approximately 1/2 inch penetration exposed in the ceiling, in Room 1722-Fire command room.

12. On 12/18/12 at 4 p.m., five of eight sprinklers shifted to one side. There were five approximately 1/2 inch to 1/4 inch penetrations exposed in the ceiling, in Room 0523-Physical Medicine and Rehabilitation (PM&R).










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13. On 12/18/12 at 1:55 p.m., there were three approximately one-half inch unsealed penetrations in the wall in Room 1303. This wall was a fire-rated wall separating Room 1303 from a mechanical room on the other side of the wall.

Based on observation and interview, the facility failed to maintain the corridor construction with a one-half hour fire rating as evidenced by unsealed penetrations in the corridor walls. This deficient practice affected 5 of 15 floors in the Main Hospital and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with staff, corridor walls and ceilings were observed.

Main Hospital
1. On 12/18/12 at 9:30 a.m., there were four one-quarter inch holes in the corridor doors to Rooms 3312, 3310, and 3308. Administrative Staff 3 stated that it looked like the door hardware had been removed.

2. On 12/18/12 at 10:57 a.m., the corridor wall near Room 2231 had three unsealed penetrations. These penetrations were located approximately 24 inches up from the floor and were areas where the gypsum board had been pushed in. The vinyl wall still partially concealed the damaged area.

3. On 12/18/12, between 11:15 a.m. and 11:45 a.m., there was two unsealed penetrations in the wall in Room 2144. One penetration was approximately one inch wide by eight feet long and the other one was approximately one inch wide by three feet long. Both penetrations were located approximately four feet up from the floor. This wall also separated Room 2144 from Corridor 2160. Room 2144 was part of a decommissioned portion of the building.





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4. On 12/17/12 at 10:06 a.m., a sprinkler was missing an escutcheon ring, in the corridor by Room 12759B. There was an approximately 1/8 inch penetration exposed.

5. On 12/17/12 at 11:10 a.m., there were twenty approximately 1/8 inch to 1/4 inch penetrations above the smoke barrier door 8700 header, by Room 8609 corridor.

6. On 12/17/12 at 3:20 p.m., there was an approximately 3 inch by 2 inch penetration in the wall, by Room 0783 corridor.

Based on observation and interview, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This affected staff and patients in 10 of 15 floors of the Main Hospital.

NFPA 101, 19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

Findings:
During a tour of the facility with the staff, doors were observed.

Main Hospital
1. On 12/17/12 at 2:32 p.m., the door to Room 5209 was impeded from closing by a door wedge. There was also a trash can that was located in the travel area of the door preventing the door from closing.

2. On 12/17/12 at 2:55 p.m., the roll down door to Room 5308 was impeded from closing by a plastic stand placed in the travel area of the door.

3. On 12/17/12 at 3:20 p.m., the door to Patient Room 5133 was impeded from closing by a scale and an isolation cart that were in front of the door.

4. On 12/17/12 at 3:24 p.m., the door to Patient Room 5113 did not close when released from a fully open position. This door was being held open by a device designed to release upon activation of the fire alarm system.

5. On 12/18/12 at 8:59 a.m., the door to Waiting Room 3220 was being held open by a trash can. Staff stated that when the door closes, it automatically locks. Administrative Staff stated that the door latching mechanism could be changed.

6. On 12/18/12 at 10:00 a.m., the door to Report Room 3684A did not positive latch when tested by releasing the door from an open position.

7. On 12/18/12 at 10:05 a.m., the door to Patient Room 3675 did not positive latch when tested by releasing the door from an open position.

8. On 12/18/12 at 2:15 p.m., the fire-rated door to Sub-Sterile Room 1346A was being held open by a door wedge.

9. On 12/18//12 at 3:16 p.m., the corridor door to the Room 0343 did not positive latch when tested by releasing it from an open position. This door was being held open by a device designed to release upon activation of the fire alarm system.

10. On 12/18/12 at 4:00 p.m., the door to Room 0204 did not positive latch when tested by releasing the door from an open position. This door was being held open by a device designed to release upon activation of the fire alarm system.


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11. On 12/17/12 at 10:24 a.m., the self closing door in Room 10716 failed to latch.

12. On 12/17/12 at 11:13 a.m., the door to Room 8603 was obstructed by a portable X-ray machine.

13. On 12/17/12 at 1:12 p.m., the self closing door to Room 7705 was obstructed by two garbage bins.

14. On 12/17/12 at 1:25 p.m., the self closing door to Room 7812 failed to latch.

15. On 12/17/12 at 1:36 p.m., the door handle to Room 6789 was tied open by a blue rubber band.

16. On 12/17/12 at 1:40 p.m., the door to Room 6763 was obstruct by a work station cart cord that prevented the door from closing.

17. On 12/17/12 at 1:48 p.m., the self closing door to Room 6812 failed to latch.

18. On 12/17/12 at 2:50 p.m., the self closing door to Room 4120 was obstructed by a wood stopper.

19. On 12/17/12 at 2:51 p.m., the self closing door to Room 4132B was obstructed by a metal stopper.

20. On 12/17/12 at 3:15 p.m., the self closing door to Room 4654 was obstructed by a propaq cart.

21. On 12/17/12 at 3:26 p.m., the self closing door to Room 4671 failed to latch.

22. On 12/18/12 at 9 a.m., the self closing door to Room 3P504 failed to latch. A tape was used to covered the latching hardware.

23. On 12/18/12 at 9:18 a.m., the self closing door to Storage room 3P892C inside Operating room (OR) 4 was obstructed by a IV pole.

24. On 12/18/12 at 10:02 a.m., the self closing door to Room 2P175 was obstructed by a metal stopper.

25. On 12/18/12 at 10:20 a.m., the door to Room 2P649 was obstructed by a garbage bin.

26. On 12/18/12 at 11 a.m., the self closing door to Room 2510A was obstructed by boxes.

27. On 12/18/12 at 2:13 p.m., the self closing door to Room 1P522 was obstructed by a round concrete block.

28. On 12/18/12 at 3:15 p.m., the self closing door to Room 00719 was obstructed by a chair.

29. On 12/18/12 at 3:21 p.m., the self closing door to Room 0767 was tied open by a plastic bag.

30. On 12/18/12 at 3:32 p.m., the self closing door to Room 0762C was obstructed by a rubber stopper.

31. On 12/18/12 at 3:36 p.m., the self closing door to Room 0762 was obstructed by a wooden wedge.

32. On 12/18/12 at 3:37 p.m., the self closing door to Room 0711B was held open by a kick stand.

33. On 12/18/12 at 3:38 p.m., the self closing door to Room 0711A was held open by a kick stand.

34. On 12/18/12 at 3:46 p.m., the self closing door to Room 0624 was obstructed by a coat stand.



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35. During a facility tour with staff, on 12/19/12 at 8:37 a.m., a roll down fire door near Room 7710A was obstructed from closing by a basket positioned directly in the roll down path of the door.

Based on observation, the facility failed to maintain its stairways. This was evidenced by penetrations in stairwell walls. This affected 2 of 15 floors in the Main Hospital and 1 of 4 floors in the Outpatient building, and could result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with staff, stairway walls and fire-rated self-closing doors were observed.

Radiation Oncology
1. On 12/19/12 at 9:10 a.m., the two-hour fire-rated Stairwell Wall 1 had two approximately one inch diameter unsealed penetrations in the wall. One penetration did not go completely through the sheeting.


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Main Hospital:
2. At 2:34 p.m., on 12/19/2012, the fire doors near the 8th floor Davis Wing elevators (Room 8712) were equipped with self-closing devices and magnetic hold-open devices. The fire alarm system was tested and activated at that time. The fire doors did not release from the magnetic hold-open devices.

3. At 3:15 p.m., the fire door 6730A near the 6th floor Davis Wing elevators was equipped with a self-closing device and a magnetic hold-open device. The fire alarm system was tested and activated at that time. The fire door released from the magnetic hold-open device but did not close. The door failed to close due to the door leaf dragging on the floor.

Based on observation and testing, the facility failed to maintain its fire alarm system to function as necessary to make the building safer for its occupants. This was evidenced by fire doors that failed to release from their magnetic hold open devices per smoke compartment during activation of the fire alarm system. This affected 3 of 15 floors in the Main Hospital, and could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

2000 NFPA 101
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

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

NFPA 101, 9.6.5.1. A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

Findings:

During the testing with staff, the smoke barrier doors were observed.

Main Hospital

1. On 12/19/12 at 2:35 p.m., the smoke barrier doors 8700A in the link area failed to release from the magnetic hold device (device N15L1D68).

2. On 12/19/12 at 3:46 p.m., the right leaf smoke barrier door in Post Anesthesia Care Unit (PACU) 3P530 failed to release from the magnetic hold device (device N33L02M56).

3. On 12/19/12 at 4:14 p.m., the right leaf smoke barrier door 0810 failed to release from the magnetic hold device (device N11L1D18).

Based on observation, the facility failed to maintain their fire-rated smoke barrier walls. This was evidenced by unsealed penetrations in four fire-rated smoke barrier walls throughout the facility. This affected 3 of 15 floors in the Main Hospital and 1 of 4 floors in the Outpatient building, and could result in the spread of smoke or fire to other smoke compartments.

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

Findings:

During a facility tour with staff, the facility's fire-rated smoke barrier walls were observed.

Main Hospital
1. On 12/18/12 at 3:55 p.m., there was an approximately 5 inch diameter pipe conduit penetrating the fire-rated smoke barrier wall near Room 10781. There was nothing sealing the opening of the pipe conduit.

2. On 12/18/12 at 4:00 p.m., there were two approximately 5 inch diameter pipe conduits penetrating the fire-rated smoke barrier wall near Room 10716. There was nothing sealing the openings of the pipe conduits.

3. On 12/19/12 at 8:55 a.m., there was an approximately 14 inch by 5 inch unsealed penetration in the fire-rated smoke barrier wall by Door 6140

4. On 12/19/12 at 10:00 a.m., there was an approximately 4 inch by 3 inch unsealed penetration in the fire-rated smoke barrier wall by Door 2200.


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Radiation Oncology
5. On 12/19/12 at 9:15 a.m., the one-hour fire-rated wall separating Room 0161 from 0165 had a 4 inch pipe sleeve with data cables in it that was not sealed with a fire-rated material.

Based on observation, the facility failed to maintain its fire doors to continuously serve as a barrier to prevent the spread of smoke and/or fire. This was evidenced by cross-corridor fire doors that were equipped with latching hardware that failed to latch when tested. This deficient practice affected all staff and patients on 5 of 15 floors at the Main Hospital and one of 1 of 4 floors in Outpatient buildings. It could potentially result in the spread of smoke and/or fire.

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

Findings:

During a tour of the facility with Staff, fire doors were inspected throughout the facility.

Main Hospital
1. On 12/17/12 at 1:40 p.m., on the sixth floor, one-half hour fire-rated door number 58216 did not close and latch when tested by releasing the door from an open position. There was an approximately six inch gap along the latch edge of the door.

2. On 12/18/12 at 9:36 a.m., the fire barrier doors to the Three South GI Procedure Room were rubbing at the top preventing the door from latching when tested by releasing the door from an open position.

3. On 12/18/12 at 2:30 p.m., the right leaf facing west of the fire barrier doors to the first floor Children's Surgery Recovery Room was damaged at the bottom preventing it from closing completely.

4. On 12/18/12 at 3:20 p.m., the double doors near Class Room 0343 did not close, leaving an approximately three inch gap at the latching edge of the door. A strong air flow could be detected holding the door open.

5. On 12/18/12 at 3:32 p.m., 90 minute fire door 58022 did not positive latch when tested, leaving an approximately three inch gap at the latching edge of the door.

6. On 12/19/12 at 1:35 p.m., the right leaf facing east of the cross corridor doors near Room 14763 did not close completely and latch.

7. On 12/19/12 at 1:52 p.m., the left leaf of the fire door 11730A facing the elevators did not coordinate properly, leaving an approximately three inch gap at the latching edge of the door.

Radiation Oncology
8. On 12/19/12 at 9:34 a.m., the 60 minute fire-rated smoke barrier doors to the Clinic Nursing Unit adjacent to Room G113J did not close completely and latch.
















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Main Hospital
9. On 12/19/12 at 1:53 p.m., the left leaf smoke barrier door 11720A failed to latch when released from the magnetic hold device.

10. On 12/19/12 at 3:28 p.m., the left leaf smoke barrier 5680 failed to close all the way. The door was dragging on the floor.

11. On 12/19/12 at 4:15 p.m., the right leaf smoke barrier door 0811 failed to close and latch.

12. On 12/19/12 at 4:30 p.m., the right leaf smoke barrier door 3500 failed to close and latch.

Based on observation, the facility failed to maintain their emergency exit door. This was evidenced by items that were stored in front of the emergency exit door. This affected 1 of 15 floors in the Main Hospital, and could result in a delay egress in the event of an emergency.

Findings:

During a tour of the facility with staff, the emergency exit doors were observed.

Main Hospital
On 12/18/12 at 3:59 p.m., the emergency exit door by 0665 in the Lower level Central processing room had a stepping stool that was stationed in front of the door.

Based on observation and record review, the facility failed to maintain their battery back-up emergency lighting units. This was evidenced by the facility's failure to document testing of monthly and annual tests on their battery back-up emergency lighting units and a failed emergency unit. This affected all patients in the Main Hospital, 2 of 3 outpatient facilities and could result in a delayed notification of a malfunctioning emergency lighting unit.

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

Findings:

During record review with staff, on 12/18/12 at 11:45 a.m., the facility's test records for their battery back-up emergency lighting units were reviewed. The facility policy indicated that the battery back-up emergency lighting units are tested monthly for thirty seconds and annually for ninety minutes. The following was noted when reviewing the test records for the emergency lighting units:

Main Hospital:
1. There were no test records for the battery back-up emergency lighting units located in the Davis Wing. The Davis Wing contains two C-Section operating rooms which are equipped with battery back-up emergency lighting units. There were no records that indicated the battery back-up emergency lighting units were tested monthly for thirty seconds or annually for ninety minutes.

2. The test records for the battery back-up emergency lighting units located in the University Wing were reviewed. There were no records of monthly thirty second testing for five of the past twelve months. There were no test records for the months of January 2012, March 2012, June 2012, August 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency lighting units during the past twelve months.

3. There were no records that indicated an annual ninety minute test had been completed on the battery back-up emergency lighting units located in the North/South/East Wing (Building 01/1). The North/South/East Wing contains four Children's Surgery operating rooms which are equipped with battery back-up emergency lighting units.

4. The test records for the battery back-up emergency lighting units located in the Pavilion Wing were reviewed. The Pavilion Wing contains twenty-four operating rooms which are equipped with battery back-up emergency lighting units. There were no records of monthly thirty second testing for five of the past twelve months. There were no test records for the months of February 2012, July 2012, September 2012, November 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency lighting units during the past twelve months.

Surgery at the Same Day
5. The test records for the battery back-up emergency lighting units located in the Same Day Surgery Center were reviewed. The Same Day Surgery Center contains four operating rooms which are equipped with battery back-up emergency lighting units. There were no records of monthly thirty second testing for two of the past twelve months. There were no test records for the months of February 2012 or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency lighting units during the past twelve months.

Surgery
6. The test records for the battery back-up emergency lighting units located in the Surgery Clinic were reviewed. There were no records of monthly thirty second testing for three of the past twelve months. There were no test records for the months of January 2012, June 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency lighting units during the past twelve months.


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7. On 12/19/12 at 11:20 a.m., one of two emergency lighting units in the Waiting Room did not function when tested by pressing the test button. Staff agreed that the light was not working.

Based on observation and record review, the facility failed to maintain their battery back-up emergency exit signs. This was evidenced by the facility's failure to document testing of monthly and annual tests on their battery back-up emergency exit signs and failed exit signs. This affected all patients in the Main Hospital and 2 of 3 outpatient facilities and could result in a delayed notification of a malfunctioning emergency exit sign.

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

Findings:

During record review with staff, on 12/18/12 at 11:32 a.m., the facility's test records for their battery back-up emergency exit signs were reviewed. The facility policy indicated that the battery back-up emergency exit signs are tested monthly for thirty seconds and annually for ninety minutes. The following was noted when reviewing the test records for the emergency exit signs:

Main Hospital:
1. The test records for the battery back-up emergency exit signs located in the Davis Wing were reviewed. There were no records of monthly thirty second testing for seven of the past twelve months. There were no test records for the months of January 2012, February 2012, July 2012, August 2012, September 2012, October 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency exit signs during the past twelve months.

2. The test records for the battery back-up emergency exit signs located in the University Wing were reviewed. There were no records of monthly thirty second testing for eight of the past twelve months. There were no test records for the months of January 2012, February 2012, April 2012, June 2012, July 2012, August 2012, September 2012, or November 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency exit signs during the past twelve months.

3. The test records for the battery back-up emergency exit signs located in the North/South/East Wing were reviewed. There were no records of monthly thirty second testing for seven of the past twelve months. There were no test records for the months of January 2012, February 2012, April 2012, July 2012, August 2012, September 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency exit signs during the past twelve months.

Surgery at Same Day
4. The test records for the battery back-up emergency exit signs located in the Same Day Surgery Center were reviewed. There were no records of monthly thirty second testing for three of the past twelve months. There were no test records for the months of February 2012, October 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency exit signs during the past twelve months.

Surgery
5. The test records for the battery back-up emergency exit signs located in the Surgery Clinic were reviewed. There were no records of monthly thirty second testing for four of the past twelve months. There were no test records for the months of January 2012, March 2012, August 2012, or December 2012. There was no record that indicated an annual ninety minute test had been completed on the battery back-up emergency exit signs during the past twelve months.



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Main Hospital
6. On 12/17/12, at 2:40 p.m., the exit sign at the end of the corridor near door 58190 was not illuminated.

7. On 12/18/12 at 2:45 p.m., the exit sign located near the first floor Clinical Nurse Specialist (CNS) Room was illuminated with one of two bulbs.

Radiation Oncology
8. On 12/19/12 at 8:45 a.m., the exit sign located in the Lobby near the elevator was not illuminated.

Outpatient Surgery
9. On 12/19/12 between 10:20 and 11:10 a.m., the exit signs located near rooms 1900, 1900 A, 1908, 1890, and 1875 were tested by pressing the test button. The light on the side of the exit sign flashed green and red indicating that the sign had insufficient charge. All exit signs did stay illuminated when tested. When asked, Fire Inspector 2 stated that it might mean that the sign would not hold a charge for the full 90 minutes.

Based on record review, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by the facility's failure to conduct one of two semi-annual emergency preparedness drills during the past twelve months. This affected all patients in the Main Hospital and three of three outpatient facilities and could result in staff being unprepared to respond to emergency situations.

NFPA 99, 1999 edition
11-5.3.9 Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During record review with staff, on 12/18/12 at 8:10 a.m., the facility's emergency preparedness drill records were requested. The facility had conducted an emergency preparedness drill in October 2012 and November 2012. There was no documentation that indicated the facility had conducted an emergency preparedness drill during the months of January 2012 to September 2012.

Based on interview, the facility failed to ensure that all staff respond properly in the event of a fire emergency. This was evidenced by two staff that were not familiar with what actions to take in the event of a fire and had not yet received training. This deficient practice affected all staff and patients on 1 of 15 floors in the Main Hospital and could potentially result in a delay in staff or first responders' responses in the event of a fire.

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

19.7.2 Procedure in Case of Fire.
19.7.2.1* For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During fire alarm testing, staff were being interview for fire and life safety procedures.

Main Hospital
1. On 12/19/12 at 3:22 p.m., in an interview with Staff, Staff 6 and 7 at the Nurses' Station near Room 6783 were asked at the same time what they would do if there were a fire in a patient's room. Both staff did not answer with the acronym RACE or PASS. Staff stated that they were not sure what to do. When asked if they had received any fire drill training, both said that they had not. When asked how long they had worked at the facility Staff 6 stated three years and Staff 7 stated six months.



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2. On 12/19/12 at 4:25 p.m., Staff 2 in the Radiology department was interviewed and was asked what she would do in the event of a large fire. Staff 2 responded that she would call the fire department. She failed to state the use of the fire alarm devices including the manual pull alarms to notify the staff and visitors of a fire in the area.

Based on observation, documentation, and interview, the facility failed to maintain their fire alarm system components. This was evidenced by manual pull alarms that were obstructed, a alarm notification device that did not emit sound, and by the lack of a trouble signal when a smoke detector was removed from service. This affected 4 of 15 floors in the Main Hospital and 1 of 3 floors in the Outpatient building, and could result in staff inability to readily access the pull alarm and the component in the event of a fire.

NFPA 101 (2000 Edition)
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

NFPA 72, 1999
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a facility tour with staff, the fire alarm system and components were observed.

Main Hospital
1. On 12/17/12 at 10:54 a.m., a fire alarm notifier was obscured from view and access by a pyxis machine, in Nurse station 1 on the 8th floor (Davis Tower).

2. On 12/17/12 at 1:28 p.m., a manual pull alarm was obstructed from access by a carefusion cart, in Nurse station 2 of 7th floor (Davis Tower).

3. On 12/17/12 at 1:29 p.m., a manual pull alarm was obstructed from access by a carefusion cart, in Nurse station 1 of 7th floor (Davis Tower).

4. On 12/17/12 at 1:30 p.m., a manual pull alarm was obstructed from access by a carefusion cart, in Nurse station 4 of 7th floor (Davis Tower).

5. On 12/17/12 at 1:37 p.m., a fire alarm notifier was obscured from view and access by a pyxis machine, in Nurse station 4 on the 6th floor (Davis Tower).

6. On 12/17/12 at 1:39 p.m., a fire alarm notifier was obscured from view and access by a pyxis machine, in Nurse station 3 on the 6th floor (Davis Tower).

7. On 12/17/12 at 1:43 p.m., a fire alarm notifier was obscured from view and access by a pyxis machine, in Nurse station 2 on the 6th floor (Davis Tower).

8. On 12/17/12 at 1:47 p.m., a fire alarm notifier was obscured from view and access by a pyxis machine, in Nurse station 1 on the 6th floor (Davis Tower).














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Surgery
9. On 12/19/12 at 10:26 a.m., the smoke detector in Room 1919 was missing. This surveyor noted that there was no audible fire alarm trouble signal at the fire alarm control panel (FACP). At 11:03 a.m., when this surveyor asked Staff to remove the smoke detector to simulate a missing detector, the FACP audible could be heard. During an interview on 12/20/12, between 11:15 a.m. and 11:45 a.m., When asked why the FACP was not producing an audible alarm, Fire Officer 1 stated that he thought that the detector had been removed and someone had silenced the FACP. When asked how long the detector had been missing, Fire Officer 1 stated that he was unsure. During record review at 11:50 a.m., documentation provided titled "System Event Report" indicated that there was a system trouble logged during the timer test on 12/18/12.







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Main Hospital:
10. During a facility tour with staff, on 12/19/12 at 4:42 p.m., the facility's fire alarm system was tested. The fire alarm chime/strobe device located in the corridor by Room 3306 was observed. The chime/strobe device failed to emit an audible alarm when the fire alarm system was activated.

Based on record review and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the facility's waterflow alarm valves that failed to alarm within ninety seconds, one automatic fire sprinkler system riser that was not equipped with a hydraulic nameplate, sprinkler heads with debris, paint, less than 18 inches of clearances, and no identification sign of test valves . This affected all patients in the Main Hospital and one of three outpatient facilities. This could result in a delayed notification of a sprinkler activation.

NFPA 72, 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.

NFPA 13, 1999 edition
10-5 Hydraulic Design Information Sign. The installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other approved means. Such signs shall be placed at the alarm valve, dry pipe valve, preaction valve, or deluge valve supplying the corresponding hydraulically designed area. the sign shall include the following information:
(1) Location of the design area or areas
(2) Discharge densities over the design area or areas
(3) Required flow and residual pressure demand at the base of the riser
(4) Occupancy classification or commodity classification and maximum permitted storage height and configuration
(5) Hose stream demand included in addition to the sprinkler demand

NFPA 25, 1998 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.

NFPA 13, 3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. This sign shall be secured with corrosion-resistant wire, chain or other approved means.

Findings:

During record review with staff, on 12/18/12 at 10:14 a.m., the facility's quarterly automatic fire sprinkler system test and inspection records were reviewed. The following waterflow alarm valve tests did not indicate alarm activation within ninety seconds:

Main Hospital:
1. The waterflow alarm valve near room 2615 was tested on 2/28/12. The recorded alarm time was 100 seconds.

2. The waterflow alarm valve in the Davis Wing near the 14th north stairwell was tested on 3/1/12. The recorded alarm time was 111 seconds.

3. The waterflow alarm valve in the Davis Wing near the 14th north stairwell was tested on 5/14/12. The recorded alarm time was 98 seconds.

4. The waterflow alarm valve in the Davis Wing near the 2nd floor Stair B was tested on 8/9/12. The recorded alarm time was 97 seconds.

5. The waterflow alarm valve in the Pavilion Wing near the 3rd floor Stair H was tested on 8/10/12. The recorded alarm time was 113 seconds.

6. The waterflow alarm valve in the Davis Wing near the lower level loading dock was tested on 11/21/12. No alarm time was recorded.
There was no documentation that indicated the waterflow alarm valves were repaired or replaced.

Surgery at the Same Day
7. During record review with staff, on 12/18/12 at 1:15 p.m., the 5-year certification report for the automatic fire sprinkler system was reviewed. The certification report was dated 10/12/12. The certification report indicated that the automatic fire sprinkler system riser was missing a hydraulic nameplate. On 12/20/12 at 7:45 a.m., a repair report from the inspection vendor was reviewed. The repair report indicated that the automatic fire sprinkler system riser was not equipped with a hydraulic nameplate. There was no other records that indicated the automatic fire sprinkler system riser was equipped with a hydraulic nameplate.


27994

Main Hospital
8. On 12/17/12 at 2:05 p.m., the sprinkler head in Storage closet 1 across from Cardiac Intensive Care Unit (CICU) did not have 18 inches of clearance around the deflector plate. The sprinkler was obstructed by a letter paper that was stationed at 12 inches of clearance.
9. On 12/17/12 at 2:06 p.m., the sprinkler head in Storage closet 2 across from Cardiac Intensive Care Unit (CICU) did not have 18 inches of clearance around the deflector plate. The sprinkler was obstructed by papers that was stationed at 12 inches of clearance.
10. On 12/17/12 at 2:43 p.m., a corridor sprinkler head by Room 5609 had paint on the strut and deflector plate.
11. On 12/17/12 at 2:47 p.m., a corridor sprinkler head by Service Intensive Care Unit (SICU) corridor had paint on the strut.
12. On 12/17/12 at 3:25 p.m., a sprinkler head outside of South stairwell exit 58176 has lint build-up around the head.
13. On 12/18/12 at 9:15 a.m., a sprinkler in Room 3P648 has a rubber band around the head.
14. On 12/18/12 at 10:50 a.m., a sprinkler head by Room 2162D has black lint build-up around the head.
15. On 12/18/12 at 2:05 p.m., the sprinkler head in Room 1P541 did not have 18 inches of clearance around the deflector plate. The sprinkler was obstructed by a box that was stationed at 10 inches of clearance.
16. On 12/18/12 at 2:47 p.m., 4 of 6 sprinkler heads in the University tower lobby, next to the Information service desk, has paints on the heads and the struts.
17. On 12/18/12 at 3:16 p.m., a corridor sprinkler deflector spoke was bent upward, by Room 0P711.
18. On 12/18/12 at 3:20 p.m., 1 of 2 sprinkler escutcheon rings was missing, in Room 0783.
19. On 12/18/12 at 3:45 p.m., a corridor sprinkler head by Room 0625 has paint on the strut and head.
20. On 12/19/12 at 3:02 p.m., a corridor sprinkler by University tower 7 elevator has paint on the strut.
All sprinkler heads with paint added on thier deflectors must be replaced.
Surgery at Same Day
20. On 12/19/12 at 9:29 a.m., an Inspector Test Valve (ITV) in Room 1155 did not have a visible identification sign posted that indicated this valve is the Inspector Test Valve.
21. On 12/19/12 at 9:32 a.m., the Riser sprinkler in Room 1140 did not have a visible identification sign posted that indicated this valve is the Main Drain.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by portable fire extinguishers that were obstructed. This affected 4 of 15 floors in the Main Hospital, and could result in a delay in accessing the fire extinguisher in the event of an emergency.

NFPA 10, 1998.1-6.6* Fire extinguishers shall not be obstructed or obscured from view. Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means all be provided to indicate the location.
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.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with staff, the portable fire extinguishers were observed.

Main Hospital
1. On 12/17/12 at 11:05 a.m., a recessed portable ABC fire extinguisher by Room 8705 was missing an identification sign that indicated a portable fire extinguisher was available at that location.

2. On 12/17/12 at 2:10 p.m., a recessed portable ABC fire extinguisher in Cardiac Intensive Care (CICU) 6th floor was obstructed from access by a ventilator.

3. On 12/17/12 at 3:30 p.m., a recessed portable ABC fire extinguisher by Restroom 4709 was missing an identification sign that indicated a portable fire extinguisher was available at that location.

4. On 12/18/12 at 9:16 a.m., a recessed portable ABC fire extinguisher by Operation room (OR) 4 and 3P745A corridor was obstructed from access by a microscope.









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5. On 12/17/12 at 11:14 a.m., the fire extinguisher located in the University Tower 8 Waiting Room was blocked by three attached chairs. The door to the extinguisher cabinet could not be opened unless the chairs were moved. In an interview with staff, Fire Officer 2 stated that sometimes people in the waiting room move the chairs.

Based on record review and interview, the facility failed to maintain their fire/smoke dampers. This was evidenced by fire/smoke dampers that had not been inspected within the past four years. This affected two of three outpatient facilities and could result in the spread of smoke or fire to other locations of the facility due to a malfunctioning fire/smoke damper.

NFPA 90A, 1999 edition
3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review with staff, on 12/17/12 at 1:29 p.m., the facility's fire/smoke damper inspection records were requested.

Radiation Oncology
1. There were no records that indicated the fire/smoke dampers in the Cancer Center had been tested, inspected, cleaned, and lubricated within the past four years. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that the facility's fire/smoke damper test and inspection was currently in progress. Fire Officer 1 indicated that the testing and inspection for the Cancer Center has not been completed.

Surgery
2. There were no records that indicated the fire/smoke dampers in the Surgery Clinic had been tested, inspected, cleaned, and lubricated within the past four years. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that the facility's fire/smoke damper test and inspection was currently in progress. Fire Officer 1 indicated that the testing and inspection for the Surgery Clinic has not been completed.

Based on observation, the facility failed to maintain their kitchen suppression system. This was evidenced by accumulation of greasy deposits on pipes inside the kitchen exhaust hoods and an ansul pull alarm that was obstructed. This affected 1 of 15 floors in the Main Hospital, and could result in an increased risk of a grease fire to ignite in the kitchen and delay access of pull alarm in the event of an emergency.

NFPA 96, 1998
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1-System serving moderate-volume cooking operations-semi-annually.

8.3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing the company. It shall also indicate areas not cleaned.

Findings:

During a tour of the facility with staff, the Kitchen system were observed.

Main Hospital
1. On 12/18/12 at 2:34 p.m., an ansul pull alarm in the Pizza oven area was obstructed by a tall pizza cart that was stationed in front of the pull alarm.

2. On 12/20/12 at 8:31 a.m., the Cafe Wok area hood exhaust was observed with thick accumulation of greasy deposits on pipes running through the interior kitchen exhaust hood.
The sticker on the hood indicated it was cleaned on 11/2011. Plant Operation 1 presented a cleaning certificated documentation that indicated the hood was cleaned on 8/2012. There was a gap in cleaning the hood over six months between cleanings.

3. On 12/20/12 at 9 a.m., the Cafe Pizza oven area hood exhaust was observed with thick accumulation of greasy deposits running through the interior kitchen exhaust hood. There was no sticker on the hood. Plant Operation 1 presented a cleaning certificated documentation that indicated the hood was lasted cleaned on 8/2012.

Based on observation, the facility failed to comply with the regulations regarding portable space heating devices. This was evidenced by an unapproved portable heater in a non-sleeping staff area. This affected all staff and residents in 1 of 15 floors in the Main Hospital and could potentially result in the ignition of fire.

1999 NFPA 99
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.

9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator ' s, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

1999 NFPA 70
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a tour of the facility with staff, electrical equipment was observed.

Main Hospital
On 12/17/12 at 1:55 p.m., there was a heater under a desk in Office Room 6304 that was plugged into a power strip. This heater had a label warning, "high temperature three feet of clearance required". There was no tag on the heater and no documentation was provided indicating that this heater had been inspected by the facility.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency. This was evidenced by items stored in the exit corridor. This deficient practice affected all staff and patients in 3 of 15 floors at the Main Hospital and could potentially result in injury or a delayed evacuation in the event of an emergency.

7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

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

7.10.8 Special Signs.
7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Findings:

During a tour of the facility with staff, exit corridors were observed.

Main Hospital
1. On 12/17/12 at 10:35 a.m., there were nine charting computers against the wall near Room 11818. On the opposite side of the corridor was a vital signs monitor. Two of the charting computers had signs on them that read "do not move". There also were four charting computers around the corner from Room 11818. These charting computers were located near Room 11802 B. These charting computers were also located against the corridor wall.
During a return visit with Administrative Staff 3 at 1:13 p.m., the above charting computers were still in the same location.

2. On 12/17/12 at 10:46 a.m., there were tinsel decorations attached to the handrails on both sides of the corridor outside the Family Waiting Room. The handrail on the Family Waiting Room side of the corridor had tinsel attached for approximately eight feet. The handrail on the opposite side of the corridor had tinsel attached for approximately 15 feet.

3. On 12/17/12 at 2:58 p.m., The corridor doors to the four Sleep Disorder Rooms in Suite 5305 could not be opened without special knowledge from the egress side. Each of these rooms did have a second door that was used as an exit door. In an interview with staff, Fire Inspector 2 stated that the corridor doors were not used as exits. These doors could be mistaken for exit doors from the sleep rooms in an emergency.







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4. On 12/17/12 at 10:10 a.m., a Stryker bed was stored in the path of egress in front of the smoke barrier door right leaf, next to Room 12701.

Based on observation and interview, the facility failed to regulate the placement of potentially combustible decorations as evidenced by a decorated cut conifer-type tree and other cut decorations located in a corridor. This was also evidenced by artificial decorations with no documentation for flame retardant. This deficient practice could increase the potential for the spread of smoke and/or fire and affected 1 of 15 floors at the Main Hospital.

19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.

Exception: Combustible decorations, such as photographs and paintings,
in such limited quantities that a hazard of fire development or spread is not present.

Findings:

During a tour of the facility with staff, the potentially combustible decorations were observed.

Main Hospital
At 1:59 p.m., there were two approximately 18 inch diameter fir tree wreaths with cones and other decorations hanging on the corridor doors leading into the 10th Floor PICU Nurses' Station 2. Behind Nurses' Stations 2 there was paper on the wall with cedar bows bordering its edges. This area was approximately four feet wide and five feet long. To the left of the Nurses' Station was an approximately seven foot tall fir-type Christmas tree. This tree had a UC Davis tag attached to it that stated that it was treated with a flame retardant. In an interview with staff, Staff agreed that they were live cut decorations. Administrative Staff had the decorations removed at that time.

Based on observation and interview, the facility failed to maintain their oxygen and gas cylinders. This was evidenced by cylinders that were not safely secured. This affected 4 of 15 floors in the Main Hospital and 1 of 1 floor in the Outpatient building, and could result in a fallen med gas cylinder turning into a projectile and causing harm to patients and staff or by persons smoking near med gas storage rooms where there were no signs on the door.

NFPA 99, 1999
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.5.2.1 (27) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m) shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum: Caution: Oxidizing Gas(es) Within, No Smoking.

Findings:

During a tour of the facility with staff, the oxygen cylinders were observed.

Main Hospital
1. On 12/17/12 at 3:18 p.m., an E cylinder was unsecured, in Room 5662.

2. On 12/17/12 at 3:33 p.m., there were six E cylinders that was unsecured, in Room 4465. Four cylinders were freestanding and two cylinders were laying on the floor.

3. On 12/18/12 at 10 a.m., an E cylinder was unsecured underneath a babytherm cart, in Room 3777. In an interview, Staff 9 stated the rack underneath the babytherm cart is not for storing a cylinder.

Surgery at Same Day
4. On 12/19/12 at 8:55 a.m., the cylinder storage room 1159 door did not have an identification sign that indicated it was an oxygen storage location. There were 16 H cylinders in the room.









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Main Hospital
5. On 12/18/12 at 4:05 p.m., Room 0226 had an approximately three foot tall compressed nitrogen gas cylinder that was sitting unsecured on the floor.

Based on document review, the facility failed to maintain their piped-in medical gas system. This was evidenced by the facility's failure to correct discrepancies noted on their most recent piped-in medical gas system inspection report. This affected one of fourteen floors in the Main Hospital and could result in a piped-in medical gas system breach or malfunction.

Findings:

During record review, on 12/17/12 at 2:02 p.m., the facility's most recent piped-in medical gas system inspection report was reviewed. The inspection was conducted in May 2012. Repairs were conducted in June 2012. The repair report indicated that outlets in four patient rooms had leaks that could not be repaired. The repair report indicated that a zone shut down is required to repair the leaking outlets in the four patient rooms.

The leaking outlets were located in patient rooms 8653, 8661, 8667, and 8677. There were no records that indicated the leaking outlets in the four patient rooms had been repaired.

Based on record review and interview, the facility failed to maintain the relative humidity levels at their anesthetizing locations. This was evidenced by the facility's failure to maintain relative humidity levels at 35 percent or greater. This affected all facility operating rooms and anesthetizing locations and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review with staff, on 12/18/12 at 2:12 p.m., the facility's policy for anesthetizing location humidity levels was reviewed. The policy indicated that the facility would maintain relative humidity levels in their anesthetizing locations between 35-60%. The facility has twenty-four operating rooms, four children's surgery rooms, two C-section rooms, and four same day surgery rooms. The relative humidity records for the facility's anesthetizing locations were requested. The relative humidity records indicated that humidity had fallen below 35% on multiple instances in the anesthetizing locations.

The facility remotely monitors the relative humidity levels for their anesthetizing locations. The humidity monitoring system would trigger an alarm at the monitoring station whenever humidity fell outside of the alarm parameters. The offsite monitoring station was observed at that time. Staff at the monitoring station was asked to display the alarm parameters for the anesthetizing locations. The following alarm parameters were noted:

1. Surgery at Same Day Operating Rooms had alarm parameters of either 20-60% or 20-65% relative humidity.

2. Main Operating Rooms had alarm parameters of 25-60% relative humidity.

3. Children's Surgery Rooms had alarm parameters of either 22-60%, 22-65%, or 20-80% relative humidity.
4. C-section Rooms had alarm parameters of either 20-60% and 25-65% relative humidity.

Staff at the monitoring station was interviewed at that time. Staff did not know why the alarm parameters were not consistent throughout the anesthetizing locations. Staff did not know why the alarm parameters were not consistent with the facility policy of 35-60% relative humidity.

Based on record review, interview, and observation, the facility failed to maintain a Halon fire extinguishing system. This was evidenced by one Halon fire extinguishing system that was not certified in past six months. This affected one of fourteen floors in the Main Hospital and could result in a malfunctioning Halon fire extinguishing system.

NFPA 101, 2000 edition
9.7.3 Other Automatic Extinguishing Equipment.

9.7.3.1 In any occupancy where the character of the potential fuel for fire is such that extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as water mist, carbon dioxide, dry chemical, foam, Halon 1301, water spray, or a standard extinguishing system of another type, that system shall be permitted to be installed in lieu of an automatic sprinkler system. Such systems shall be installed, inspected, and maintained in accordance with appropriate NFPA standards.

19.3.5.4 Isolated hazardous areas shall be permitted to be protected in accordance with 9.7.1.2. For new installations in existing health care occupancies, where more than two sprinklers are installed in a single area, waterflow detection shall be provided to sound the building fire alarm, or to notify by a signal, any constantly attended location, such as PBX, security, or emergency room, at which the necessary corrective action shall be taken.

NFPA 12A, 1997 edition
4-1 Inspection and Tests.
4-1.1 At least semiannually, all systems shall be thoroughly inspected, tested, and documented for proper operation by trained competent personnel. Tests shall be in accordance with the appropriate NFPA or Canadian standards.
4-1.2 The documented report with recommendations shall be filed with the owner.

Findings:

During record review with staff, on 12/18/12 at 9:47 a.m., the facility's Halon fire extinguishing system inspection records were reviewed. The facility has a Halon fire extinguishing system protecting the MRI Computer Room 1355. The Halon fire extinguishing system was last inspected on 6/22/12. The inspection report indicated that the system did not pass inspection. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that the repairs had been made on the Halon fire extinguishing system. There was no record that indicated the inspection vendor had returned to re-inspect and certify the Halon fire extinguishing system after the repairs had been completed. The Halon fire extinguishing system was observed at 8:35 a.m. on 12/20/12. The Halon fire extinguishing system had a certification tag on it dated 12/29/11.

Based on observation and interview, the facility failed to maintain its area alarm panel. This was evidenced by an area alarm panel screen that did not display any reading. This affected 1 of 15 floors in the Main Hospital and could result in staff not being notified in the event the line pressure for the medical air increases/decreases from the normal operating pressure.

NFPA 99, 1999
4-3.1.2.2 Gas Warning Systems.
2. Local, master, and area alarms shall indicate visually and audibly if:
(a) the monitored condition occurs (b) the wiring to the sensor or switch is disconnected
C (3) Area alarms shall indicate if the pressure in the local line increases 20 percent or decreases 20 percent from normal line pressure.

Findings:

During a tour of the facility with staff, the area alarm panels were observed.

Main Hospital
On 12/18/12 at 1:45 p.m., the area alarm panel in the Pediatric Emergency Department (ED) in the Nurse station failed to display line pressure reading. The power icon was blinking and the screen was blank. The area alarm panel supply rooms 1P762, 1P763, 1P764, 1P766, 1P779, 1P777, 1P778, 1P776, 1P775, 1P774, 1P773. There was a patient in Room 1P773 at the time.

In an interview, Staff 8 stated she did not know how long the area alarm panel screen was not working.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, the permanent use of extension cords, improper clearance in front of electrical panels, fixtures missing covers, and damaged electrical equipment. This deficient practice affected all staff and patients in 10 of 15 floors and could potentially result in electrical shock or the ignition of fire.

NFPA 70, 1999
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.
110-12 requires that electrical equipment be installed in a neat and workman like manner.
110-26 (a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less
370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.
110-12 requires that electrical equipment be installed in a neat and workmanlike manner. 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.
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.
400-8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.
110-26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in.
(762 mm), whichever is greater.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During a tour of the facility with staff, electrical wiring and equipment were observed.

Main Hospital
1. On 12/17/12 at 1:49 p.m. there was a water cooler, a microwave oven, and a half size refrigerator plugged into a power strip in Room 6302.

2. On 12/17/12 at 1:50 p.m. in Room 6312 C, there was a coffee pot plugged into a white, unapproved, approximately 16 gauge extension cord that had a multiple outlet end with no over-current protection.

3. On 12/17/12 at 1:59 p.m., there was a receptacle plate cover missing in Utility Room 6307.

4. On 12/17/12 at 2:15 p.m., there was a refrigerator in Room 6212 that had tape wrapped around the cord near the plug end. The cord was stretched tightly creating tension to the joint and terminals.

5. On 12/17/12 at 2:32 p.m., there was a toaster oven plugged into a power strip in Room 5209.

6. On 12/18/12 at 8:37 a.m., there was a power strip plugged into a power strip in Room 3211.

7. On 12/18/12 at 8:55 a.m., there was an extension cord with a multiple outlet end and no over-current protection with a coffee pot plugged into it in Room 3219.

8. On 12/18/12 at 9:06 a.m., there was an unapproved extension cord under a desk in Room 3012 B.

9. On 12/18/12 at 9:13 a.m., there was a power strip under a desk in the third floor Student Sleep Room 3302 that had the top cover disconnected exposing un-insulated wires. The power strip was plugged in. Administrative Staff 3 unplugged the power strip and had it removed at that time.

10. On 12/18/12 at 9:55 a.m., there was a receptacle outlet that was missing a plate cover in Room 3125.

11. On 12/18/12 at 11:07 a.m., there was a power strip suspended above the floor in Office 2304.

12. On 12/18/12 at 11:35 a.m., there was a power strip plugged into another power strip in Laboratory Office 2P323.

13. On 12/18/12 at 2:03 p.m., there was a half size refrigerator plugged into a power strip in Room 1525.

14. On 12/18/12 at 3:20 p.m., Equipment Storage Room 0322 had three electrical panels with boxes and equipment stored in front of the panels.

15. On 12/18/12 at 3:30 p.m., the was an extension cord in Room 0317 that was wrapped around a pipe and traveled across the wall, behind a bulletin board, and down to the floor. This extension cord had a multiple outlet end with no over-current protection.

16. On 12/18/12 at 4:28 p.m., the Lower Level Optical Biopsy Research Laboratory had four power strips chained together under a large table.




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17. On 12/17/12 at 10:16 a.m., a surge protector was hanging suspended from the receptacle transmitting tension to the joint and terminals, with items plugged into it, in the Nurse station by Room 12710.

18. On 12/17/12 at 10:30 a.m., a junction box was missing a cover plate, in Room 10778.

19. On 12/17/12 at 11:11 a.m., two 8 inch by 8 inch openings in the ceiling were missing cover plates, in Room 8608.

20. On 12/17/12 at 1:45 p.m., an electrical panel C6LA2-91229 in Room 6742 was obstructed by tool cart that was stationed within inches of the electrical panel.

21. On 12/17/12 at 1:56 p.m., four battery chargers were plugged into a non hospital grade surge protector that was connected to a two plugs wall receptacle, in Room 6752. The manufacture specification on the back of the battery machine indicated, "to be connected to a hospital grade power outlet.

22. On 12/17/12 at 2:11 p.m., two electrical panels 6A section 1 and 2 in Room 6652 were obstructed by boxes and oxygen tanks. The sign on the electrical panel read: Area in front of this electrical panel must be keep clear for 36 inches.

23. On 12/17/12 at 2:13 p.m., an electrical box was missing a cover plate, in Room 6606.

24. On 12/17/12 at 3:02 p.m., a white refrigerator was plugged into a surge protector, in Room 4210 north.

25. On 12/17/12 at 3:16 p.m., a cover plate shifted to one side and exposed opening junction box, in Room 4656.

26. On 12/18/12 at 8:52 a.m., a phone charger was plugged into a white extension cord, in Room 3P609-CRD/THO Fellow room.

27. On 12/18/12 at 8:54 a.m., an electrical panel N3YL2 in Room 3P606 were obstructed by a 6 foot and 8 foot ladders that were stationed within inches of the electrical panel.

28. On 12/18/12 at 8:55 a.m., an electrical panel C3XL2 in Room 3P344 were obstructed by a 6 foot and 8 foot ladders that were stationed within inches of the electrical panel.

29. On 12/18/12 at 10:30 a.m., a surge protector was hanging suspended from the receptacle transmitting tension to the joint and terminals, with items plugged into it, in Room 2P518.

30. On 12/18/12 at 10:58 a.m., a junction box was missing a cover plate. The box exposed blue and white IT wires, in Room 2303.

31. On 12/18/12 at 1:39 p.m., a surge protector was plugged into another surge protector, in Room 1P934 cubicle 4.