HospitalInspections.org

Based on observation and interview, the facility failed to maintain clear paths of egress in corridors. This was evidenced by obstructed egress at three sets of smoke barrier doors. This could delay the evacuation of patients and staff during a fire emergency, and affected one of three floors in the hospital.

NFPA 101, Life Safety Code, 2012 Edition
7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.2.1.15.7 As a minimum, the following items shall be verified:
(1) Floor space on both sides of the openings is clear of obstructions, and door leaves open fully and close freely

19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2)*Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in.(1525 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c)*The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment

During the facility tour and interview with Manager of Plant Services (MPS) and Construction Staff 2 (CS2), the egress corridors were observed.

8/14/18
2nd Floor
1. At 11:38 a.m., there was a blue cart that was stored next to the south leaf door frame at the smoke barrier doors (20362B) in Pediatric Intensive Care Unit (PICU) South. When the smoke barrier doors were closed, the clear width for egress between the cart and the opposite swinging door was less than 30 inches. At 11:39 a.m., CS2 confirmed that the cart was located in front of the panic bar when the doors were closed.

2. At 11:45 a.m., there was a blue cart that was stored next to the south leaf door frame at the smoke barrier doors (20362A) PICU West. When the smoke barrier doors were closed, the clear width for egress between the cart and the opposite swinging door was less than 30 inches. At 11:46 a.m., CS2 confirmed that the cart was located in front of the panic bar when the doors were closed.

3. At 1:20 p.m., there was an environmental services cart that was located next to the west leaf of the smoke barrier doors near the Neonatal Intensive Care Unit (NICU) South Nurse station. When the smoke barrier doors were closed, the clear width for egress between the cart and the opposite swinging door was less than 24 inches. At 1:21 p.m., the MPS mentioned that the cart may be in use, but there was no housekeeping person in sight.

Based on observation and interview, the facility failed to maintain the horizontal sliding doors. This was evidenced by three accordion style horizontal sliding fire doors that failed to close completely. This could result in the spread of fire during a fire emergency, and affected three of three floors in the hospital.

NFPA 101, Life Safety Code, 2012 Edition
7.2.1.14 Horizontal-Sliding Door Assemblies.
Horizontal sliding door assemblies shall be permitted in means of egress, provided that all of the following criteria are met:
(5) The door assembly complies with the fire protection rating, if required, and, where rated, is self-closing or automatic closing by means of smoke detection in accordance with 7.2.1.8 and is installed in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protective's.

NFPA80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition
5.2.5.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
5.2.5.2 The following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Slats, endlocks, bottom bar, guide assembly, curtain entry hood, and flame baffle are correctly installed and intact.
(3) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(4) Curtain, barrel, and guides are aligned, level, plumb, and true.
(5) Expansion clearance is maintained in accordance with manufacturer's listing.
(6) Drop release arms and weights are not blocked or wedged.
(7) Mounting and assembly bolts are intact and secured.
(8) Attachments to jambs are with bolts, expansion anchors, or as otherwise required by the listing.
(9) Smoke detectors, if equipped, are installed and operational.
(10) No parts are missing or broken.
(11) Fusible links, if equipped, are in the location; chain/cable, S-hooks, eyes, and so forth, are in good condition (i.e., no kinked or pinched cable, no twisted or inflexible chain); and links are not painted or coated with dust or grease.
(12) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(13) No field modifications to the door assembly have been performed that void the label.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.13 Prevention of Door Blockage.
5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.
5.2.13.2 Where necessary, a barrier shall be built to prevent the piling of material against sliding doors.
5.2.13.3 Blocking or wedging of doors in the open position shall be prohibited.

8.1.3.1.1* Horizontally sliding doors shall be wall mounted in a track attached to a wall or bottom roller mounted with a top guide in accordance with the manufacturer's instructions and individual published listing.
8.1.3.1.2 Doors in detention security applications shall be mounted to a listed detention sliding door device in accordance with the manufacturer's instructions and individual published listing.
8.1.3.1.3 When in the closed position, the clearance between the wall and the door or the frame and the door shall not be more than 3/4 in. (19.05 mm) unless otherwise tested and listed in the manufacturer's individual published listings.
8.1.3.2.1 Unless tested otherwise, doors shall lap openings at least 4 in. (102 mm) at the sides and top.

9.1.3.1* Horizontally sliding accordion or folding doors shall be ceiling or wall mounted in track or tracks attached to a lintel or wall in accordance with the manufacturer's instructions and individual published listings.
9.1.3.2 Doors shall lap the opening if mounted completely on the surface of the wall or shall extend across the opening if ceiling mounted or surface mounted.
9.1.3.2.1 Doors shall completely close the opening.
9.1.3.2.2 Where doors provide protection of openings located in walls above floor level and no projecting sill is provided, the doors shall extend below the bottom of the opening in accordance with the listing.
9.1.3.3* Single doors shall be affixed to a jamb at one wall and shall close against a strike jamb provided at the other
wall in accordance with the individual manufacturers' published listings.
9.1.3.4 Biparting doors shall each be affixed to a jamb at a wall and shall close together at the meeting stiles in accordance with the individual manufacturers' published listings.

Findings:

During the facility tour of the main hospital, the horizontal sliding fire door assemblies were observed.

8/13/18
2nd Floor Outpatient Surgery
1. At 9:57 a.m., the horizontal sliding fire door assembly at the outpatient registration failed to close completely. The horizontal sliding fire rated door was stopped by a chair that was pinned against the divider between the first and second registration counters, more than 6 feet from the fully closed position.

8/15/18
2nd Floor Elevators 18 and 19
2. At 9:56 a.m., the horizontal sliding fire door assembly for Elevators 18 and 19 failed to fully close in two of two tests. At 9:57 a.m., the Director of Facilities (DF) confirmed that the bi-parting doors failed to fully lap when closed.

Ground Level Elevators 18 and 19
2. At 10:26 a.m., the horizontal sliding fire door assembly for Elevators 18 and 19 failed to fully close in two of two tests. At 10:27 a.m., DF confirmed that the bi-parting doors failed to fully lap when closed.

Based on observation and interview, the facility failed to maintain the emergency battery backup lighting system. This was evidenced by an emergency battery backup lighting unit that failed to illuminate when tested. This could result in a failure to provide backup lighting in the event of an emergency, and affected St. Agnes Medical Center Satellite Neonatal Intensive Care Unit (NICU).

NFPA 101, Life Safety Code, 2012 Edition
19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Surveyor Delosantos, Madonna
Aug 15 2018

During a tour of the facility and interview with Construction Staff 2 (CS2) and the Manager of Plant Services (MPS) on 8/16/18, the emergency battery backup lighting system was observed and the staff were interviewed.

St. Agnes Medical Center (NICU).
At 11:05 a.m., one of two emergency battery backup lighting units on the fourth floor failed to illuminate when the test button was pressed by the MPS. The finding was confirmed by the MPS and CS2.

Based on observation, record review, and interview, the facility failed to maintain their exit signs. This was evidenced by five exit signs that failed to illuminate in the Main Hospital and three battery backup exit signs that failed to illuminate when tested in the Medical Office Building (MOB). This was also evidenced by no records of monthly inspections and testing. This affected two of three floors in the main hospital and one of two floors in the MOB, and could result in a delayed evacuation during a fire or disaster emergency.

NFPA 101, 2012 Edition
7.10.9 Testing and Maintenance.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3.
7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

8/13/18
During the entrance to the hospital the exit signs were observed.

1. At 8:10 a.m., the exit sign posted over the main entrance doors was not illuminated.

2. At 8:11 a.m., the exit sign posted over the smoke barrier doors (10811) leading to the corridor on the east side of the Rotunda was not illuminated

During a tour of the facility with Director of Facilities (DF), Construction Staff 2 (CS2), the Manager of Plant Services (MPS), and the Vice President of Ancillary Services (VPAS) on 8/13/18, the exit signs were observed.

2nd Level Hospital
3. At 9:35 a.m., an exit sign at the east side of the Rotunda near the Boardroom corridor failed to illuminate. The MPS confirmed that the exit sign was not illuminated.

4. At 9:37 a.m., two exit signs located on the west side of the Rotunda failed to illuminate. The MPS explained that he contacted maintenance to perform repairs on the exit signs at the first floor entrance and second floor Rotunda area.

8/14/18
During record review with DF and CS2, the monthly exit sign inspections were requested

5. In an interview at 10:28 a.m., DF and CS2 stated that there were no monthly visual inspections performed on the exit signs.

In an interview at 11:55 a.m., the MPS explained that the five exit signs that failed to illuminate were due to failures of the light emitting diode lights.



31201

8/15/18
2nd Floor - Medical Office Building
6. At 11:40 a.m., two battery backup exit signs near door M-19 failed to illuminate when tested.

7. At 11:42 a.m., one battery backup exit sign near door M-1 failed to illuminate when tested.

In an interview at 11:43 p.m., CS2 explained that the preventative maintenance task for exit signs had been dropped from their maintenance program at some point for both the Hospital and MOB.

Based on observation and interview, the facility failed to maintain their fire rated doors. This was evidenced by eight fire rated doors that failed to close completely. This could result in an accelerated spread of fire during a fire emergency, and affected two of three floors.

NFPA 101 LIFE SAFETY CODE, 2012 Edition
7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.

7.2.13.3 Elevator Lobby. Every floor served by the elevator shall have an elevator lobby. Barriers forming the elevator lobby shall have a minimum 1-hour fire resistance rating and shall be arranged as a smoke barrier in accordance with Section 8.5.
7.2.13.4 Elevator Lobby Door Assemblies. Elevator lobby door assemblies shall have a minimum 1-hour fire protection rating. The transmitted temperature end point shall not exceed 450°F Ä (250°C Ä) above ambient at the end of 30 minutes of the fire exposure specified in the test method referenced in 8.3.3.2. Elevator lobby door leaves shall be self closing or automatic-closing in accordance with 7.2.1.8.
7.2.13.5 Door Leaf Activation. The elevator lobby door leaves shall close in response to a signal from a smoke detector located directly outside the elevator lobby adjacent to or on each door opening. Elevator lobby door leaves shall be permitted to close in response to a signal from the building fire alarm system. Where one elevator lobby door leaf closes by means of a smoke detector or a signal from the building fire alarm system, all elevator lobby door leaves serving that elevator evacuation system shall close.

8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

8.3.3.2.3* Labels on fire door assemblies shall be maintained in a legible condition.

8.3.4.2* The fire protection rating for opening protectives in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions shall be in accordance with Table 8.3.4.2, except as otherwise permitted in 8.3.4.3 or 8.3.4.4.

Table 8.3.4.2 Minimum Fire Protection Ratings for Opening Protectives in Fire Resistance-Rated Assemblies and Fire-Rated Glazing Markings Elevator lobby (per 7.2.13.4)1 Hour Fire Rating

NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2020 Edition
6.3.1.7* Clearances.
6.3.1.7.1 The clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, shall be 1/8 in. ± 1/16 in. (3.18 mm ± 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.
6.3.1.7.2 Clearances shall be measured from the pull face of the door(s).

Findings:

During the facility tour with Construction Staff 2 (CS2) and Manager of Plant Services (MPS), the fire rated enclosures were observed.

8/13/18
2nd Floor
1. At 10:08 a.m., the south leaf on the 1 1/2 hour fire rated cross corridor doors (200155) failed to close the last one inch. This door assembly was located at the occupancy separation for the West Expansion. The automatic closing door was held open to the fullest extent and allowed to close. The door failed to fully close and latch.

2. At 10:09 a.m., the north leaf of the cross corridor doors (200155) was missing a fire rating label. CS2 confirmed the fire rating label was missing for the door assembly located in a two-hour fire rated occupancy separation for the West Expansion.

3. At 1:17 p.m., the lobby smoke barrier doors for Elevators 5, 6, 7, and 8 failed to close completely. The west leaf of the smoke barrier doors was released from the fully open position three times after CS2 deactivated the power door operator that held the doors in the fully open position. The door failed to close the last one inch in each attempt. At 1:18 p.m., CS2 confirmed that the west leaf did not close completely.

4. At 2:44 p.m., the door closer was disconnected from the west leaf of the Water Elevator lobby doors. The one-hour fire rated enclosure doors were labeled with a 20-minute smoke barrier door rating. At 2:45 p.m., CS2 acknowledged the disconnected door closer.

8/14/18
2nd Floor
5. At 11:30 a.m., the west leaf of a 1 1/2 hour fire rated cross corridor doors (20362C) in the Pediatric Intensive Care Unit failed to close the last one inch. The door was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to fully close and latch.

6. At 3:05 p.m., the door closer failed to close the one hour fire rated door (2018157). The door was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to fully close and latch.

Ground Floor
7. At 8:28 a.m., the east leaf of the elevator lobby doors (G07051) failed to close completely. The door was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to fully close and latch.

8. At 2:44 p.m., the west leaf of the Water Elevator lobby doors failed to close. The door was equipped with a self-closing device. The door was held-open to the fullest extent and allowed to close. The door failed to close. At 2:45 p.m., the MPS acknowledged the door closing device was disconnected from the west leaf door.

8/15/18
Ground Floor

9. At 8:40 a.m., the 1-hour fire rated door (G07005) failed to self close completely. The door was held open to the fullest extent and allowed to close. The door failed to fully close and latch. At 8:41 a.m., CS2 confirmed the finding and acknowledged that this was part of the fire rated enclosure that separated the galley from the kitchen.

10. At 8:47 a.m., the door closer was disconnected from the 1-hour fire rated door (G0270A) near the unload end of the dishwashing area. At 8:48 a.m., CS2 confirmed the finding and acknowledged that this was part of the fire rated enclosure that separated the galley from the kitchen.

Based on observation and interview, the facility failed to maintain a vertical opening. This was evidenced by a second floor stairwell door in the west expansion area that failed to self close completely and latch. This could result in the spread of fire and smoke, and affected three of three floors in the Hospital.

NFPA 101, Life Safety Code, 2012 Edition
19.3 Protection.
19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8.
19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

19.3.1.7 A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position, unless otherwise permitted by 19.3.1.8.
19.3.1.8 Doors in stair enclosures shall be permitted to be held open under the conditions specified by 19.2.2.2.7 and 19.2.2.2.8.

19.2.2.2.7* 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.

8.4.3.4* Door clearances shall be in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
8.4.3.5 Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.
8.6.2* Continuity. Openings through floors shall be enclosed with fire barrier walls, shall be continuous from floor to floor, or floor to roof, and shall be protected as appropriate for the fire resistance rating of the barrier.

Findings:

During the facility tour with Director of Facilities, Construction Staff 2 (CS2), the Manager of Plant Services, and the Vice President of Ancillary Services on 8/13/18, the stairwell doors at the vertical openings were observed.

2nd Floor
At 9:45 a.m., the door to Stairwell 16-2 located near the smoke barrier doors to the west expansion area was obstructed from closing completely. The door was held open to the fullest extent and allowed to close. The door failed to fully close and latch.

In an interview at 9:46 a.m., CS2 acknowledged that the door closer required adjustment.

Based on observation and interview, the facility failed to maintain hazardous storage areas. This was evidenced by a Decontamination Room corridor door that failed to close completely and latch, and by no fire rated enclosure for a supply room in the Classroom that was filled with combustible storage. This could result in the spread of smoke or fire during a fire emergency, and affected two of three floors in the Hospital.

NFPA 101 LIFE SAFETY CODE, 2012 edition
19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.4 Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (1220 mm) above the bottom of the door.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During the facility tour and interviews with the Director of Facilities (DF), the Manager of Plant Services (MPS), the Director of Facilities (DF), and the Vice President of Ancillary Services (VPAS), the hazardous storage enclosures were observed.

8/13/18
2nd Floor

1. At 1:35 p.m., the door to the Decontamination Room (20214) was obstructed from closing completely. The room was greater than 50 square feet in area and contained two large waste bins filled with trash and two 40-gallon containers of soiled trash. The door was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to fully close and latch. At 1:36 p.m., the MPS acknowledged that the door failed to close completely and latch.

8/15/18
Ground Floor

2. At 2:24 p.m., the supplies storage area for the Classroom was not protected with a one hour fire rated enclosure. The storage room was greater than 100 square feet in area and was filled with miscellaneous combustible items in shelving and on the floor. At 2:25 p.m., the DF and the VPAS acknowledged that the supply room was not a fire rated enclosure and did not have a self-closing door.

Based on observation and interview, the facility failed to maintain the kitchen hood fire extinguishing systems. This was evidenced by no certificates of exhaust and hood cleaning maintained on premises for four of four kitchen hood exhaust systems. This was also evidenced by dislodged or missing suppression system nozzle caps under three of four exhaust hoods. This affected the entire facility and could result in the malfunction of the kitchen hood fire suppression system, and the uncontrolled spread of a grease fire due to a residual grease build-up inside the sprinkler nozzles and inside the exhaust duct and range hood.

NFPA 101. Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition
10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A

Table 11.4 Schedule of Inspection for Grease Buildup

Type or Volume of Cooking Inspection Frequency

Systems serving high-volume cooking
operations, such as 24-hour cooking,
charbroiling, or wok cooking Quarterly

Systems serving moderate-volume
cooking operations Semiannually

Systems serving low-volume cooking
operations, such as churches, day camps,
seasonal businesses, or senior centers Annually

11.6 Cleaning of Exhaust Systems.
11.6.1 Upon inspection, if the exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction.

11.6.13 When an exhaust cleaning service is used, a certificate showing the name of the servicing company, the name of the person performing the work, and the date of inspection or cleaning shall be maintained on the premises.

11.6.14 After cleaning or inspection is completed, the exhaust cleaning company and the person performing the work at the location shall provide the owner of the system with a written report that also specifies areas that were inaccessible or not cleaned.

11.6.15 Where required, certificates of inspection and cleaning and reports of areas not cleaned shall be submitted to the authority having jurisdiction.

NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 2009 edition.
4.3 Discharge Nozzles. (See also Section 5.5.)
4.3.1 Discharge nozzles shall be listed for their intended use.
4.3.1.1 Discharge nozzles shall be provided with an internal strainer or a separate listed strainer located immediately upstream of the nozzle.
4.3.1.2 Discharge nozzles shall be of brass, stainless steel, or other corrosion-resistant materials, or be protected inside and out against corrosion.
4.3.1.3 Discharge nozzles shall be made of noncombustible materials and shall withstand the expected fire exposure without deformation.
4.3.1.4* Discharge nozzles shall be permanently marked for identification.
4.3.1.5 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping.
4.3.1.6 The protection device shall blow off, blow open, or blow out upon agent discharge.

Findings:

8/13/18

During record review with staff, the kitchen range and exhaust hood cleaning records were requested.

At 11:21 a.m., there were no kitchen hood and exhaust duct cleaning and exception records provided.

8/14/18

During record review and interview with staff, the kitchen range and exhaust hood cleaning records were again requested.

At 11:21 a.m., there were no kitchen hood and exhaust duct cleaning and exception records available. The Director of Facilities (DF) explained that the kitchen staff maintain their own records for cleaning the hoods and exhaust system.

8/15/17
Ground Floor

During an interview with the Kitchen Manager the kitchen hood and exhaust duct cleaning reports were requested.

1. At 8:55 a.m., the Kitchen Manager explained that there were no records available and that she would request them from the vendor and make them available. There were no certificates of inspection and cleaning of the exhaust system and hoods maintained on the premises.

During a facility tour and interview with the DF, Construction Staff 2 (CS 2), and the Manger of Plant Services (MPS), the kitchen hoods and fire extinguishing systems were observed.

2. At 8:34 a.m., there were three missing caps on the hood suppression system nozzles at the George's Galley. At 8:35 a.m., CS2 and MPS acknowledged the caps were missing.

3. At 8:42 a.m., there were two suppression system nozzle caps that had melted off at the discharge side of the pizza conveyor oven. At 8:43 a.m., CS2 explained that they had tried several kinds of high temperature plastic caps but they all eventually melted from the heat.

4. At 8:43 a.m., two of eleven sprinkler nozzle caps were dislodged and hanging from the nozzles they were protecting under the hood for the main cook line. At 8:44 a.m., CS2 acknowledged the dislodged sprinkler head caps.

As of 5:00 p.m., on 8/21/18 there were no certificates of inspection and cleaning provided for any of the kitchen exhaust hoods and ducting systems received by email from the facility.

Based on interview and record review, the facility failed to maintain their Fire Alarm System (FAS). This was evidenced by no semi-annual FAS inspection and testing of the smoke detectors and remote annunciators. This affected the entire facility and could result in a delay in notification and evacuation during a fire emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
14.2.1.1.2 Inspection, testing, and maintenance program shall verify correct operation of the system.
14.2.1.2.2 System defects and malfunctions shall be corrected.
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
Table 14.3.1 Visual Inspection Frequencies
3. Batteries
-(d) Sealed lead-acid - Semiannually
5. Fire alarm control unit trouble signals - Semiannually
8. Remote annunciators - Semiannually
9. Initiating devices
-(b) Duct detectors - Semiannually
-(e) Manual fire alarm boxes - Semiannually
-(f) Heat detectors - Semiannually
-(h) Smoke detectors - Semiannually
-(i) Supervisory signal devices - Semiannually
-(j) Waterflow devices - Semiannually
12. Interface equipment - Semiannually
13. Alarm notification appliances - Semiannually
15. Supervising station alarm systems - transmitters - Semiannually

Findings:

During document review with staff on 8/13/18, the fire alarm system inspection, and testing records were requested.

At 10:40 a.m., there was no semi-annual fire alarm system inspection and testing report available for the smoke detectors and remote annunciators.

In an interview on 8/14/18 at 9:05 a.m., Construction Staff 2 (CS2) was not able to locate the semi-annual inspection and testing reports for the smoke detectors and remote annunciators. CS2 acknowledged that the smoke detectors were functionally tested on an annual basis.

Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by missing escutcheons, by sprinkler heads that were loaded, by an obstructed sprinkler head, and by failing to complete monthly and annual visual inspections of the sprinkler system. This could affect the operation of the sprinkler system that could result in delay in extinguishing a fire, resulting in injury to residents. This affected the Main Hospital, the Medical Office Building (MOB), and the St. Agnes Medical Center satellite Neonatal Intensive Care Unit (NICU).

NFPA 101, Life Safety Code, 2012 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.
5.2.1.2* The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.

5.2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level.
5.2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level.

5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

5.2.8* Information Sign. The information sign shall be inspected annually to verify that it is securely attached and is legible.

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

8/13/18
2nd Floor

During the facility tour with the Director of Facilities (DF), Construction Staff 2 (CS2), the Manager of Plant Services (MPS), and the Vice President of Ancillary Services (VPAS), the fire sprinkler system was observed.

1. At 1:23 p.m., there was an escutcheon missing on a sprinkler head in the Men's Surgery Locker Room.

2. At 1:25 p.m., a sprinkler head was obstructed in the Women's Surgery Locker Room. There were less than 12 inches of clearance to storage items below the sprinkler head.

3. From 2:00 p.m. to 2:10 p.m., there were eight sprinkler heads in the Main Lab that were loaded with debris.

4. At 2:15 p.m., there was a sprinkler head in Immunology that was loaded with debris.

8/14/18

During document review with DF, CS2, MPS, and VPAS, the fire sprinkler system inspection records were requested.

5. At 9:15 a.m., there were no monthly fire sprinkler system visual inspections available for the Main Hospital and the MOB.

In an interview at 9:16 a.m., MPS indicated there were no monthly visual inspections.

6. At 9:16 a.m., there was no annual fire sprinkler inspection available for the Main Hospital and the MOB.

In an interview at 9:17 a.m., the DF stated an annual fire sprinkler system inspection was not performed.

In an interview at 9:20 a.m., CS2 explained that they did not believe the annual fire sprinkler inspection was required and cited an Environment of Care Standard that referenced the 2010 edition of National Fire Protection Association, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (NFPA 25). He was not aware that the 2012 Edition of the Life Safety Code (NFPA 101) referenced a more recent edition, the 2011 edition of NFPA 25.

7. At 11:28 a.m., there was a loaded sprinkler head in the Pediatric Intensive Care Unit (PICU) at the PICU East Nurse Station area. At 11:29 a.m., CS2 acknowledged the finding.

8/15/18

During the facility tour with CS2 and MPS, the sprinkler system was observed.

8. At 8:15 a.m., there was a loaded sprinkler head outside of the G150A Conference Room. CS2 confirmed the finding.

9. At 8:18 a.m., there was a loaded sprinkler head inside the G150A Conference Room.

10. At 12:13 p.m., there was no Fire Department Connection sign on the Y-coupling for the MOB. At 12:15 p.m., CS2 acknowledged there was no sign displayed.

11. At 2:10 p.m., there was a loaded sprinkler head in G04129. MPS confirmed the finding.

12. At 2:16 p.m., there was a loaded sprinkler head at the Discovery East Nurse Station. MPS confirmed the finding.

13. At 9:44 a.m., there was no Inspector Test Valve sign displayed on the zone test valve located at Stair 11 Floor 2. In an interview at 9:45 a.m., CS2 acknowledged that the sign was missing.


Main Hospital
8/15/18

14. At 8:39 a.m., there was a missing escutcheon ring in the Server Room G0181 located on the Garden floor. The finding was confirmed by VPAS.

St. Agnes Medical Center
8/16/18

15. At 11:10 a.m., the facility failed to provide eight of twelve monthly inspections of the sprinkler gauges and valves during the survey. The finding was confirmed by MPS.



31201

Main Hospital
8/15/18

14. At 8:39 a.m., there was a missing escutcheon ring in the Server Room G0181 located on the Garden floor. The finding was confirmed by VPAS.

St. Agnes Medical Center
8/16/18

15. At 11:10 a.m., the facility failed to provide eight of twelve monthly inspections of the sprinkler gauges and valves during the survey. The finding was confirmed by MPS.

Based on observation and interview, the facility failed to maintain their fire extinguishers. This was evidenced by one unsecured fire extinguisher. This could result in damage to or malfunction of the fire extinguisher, and affected the Main Hospital.

NFPA 101, Life Safety Code, 2012 Edition
9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses
6.1.3.5 Wheeled fire extinguishers shall be located in designated locations.
6.1.3.6 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed for this problem.
6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.

Findings:

During a tour of the facility with staff on 8/14/18, the fire extinguishers were observed.

1. At 3:33 p.m., on the Garden floor, there was a portable ABC fire extinguisher in the West Main Electrical Room that was on the floor unsecured. When interviewed, the Director of Facilities confirmed the finding, and stated that the portable fire extinguisher did not belong to the facility.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke and/or fire. This was evidenced by doors that were obstructed from closing and by doors that failed to latch. This could result in the passage smoke and flames in the event of a fire, and affected the Main Hospital.

NFPA 101 - Life Safety Code, 2012 Edition
19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
19.3.6.3.10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled.

Findings:

During a tour of the facility and interviews with Director of Facilities (DF), Construction Staff 2 (CS2), the Manager of Plant Services (MPS), and the Vice President of Ancillary Services, the corridor doors were observed.

8/13/18
2nd Floor

1. At 2:29 p.m., the north leaf on the Lab Storeroom double doors (20640) failed to self close completely in three of four attempts. The doors were equipped with a door closer that worked inconsistently. At 2:30 p.m., CS2 confirmed that the door coordinator was not working correctly.

2. At 2:50 p.m., the corridor door (20775) to the Medical Staff Credentialing Office failed to fully close in two of three tests from the fully open position. CS2 confirmed the finding.

8/14/18
2nd Floor

3. At 1:31 p.m., the Respiratory Care Storage door (20472) failed to close completely an latch. The finding was confirmed by MPS.


31201

8/14/18
1st Floor

4. At 11:40 a.m., the door to the Emergency Department Waiting Room (10123) was equipped with a self-closing device that failed to latch when fully opened and released.

5. At 2:38 p.m., the door to the Chapel Supply Closet was equipped with a self-closing device that failed to latch when fully opened and released. The door was tested three times and failed.

6. At 2:42 p.m., the door to Room 1610 was obstructed by a bed. The finding was confirmed by the DF.

8/15/18
2nd Floor

7. At 1:47 p.m., the door to the Storage Room located in the Operating Unit area (200136) was equipped with a self-closing device that failed to latch when fully opened and released. The door was tested four times and failed. The finding was confirmed by MPS.

8. At 1:50 p.m., the door to the Sterile Corridor Room located in the Operating Unit area (200142) was equipped with a self-closing device that failed to latch when fully opened and released. The finding was confirmed by MPS.

9. At 1:52 p.m., the door to the Electrical Room located in the Operating Unit area (200150) was equipped with a self-closing device that failed to latch when fully opened and released. The finding was confirmed by MPS.

Based on observation and interview, the facility failed to maintain their smoke barriers. This was evidenced by to smoke barrier doors that failed to close when tested. This could result in the spread of smoke during fire emergency, and affected two of three floors in the Hospital.

NFPA 101 - Life Safety Code, 2012 Edition
19.2.2.2.7* 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 Self-Closing Devices.
7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.
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, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf 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 leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair

8.4.3.5 Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Findings:

During the facility tour and interview with the Director of Facilities, Construction Staff 2, the Manager of Plant Services (MPS), and the Vice President of Ancillary Services (VPAS), the smoke barrier doors were observed.

8/14/18
2nd Floor

1. At 3:32 p.m., the west leaf of smoke barrier doors (208110) failed to close when tested. The finding was confirmed by MPS.


31201

/15/18
1st Floor

2. At 10:42 a.m., the left smoke barrier door near Room 108156 on the first floor (10858), failed to release from the magnetic hold-open device upon activation of the fire alarm system. The finding was confirmed by VPAS.

Based on interview and record review, the facility failed to maintain their emergency generator. This was evidenced by a failure to take action required based on the laboratory fuel quality analysis on four of their five emergency generator diesel fuel tanks. This could result in a delay providing emergency power during a public utility power outage, and affected the Main Hospital and the Medical Office Building.

NFPA 101 Life Safety Code, 2012 edition
9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

NFPA 110 Standard for Emergency and Standby Power Systems, 2010 edition.
8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.
8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Findings:

During document review with the Director of Facilities (DF), Construction Staff 2 (CS2), and the Manager of Plant Services on 8/14/18, the emergency generator maintenance records were requested.

At 1:30 p.m., the lab tests for the emergency generator diesel fuel tanks indicated action was required for four of five fuel tanks. The vendor lab recommended fuel polishing to reduce the metallic and non metallic materials in the fuel. There were no records indicating that the fuel was cleaned.

In an interview with DF and CS2 on 8/14/18 at 1:32 p.m., the DF confirmed that they had not acted on their vendor's recommendation to clean their diesel fuel supplies.

Based on observation and interview, the facility failed to maintain electrical wiring connections. This was evidenced by appliances plugged into surge protectors, and by the use of surge protectors and adaptors to substitute for the fixed wiring of the structure. This could result in electrical shock or an electrical fire, and affected three of three floors in the Main Hospital.

NFPA 99 Health Care Facilities 2012 edition
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70 National Electrical Code 2011 edition
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage

Findings:

During the facility tours and interviews with Director of Facilities (DF), Construction Staff 2 (CS2), the Manager of Plant Services (MPS), and the Vice President of Ancillary Services (VPAS), the electrical devices and wiring connections were observed.

8/13/18
2nd Floor

1. At 1:41 p.m., in the Anesthesiologist Workroom there was a microwave oven plugged into a surge protector which was plugged into a wall outlet. At 1:42 p.m., CS2 confirmed the finding.

2. At 2:35 p.m., in the Lab Employee Break Room, there was a toaster oven plugged into a surge protected extension cord which was plugged into a wall outlet. At 2:36 p.m., CS2 confirmed the use of the surge protectors on the appliances and stated that in some cases there was an adequate number of electrical outlets already available.

8/14/18
2nd Floor

3. At 1:06 p.m., in the Neonatal Intensive Care Unit, there was a refrigerator plugged into a surge protected extension cord. At 1:07 p.m., MPS acknowledged the refrigerator was not plugged directly into the wall outlet.

4. At 1:23 p.m., in Physicians Room 2, there was a microwave oven plugged into a surge protected extension cord which was plugged into a wall outlet. At 1:24 p.m., MPS acknowledged the finding.

5. At 1:40 p.m., in Respiratory Care Service (203094), there was a refrigerator and a coffee maker plugged into a surge protected extension cord which was plugged into a wall outlet. At 1:41 p.m., MPS acknowledged the finding.

6. At 1:48 p.m., in the Neonatologist Office (20460), there was a microwave oven plugged into a surge protector which was plugged into a wall outlet.

7. At 2:03 p.m., in 205280, there was a microwave oven and and a refrigerator that were plugged into a surge protected extension cord which wrapped around two walls and then plugged into a wall outlet. At 2:04 p.m., MPS acknowledged the finding.

8. At 3:12 p.m., in the Gastroenterologist Office, there was a refrigerator plugged into a surge protector.

9. At 3:31 p.m., in Room 208090, there was a coffee maker, a refrigerator, and a microwave oven plugged into a surge protector which was plugged into a wall outlet.

8/15/18
Ground Floor

10. At 3:45 p.m., in Room G08144 there was a refrigerator, a coffee maker, and a microwave oven plugged into a surge protected extension cord which was plugged into a duplex wall outlet.



31201

11. At 11:46 a.m., a contrast warmer machine was plugged into a surge protector, in the CT Control Room. When interviewed, VPAS stated that the contrast warmer machine was considered medical equipment.

12. At 1:34 p.m., a microwave oven and a refrigerator were plugged into a suspended surge protector, in the Hematology Clinic Office.

13. At 1:36 p.m., a microwave oven and a refrigerator were plugged into a surge protector, in the Cardiac Testing Center Break Room.

14. At 2:00 p.m., a lamp was plugged into a three-plug adapter and two lamps were plugged into an extension cord, in the Gift Shop. The findings were confirmed by VPAS and the DF.

15. At 2:02 p.m., a projector machine was plugged into a white extension cord, in the Medical Education Conference Room.

16. At 2:08 p.m., in the Medical Records Office, a cell phone charger was plugged into a white extension cord that was connected to a surge protector, and a toaster and a microwave oven were plugged into a surge protector that was connected to another surge protector. The findings were confirmed by VPAS and DF.

8/15/18
Ground Floor

17. At 8:34 a.m., a refrigerator was plugged into a suspended surge protector, in the Security Operations Center. The finding was confirmed by the DF.

18. At 8:37 a.m., a computer was plugged into an orange extension cord that was plugged into a surge protector, in the Pharmacy.

19. At 9:04 a.m., a microwave oven was plugged into an orange extension cord, in the Human Resource Department. The finding was confirmed by the DF.

Power strips being used for patient care related electrical equipment (PCREE) in the patient care vicinity are required to meet specific UL requirements. Power strip for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in patient care rooms (outside of vicinity) meet UL 1363.