HospitalInspections.org

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Based on the observation during the survey on 04/21/2015, the facility failed to provide corridor walls that resist the passage of smoke due to a sliding window not fitting correctly in it's frame. Findings include:

First floor - The facility failed to provide a smoke resistive sliding window in the corridor wall at the Vascular Lab. There was approximately 1/4" gap between the glass of the window and the bottom of the window frame on the right side, regardless if the window was open or closed.

This deficiency impacted 1 of 14 smoke compartments on the first floor.
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Review of 2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
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A) Based on the observation of 1/2 of the corridor doors during the survey on 04/21/2015, the facility failed to provide corridor doors that resist the passage of smoke. Findings include:

The facility failed to provide smoke resistive corridor doors at the following locations:
1. Ground floor - Dietary Storage Room (near the loading dock) double corridor doors, one was missing the door hardware.
2. Ground floor - Medical Records (G314) was observed with an approximately 1/4" size hole at the door hardware

This deficiency impacted 2 of 13 smoke compartments on the ground floor.
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33999

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B) Based on the observation of approximately 1/3 of doors opening onto the corridor located on the third, fourth and fifth floors on 4/20/2015, the facility failed to maintain corridor doors with a suitable means of keeping the door closed. Findings include:

Resident Room 5633 corridor door failed to positive latch into the frame.

The deficiency impacted 1 of 8 smoke compartments on the fifth floor.

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2000 NFPA 101, 19.3.6.3.1 Exception No.2.
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Based on the observation of 10 of the 32 total elevators on 4/20/2015, the facility failed to maintain the elevator shafts per code. Findings include:

1. Elevator 2 was observed with an unsealed penetration around a black cable on the left side and around a pipe on the right side.
2. Elevator 11 was observed with an unsealed penetration around a metal conduit at the back of the shaft.
3. Elevator 13 was observed with a hole in the wall at the back of the shaft.
4. Elevator 38 was observed with an unsealed penetration at the right and back walls of the shaft.
5. Elevator 20 was observed with an unsealed penetration around a black pipe at the right side of the elevator shaft.
6. Elevator 18 was observed several holes at the right and back walls and approximately a 2' -0" by 14' -0" opening in the shaft wall.

The deficiency impacted 4 of 13 smoke compartments on the third floor.

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NFPA 101, 19.3.1.1 Any vertical openings shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
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Based on the observation on 4/20/2015, the facility failed to maintain smoke barrier so as to resist the passage of smoke. Findings include:

Unsealed penetrations around a single black cable in the smoke barrier by Zone 2.
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Review of 2000 NFPA 101, 19.3.7.3

Review of 2000 NFPA 101, 8.3.2
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Based on the observation of 1/4 of the smoke barriers during the survey on 04/21/2015, the facility failed to maintain smoke barriers with a fire rating of a minimum of 30 minutes and resist the passage of smoke. Findings include:

1. First floor - The smoke barrier above the smoke doors at room 1303 had an unsealed conduit.
2. First floor - The smoke barrier above the smoke doors at room 1336 was missing a 2' x 2' section of gyp. board.

This deficiency impacted 4 of 14 smoke compartments on the first floor.
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Review of 2000 NFPA 101, 8.3.2
Review of 2000 NFPA 101, 8.2.4.4.1

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A) Based on the observation on 4/21/2015, the facility failed to maintain separation of a hazardous room from other compartments. Findings include:

Unsealed penetrations in the wall around a water line, in Mechanical Room 2611.
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27382

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B) Based on the observation of 1/3 of the hazardous areas during the survey on 04/21/2015, the facility failed to maintain these hazardous areas. Findings include:

1. Ground floor - Medical Records Room for Radiology/Oncology (G807) - the self-closing device was not working.
2. First floor - Supply Room in SICU both doors had two holes of approximately 1/4" in size below the door hardware.
3. Ground floor - Dietary Storage Room (G645) was over 100 sq/ ft. with combustibles, the double doors did not have self-closing devices.
4. Ground floor - Plant Operations File Room was over 100 sq. ft. with combustibles, the door did not have a self-closing device.
5. Basement - Medical Library was over 100 sq. ft. with combustibles, the two doors did not have self-closing devices.

This deficiency impacted 5 of 28 smoke compartments on the basement, ground and first floors.
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33999

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C) Based on the observation of all hazardous areas located on the third, fourth and fifth floors on 4/20/2015, the facility failed to maintain one of the hazardous area doors self closing and positive latching hardware. Findings include:

The Linen Storage Room 3259 corridor door was unable to self close and latch into the frame.

The deficiency impacted 1 of 8 smoke compartments on the third floor.

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2000 NFPA 101, 19.3.2.1
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Based on the observation of the means of egress during the survey on 04/20 - 21/2015, the facility failed to maintain the means of egress. Findings include:

Ground floor - The facility failed to maintain the means of egress, the Oncology/Radiology corridor at room G839 (Dr.'s Office) was observed having for 5 filing carts with files stored on both sides of the corridor.

This deficiency impacted 1 of 13 smoke compartments on the ground floor.
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Review of 2000 NFPA 101, 3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.
Review of 2000 NFPA 101, 7.1.10.1 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.
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Based on the observation of 1/3 of the horizontal exits during the survey on 04/20 - 21/2015, the facility failed to maintain the horizontal exits. Findings include:

Third floor - The left leaf of the fire doors was observed to drag on the floor failing to close under activation of the fire alarm, at the POB.

This deficiency impacted 1 of 7 smoke compartments on the third floor.
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Review of 2000 NFPA 101, 7.2.4.3.8
Review of 1999 NFPA 80, 3-4.1*
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Based on the observation of all exit signs located on the third, fourth and fifth floors on 4/20/2015, the facility failed to maintain exit signs per code. Findings include:

1. The exit sign in the corridor outside the Dayroom 5 Southeast was observed with one exit sign arrow pointing in the wrong direction.
2. The exit sign in the corridor outside Room 5531 was observed with one exit sign arrow pointing in the wrong direction.

The deficiency impacted 2 of 8 smoke compartments on the fifth floor.

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2000 NFPA 101, 7.10.2
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Based on the observation of the fire drill documentation on 4/20/2015, the facility failed to conduct fire drills per code. Findings include:

The Third Shift fire drills for the past year were all performed within 5 minutes of each other.
First Quarter 5:20 AM
Second Quarter 5:15 AM
Third Quarter 5:15 AM
Fourth Quarter 5:15 AM

The deficiency impacted all smoke compartments.

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NFPA 101, 19.7.1.2 Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

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Based on the observation of the fire drill documentation on 4/20/2015, the facility failed to conduct fire drills per code. Findings include:

The Third Shift fire drills for the past year were all performed within 5 minutes of each other.
First Quarter 5:20 AM
Second Quarter 5:15 AM
Third Quarter 5:15 AM
Fourth Quarter 5:15 AM

The deficiency impacted all smoke compartments.

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NFPA 101, 19.7.1.2 Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.
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Based on the observation of the activation of the fire alarm system during the survey on 04/21-22/2015, the facility failed to maintain a fire alarm system per code. Findings include:

When a fire alarm pull station was pulled outside of the First floor SICU and Ground floor IT/Accounts Payable these 2 Units did not receive the alarm. When a fire alarm pull station was pulled inside of the Ground floor IT/Accounts Payable and First floor SICU the rest of the facility did receive the alarm.

This deficiency impacted 2 of 28 smoke compartments on the basement, ground and first floors.
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Review of 2000 NFPA 101, 9.6.2.1
Review of 2000 NFPA 101, 9.6.3.1
Review of 2000 NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
Review of 1999 NFPA 72, 3-8.1*
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Per documentation provided on 04/21/2015, the facility failed to provide the annual fire alarm testing/inspection documentation. Findings include:

The facility failed to provide the annual fire alarm testing/inspection documentation.

This deficiency impacted 1 of 1 smoke compartments.
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Review of 1999 NFPA 72, 1-6.3 Records.
A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.

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Per documentation provided on 04/21/2015, the facility failed to provide the biannual fire alarm smoke detector testing/inspection documentation. Findings include:

The facility failed to provide the biannual fire alarm smoke detector testing/inspection documentation.

This deficiency impacted 1 of 1 smoke compartments.
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Review of 1999 NFPA 72, 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
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Based on the observation on 4/21/2015, the facility failed to adequately provide sprinkler coverage. Findings include:

7 ceiling tiles were missing in the Data Processing Room.
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NFPA 13 5-6
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Based on observation on 4/20/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

The fire alarm panel indicated trouble condition for the tamper switch located in the fire pit.
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NFPA 101, 2000 Edition, 9.7.2.1, Supervisory Signals.

1999 NFPA 72, 2-9.1. Control Valve Supervisory Signal-Initiating Device.
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A) Based on the observation on 4/20/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

The fire department connection failed to rotate smoothly.
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NFPA 101,2000 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, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good condition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.
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27382

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B) Per documentation provided on 04/21/2015, the facility failed to provide the quarterly automatic sprinkler system testing/inspection documentation for the past twelve months

This deficiency impacted 1 of 1 smoke compartments.
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Review of 2000 NFPA 101, 9.7.5 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.
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Based on the observation on 4/21/2015, the facility failed to adequately maintained sprinkler coverage. Findings include:

1. In the Data Processing Room, clearance of items stored were approximately 2 inches from the sprinklers on the top shelf.

2. The escutcheon plate was missing on a sprinkler in the Data Processing Room.
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The clearance between the deflector and the top of storage shall be
18 inches or greater. 1999 NFPA 13,5-5.5.2.1 and 5-6.5.2.1.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
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Based on the observation of only three of the smoke dampers during the survey on 04/21/2015, the facility failed to provide a smoke damper that closed upon activation of the fire alarm system. Findings include:

First floor - The facility failed to provide a smoke damper that closed upon activation of a fire alarm pull station located at the damper.

This deficiency impacted 2 of 14 smoke compartments on the first floor.
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Review of 2000 NFPA 101, 8.3.5.2 Required smoke dampers in ducts penetrating smoke barriers shall close upon detection of smoke by approved smoke detectors in accordance with NFPA 72, National Fire Alarm Code.

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A) Based on the observation on 4/20/2015, the facility failed to maintain the smoke barriers. Findings include:

1. Unsealed penetrations around a duct in the smoke barrier by the Recovery Doors first floor.

2. The doors in the barrier failed to close tight upon activation of the fire alarm system, Second Floor by Medical Records.
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NFPA 101, 2000 Edition,21.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.




B) Based on the observation on 4/20/2015, the facility failed to provide adequate sprinkler coverage. Findings include:

A sprinkler in the housekeeping closet had a bend deflector.
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1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

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Based on the observation of the following systems during the survey on 04/21-22/2015, the facility failed to maintain the these systems. Findings include:

1. Second floor - C- Section Rooms were observed without battery-powered emergency lighting units.
2. Basement - The 2 hour fire barrier at the parking deck was observed with an unsealed penetration of wires.
3. Ground floor - The cafe's rolldown fire shutter's (located in the corridor wall), the safety stop (an infrared eye beam) did not stop the shutter.
4. First floor - the means of egress corridor leading into the atrium was observed with two roll down fire shutters, not side hinged or horizontal sliding doors, that are operated by gravity, once the hold open devices were released. There are no safety features on these roll down shutters and they were observed going from fully open to fully closed in seconds.

This deficiency impacted 4 of 35 smoke compartments on the ground and first floors.
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Review of 1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas.
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Review of 19.1.2.3 Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 19.1.1.4.

Review of 2000 NFPA 101, 4.1.2* Crowd Movement.
An additional goal is to provide for reasonably safe emergency crowd movement and, where required, reasonably safe nonemergency crowd movement.

Review of 2000 NFPA 101, 4.2.3 Systems Effectiveness.
Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

Review of 2000 NFPA 101, 7.2.1.4.1*
Any door in a means of egress shall be of the side-hinged or pivoted-swinging type. The door shall be designed and installed so that it is capable of swinging from any position to the full required width of the opening in which it is installed.
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Based on the observation on 4/20/2015, the facility failed to maintain the electrical system. Findings include:

Junction box was missing the cover above the ceiling at barrier by OR # 3.
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1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.
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Based on the observation of the electrical wiring and equipment during the survey on 04/21-22/2015, the facility failed to maintain the electrical wiring and equipment. Findings include:

The following locations failed to maintain the electrical wiring and equipment as stated:
1. First floor - Radiology Film Area had a copier plugged into an extension cord.
2. First floor - Radiology QC had a computer plugged into a multi outlet extension cord.
3. Ground Floor - Equipment Coordinator's Office had the following:
a. An extension cord (in use) plugged into a power strip
b. Multi outlet device was in use
4. Ground floor - Mail Room had a heat gun plugged into a power strip.

This deficiency impacted 3 of 27 smoke compartments on the ground and first floors.
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Review of 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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Based on the observation during the survey on 04/21/2015, the facility failed to provide corridor walls that resist the passage of smoke due to a sliding window not fitting correctly in it's frame. Findings include:

First floor - The facility failed to provide a smoke resistive sliding window in the corridor wall at the Vascular Lab. There was approximately 1/4" gap between the glass of the window and the bottom of the window frame on the right side, regardless if the window was open or closed.

This deficiency impacted 1 of 14 smoke compartments on the first floor.
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Review of 2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
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A) Based on the observation of 1/2 of the corridor doors during the survey on 04/21/2015, the facility failed to provide corridor doors that resist the passage of smoke. Findings include:

The facility failed to provide smoke resistive corridor doors at the following locations:
1. Ground floor - Dietary Storage Room (near the loading dock) double corridor doors, one was missing the door hardware.
2. Ground floor - Medical Records (G314) was observed with an approximately 1/4" size hole at the door hardware

This deficiency impacted 2 of 13 smoke compartments on the ground floor.
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33999

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B) Based on the observation of approximately 1/3 of doors opening onto the corridor located on the third, fourth and fifth floors on 4/20/2015, the facility failed to maintain corridor doors with a suitable means of keeping the door closed. Findings include:

Resident Room 5633 corridor door failed to positive latch into the frame.

The deficiency impacted 1 of 8 smoke compartments on the fifth floor.

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2000 NFPA 101, 19.3.6.3.1 Exception No.2.
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Based on the observation of 10 of the 32 total elevators on 4/20/2015, the facility failed to maintain the elevator shafts per code. Findings include:

1. Elevator 2 was observed with an unsealed penetration around a black cable on the left side and around a pipe on the right side.
2. Elevator 11 was observed with an unsealed penetration around a metal conduit at the back of the shaft.
3. Elevator 13 was observed with a hole in the wall at the back of the shaft.
4. Elevator 38 was observed with an unsealed penetration at the right and back walls of the shaft.
5. Elevator 20 was observed with an unsealed penetration around a black pipe at the right side of the elevator shaft.
6. Elevator 18 was observed several holes at the right and back walls and approximately a 2' -0" by 14' -0" opening in the shaft wall.

The deficiency impacted 4 of 13 smoke compartments on the third floor.

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NFPA 101, 19.3.1.1 Any vertical openings shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
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Based on the observation on 4/20/2015, the facility failed to maintain smoke barrier so as to resist the passage of smoke. Findings include:

Unsealed penetrations around a single black cable in the smoke barrier by Zone 2.
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Review of 2000 NFPA 101, 19.3.7.3

Review of 2000 NFPA 101, 8.3.2
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Based on the observation of 1/4 of the smoke barriers during the survey on 04/21/2015, the facility failed to maintain smoke barriers with a fire rating of a minimum of 30 minutes and resist the passage of smoke. Findings include:

1. First floor - The smoke barrier above the smoke doors at room 1303 had an unsealed conduit.
2. First floor - The smoke barrier above the smoke doors at room 1336 was missing a 2' x 2' section of gyp. board.

This deficiency impacted 4 of 14 smoke compartments on the first floor.
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Review of 2000 NFPA 101, 8.3.2
Review of 2000 NFPA 101, 8.2.4.4.1

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A) Based on the observation on 4/21/2015, the facility failed to maintain separation of a hazardous room from other compartments. Findings include:

Unsealed penetrations in the wall around a water line, in Mechanical Room 2611.
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27382

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B) Based on the observation of 1/3 of the hazardous areas during the survey on 04/21/2015, the facility failed to maintain these hazardous areas. Findings include:

1. Ground floor - Medical Records Room for Radiology/Oncology (G807) - the self-closing device was not working.
2. First floor - Supply Room in SICU both doors had two holes of approximately 1/4" in size below the door hardware.
3. Ground floor - Dietary Storage Room (G645) was over 100 sq/ ft. with combustibles, the double doors did not have self-closing devices.
4. Ground floor - Plant Operations File Room was over 100 sq. ft. with combustibles, the door did not have a self-closing device.
5. Basement - Medical Library was over 100 sq. ft. with combustibles, the two doors did not have self-closing devices.

This deficiency impacted 5 of 28 smoke compartments on the basement, ground and first floors.
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33999

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C) Based on the observation of all hazardous areas located on the third, fourth and fifth floors on 4/20/2015, the facility failed to maintain one of the hazardous area doors self closing and positive latching hardware. Findings include:

The Linen Storage Room 3259 corridor door was unable to self close and latch into the frame.

The deficiency impacted 1 of 8 smoke compartments on the third floor.

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2000 NFPA 101, 19.3.2.1
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Based on the observation of the means of egress during the survey on 04/20 - 21/2015, the facility failed to maintain the means of egress. Findings include:

Ground floor - The facility failed to maintain the means of egress, the Oncology/Radiology corridor at room G839 (Dr.'s Office) was observed having for 5 filing carts with files stored on both sides of the corridor.

This deficiency impacted 1 of 13 smoke compartments on the ground floor.
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Review of 2000 NFPA 101, 3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.
Review of 2000 NFPA 101, 7.1.10.1 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.
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Based on the observation of 1/3 of the horizontal exits during the survey on 04/20 - 21/2015, the facility failed to maintain the horizontal exits. Findings include:

Third floor - The left leaf of the fire doors was observed to drag on the floor failing to close under activation of the fire alarm, at the POB.

This deficiency impacted 1 of 7 smoke compartments on the third floor.
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Review of 2000 NFPA 101, 7.2.4.3.8
Review of 1999 NFPA 80, 3-4.1*
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Based on the observation of all exit signs located on the third, fourth and fifth floors on 4/20/2015, the facility failed to maintain exit signs per code. Findings include:

1. The exit sign in the corridor outside the Dayroom 5 Southeast was observed with one exit sign arrow pointing in the wrong direction.
2. The exit sign in the corridor outside Room 5531 was observed with one exit sign arrow pointing in the wrong direction.

The deficiency impacted 2 of 8 smoke compartments on the fifth floor.

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2000 NFPA 101, 7.10.2
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Based on the observation of the fire drill documentation on 4/20/2015, the facility failed to conduct fire drills per code. Findings include:

The Third Shift fire drills for the past year were all performed within 5 minutes of each other.
First Quarter 5:20 AM
Second Quarter 5:15 AM
Third Quarter 5:15 AM
Fourth Quarter 5:15 AM

The deficiency impacted all smoke compartments.

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NFPA 101, 19.7.1.2 Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

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Based on the observation of the fire drill documentation on 4/20/2015, the facility failed to conduct fire drills per code. Findings include:

The Third Shift fire drills for the past year were all performed within 5 minutes of each other.
First Quarter 5:20 AM
Second Quarter 5:15 AM
Third Quarter 5:15 AM
Fourth Quarter 5:15 AM

The deficiency impacted all smoke compartments.

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NFPA 101, 19.7.1.2 Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.
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Based on the observation of the activation of the fire alarm system during the survey on 04/21-22/2015, the facility failed to maintain a fire alarm system per code. Findings include:

When a fire alarm pull station was pulled outside of the First floor SICU and Ground floor IT/Accounts Payable these 2 Units did not receive the alarm. When a fire alarm pull station was pulled inside of the Ground floor IT/Accounts Payable and First floor SICU the rest of the facility did receive the alarm.

This deficiency impacted 2 of 28 smoke compartments on the basement, ground and first floors.
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Review of 2000 NFPA 101, 9.6.2.1
Review of 2000 NFPA 101, 9.6.3.1
Review of 2000 NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
Review of 1999 NFPA 72, 3-8.1*
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Per documentation provided on 04/21/2015, the facility failed to provide the annual fire alarm testing/inspection documentation. Findings include:

The facility failed to provide the annual fire alarm testing/inspection documentation.

This deficiency impacted 1 of 1 smoke compartments.
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Review of 1999 NFPA 72, 1-6.3 Records.
A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.

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Per documentation provided on 04/21/2015, the facility failed to provide the biannual fire alarm smoke detector testing/inspection documentation. Findings include:

The facility failed to provide the biannual fire alarm smoke detector testing/inspection documentation.

This deficiency impacted 1 of 1 smoke compartments.
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Review of 1999 NFPA 72, 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
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Based on the observation on 4/21/2015, the facility failed to adequately provide sprinkler coverage. Findings include:

7 ceiling tiles were missing in the Data Processing Room.
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NFPA 13 5-6
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Based on observation on 4/20/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

The fire alarm panel indicated trouble condition for the tamper switch located in the fire pit.
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NFPA 101, 2000 Edition, 9.7.2.1, Supervisory Signals.

1999 NFPA 72, 2-9.1. Control Valve Supervisory Signal-Initiating Device.
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A) Based on the observation on 4/20/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

The fire department connection failed to rotate smoothly.
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NFPA 101,2000 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, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good condition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.
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B) Per documentation provided on 04/21/2015, the facility failed to provide the quarterly automatic sprinkler system testing/inspection documentation for the past twelve months

This deficiency impacted 1 of 1 smoke compartments.
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Review of 2000 NFPA 101, 9.7.5 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.
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Based on the observation on 4/21/2015, the facility failed to adequately maintained sprinkler coverage. Findings include:

1. In the Data Processing Room, clearance of items stored were approximately 2 inches from the sprinklers on the top shelf.

2. The escutcheon plate was missing on a sprinkler in the Data Processing Room.
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The clearance between the deflector and the top of storage shall be
18 inches or greater. 1999 NFPA 13,5-5.5.2.1 and 5-6.5.2.1.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
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Based on the observation of only three of the smoke dampers during the survey on 04/21/2015, the facility failed to provide a smoke damper that closed upon activation of the fire alarm system. Findings include:

First floor - The facility failed to provide a smoke damper that closed upon activation of a fire alarm pull station located at the damper.

This deficiency impacted 2 of 14 smoke compartments on the first floor.
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Review of 2000 NFPA 101, 8.3.5.2 Required smoke dampers in ducts penetrating smoke barriers shall close upon detection of smoke by approved smoke detectors in accordance with NFPA 72, National Fire Alarm Code.

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A) Based on the observation on 4/20/2015, the facility failed to maintain the smoke barriers. Findings include:

1. Unsealed penetrations around a duct in the smoke barrier by the Recovery Doors first floor.

2. The doors in the barrier failed to close tight upon activation of the fire alarm system, Second Floor by Medical Records.
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NFPA 101, 2000 Edition,21.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.




B) Based on the observation on 4/20/2015, the facility failed to provide adequate sprinkler coverage. Findings include:

A sprinkler in the housekeeping closet had a bend deflector.
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1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

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Based on the observation of the following systems during the survey on 04/21-22/2015, the facility failed to maintain the these systems. Findings include:

1. Second floor - C- Section Rooms were observed without battery-powered emergency lighting units.
2. Basement - The 2 hour fire barrier at the parking deck was observed with an unsealed penetration of wires.
3. Ground floor - The cafe's rolldown fire shutter's (located in the corridor wall), the safety stop (an infrared eye beam) did not stop the shutter.
4. First floor - the means of egress corridor leading into the atrium was observed with two roll down fire shutters, not side hinged or horizontal sliding doors, that are operated by gravity, once the hold open devices were released. There are no safety features on these roll down shutters and they were observed going from fully open to fully closed in seconds.

This deficiency impacted 4 of 35 smoke compartments on the ground and first floors.
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Review of 1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas.
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Review of 19.1.2.3 Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 19.1.1.4.

Review of 2000 NFPA 101, 4.1.2* Crowd Movement.
An additional goal is to provide for reasonably safe emergency crowd movement and, where required, reasonably safe nonemergency crowd movement.

Review of 2000 NFPA 101, 4.2.3 Systems Effectiveness.
Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

Review of 2000 NFPA 101, 7.2.1.4.1*
Any door in a means of egress shall be of the side-hinged or pivoted-swinging type. The door shall be designed and installed so that it is capable of swinging from any position to the full required width of the opening in which it is installed.
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Based on the observation on 4/20/2015, the facility failed to maintain the electrical system. Findings include:

Junction box was missing the cover above the ceiling at barrier by OR # 3.
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1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.
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Based on the observation of the electrical wiring and equipment during the survey on 04/21-22/2015, the facility failed to maintain the electrical wiring and equipment. Findings include:

The following locations failed to maintain the electrical wiring and equipment as stated:
1. First floor - Radiology Film Area had a copier plugged into an extension cord.
2. First floor - Radiology QC had a computer plugged into a multi outlet extension cord.
3. Ground Floor - Equipment Coordinator's Office had the following:
a. An extension cord (in use) plugged into a power strip
b. Multi outlet device was in use
4. Ground floor - Mail Room had a heat gun plugged into a power strip.

This deficiency impacted 3 of 27 smoke compartments on the ground and first floors.
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Review of 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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