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Based on observation, the facility failed to maintain the building construction as evidenced by unsealed penetrations through the ceilings and walls. This could result in the spread of smoke or fire to other smoke compartments, and affected 4 of 6 floors of the facility.

Findings:

During the facility tour with Staff 1 between December 13 and 15, 2010, the building construction was observed:

At 1:05 p.m. on 12-13-10, there was an approximately one-half inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 5A121 over bed A. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling. An escutcheon ring is a cover plate that cover the sprinker head.

At 1:23 p.m. on 12-13-10, there was an approximately one-half inch gap between the sprinkler escutcheon and the ceiling exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 5A115 over bed A. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 2:35 p.m. on 12-13-10, in Dem 2 (2B121), Bay 4, there were four approximately 1/4 inch penetrations in the center left of the wall.

At 2:45 p.m. on 12-13-10, in the Emergmncy Room, ENT 6, there were nine approximately 1/2 inch penetrations in the center left of the wall behind the patient bed.

At 3:12 p.m. on 12-13-10, there was one approximately one inch by three inch unsealed penetration in the corridor wall between rooms 4A110 and 4A109. Staff 1 confirmed there was a penetration in the wall.

At 3:22 p.m. on 12-13-10, there was an approximately three-quarter inch gap between the sprinkler escutcheon ring and the ceiling exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 4D117. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 3:50 p.m. on 12-13-10, there was an approximately three-quarter inch gap between 2 of 2 sprinkler escutcheon rings and the ceiling, exposing a three quarter inch gap around each sprinkler pipe where the pipe penetrated the ceiling in room 4C125. Staff 1 confirmed there was a three quarter inch unsealed gap around the two sprinkler pipes where the pipes penetrated the ceiling.

At 8:55 a.m. on 12-14-10, there was an approximately one-half inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in unit 4B clean utility room. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 8:55 a.m. on 12-14-10, there was an approximately one-half inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the corridor adjacent to room 4B128. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 9:08 a.m. on 12-14-10, there was an approximately one-half inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in unit 4B room with door labeled SE4208. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 10:08 a.m. on 12-14-10, there was an approximately one-half inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 3D116. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 10:50 a.m. on 12-14-10, there was an approximately three-quarter inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the NICU above bed 20. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 11:15 a.m. on 12-14-10, there was an approximately one-half inch gap between 1 of 3 sprinkler escutcheon rings and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the OR Sterile Supply room 3B103. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 4:20 p.m. on 12-14-10, in the room with the door frame labeled NE2271, there was a one-quarter inch unsealed gap around a pipe that penetrated the wall facing the door. Staff 1 confirmed the pipe was not sealed

At 8:40 a.m. on 12-15-10, there was an approximately three-quarter inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the room with the door designation of NW2116. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling and adjusted the escutcheon.

At 9:10 a.m. on 12-15-10, there was an approximately three-quarter inch gap between 1 of 2 sprinkler escutcheon rings and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the room with the door designation of 2D112. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 9:15 a.m. on 12-15-10, there was an approximately three-quarter inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the Janitor room with the door designation of SW2233. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 9:20 a.m. on 12-15-10, there was an approximately three-quarter inch gap between 2 of 3 south sprinkler escutcheon rings and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 2D139. Staff 1 confirmed there was a three quarter inch unsealed gap around the two sprinkler pipes where the pipes penetrated the ceiling.

At 9:27 a.m. on 12-15-10, there was an approximately three-quarter inch gap between 2 of 3 south sprinkler escutcheon rings and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 2C120. Staff 1 confirmed there was a three quarter inch unsealed gap around the two sprinkler pipes where the pipes penetrated the ceiling.

Based on observation and interview, the facility failed to maintain the corridor doors, as evidenced by corridor doors that were obstructed from closing and by corridor doors that failed to positive latch upon closure. This had the potential to fail to contain the spread of smoke and fire throughout the facility, and affected 4 of 6 floors of the facility.

Findings:

During the facility tour with Staff 1 December 13 to 15, 2010, the corridor doors were observed.

At 11:00 a.m. on 12-13-10, the self-closing corridor door to Electrical Room A on Unit 6D failed to fully close and positive latch without assistance. Staff 1 confirmed the door failed to fully close and latch without assistance.

At 1:28 p.m. on 12-13-10, the self-closing corridor door to the Wheelchair Shower NW5206 failed to fully close and positive latch without assistance. Staff 1 confirmed the door failed to fully close and latch without assistance.

At 1:30 p.m. on 12-13-10, the self-closing corridor door to room 5A108 was obstructed from closing by a recycle bin. Staff 1 confirmed the recycle bin obstructed the door from closing.

At 2:33 p.m. on 12-13-10, the self-closing corridor door to room 5C106 was obstructed from closing by a chair. Staff 1 confirmed the chair obstructed the door from closing.

At 10:10 a.m. on 12-14-10, in Mailroom Storage NE1151, the door was blocked open with storage items.

At 10:10 a.m. on 12-14-10, the self-closing corridor door to room 3D105 failed to fully close and positive latch without assistance. Staff 1 confirmed the door failed to fully close and latch without assistance.

At 4:01 p.m. on 12-14-10, the self-closing corridor door to rooms 2B163 and 2B165 were obstructed from closing by a door wedge. Staff 1 confirmed a wedge obstructed the door to 2B163 and the door to 2B165 from closing.

At 8:53 a.m. on 12-15-10, the self-closing door from Patient Inquiry 2D101 to the Out-Patient Lobby was obstructed from closing by a door wedge. Staff 1 confirmed a wedge obstructed the door to 2D101 from closing.

At 9:07 a.m. on 12-15-10, the self-closing door corridor door to the copy room with the door designation of NW2291 was obstructed from closing by a door wedge. Staff 1 confirmed a wedge obstructed the door designated NW2291 from closing.

Based on observation and interview, the facility failed to maintain access to exits as evidenced by the failure to provide visible exit signs pointing to the path of egress. This affected 2 of 6 floors of the facility, and had the potential for occupants not to readily reach an exit.

Findings:

During the facility tour with Staff 1 on December 13, 2010, access to the exits were observed.

At 2:15 p.m., there was no exit sign visible on the 5th floor when looking south in the east corridor towards unit 5C. There was a sign over the door to unit 5C stating " Not and Exit. " When standing in the corridor, an exit sign was only visible when looking to the north end of the corridor. Staff 1 confirmed an exit sign was not visible when looking south in the corridor.

At 3:35 p.m., there was no exit sign visible on the 4th floor when looking from unit 4A down the corridor towards unit 4C. When standing in the corridor, an exit sign was only visible when looking to the north end of the corridor. Staff 1 confirmed an exit sign was not visible when looking south in the corridor.

Based on observation and interview, the facility failed to ensure that the integrity and maintenance of the smoke barrier walls as evidenced by a sealed cap in a pipe that was loose. This affected 1 of 6 floors of the facility, and had the potential to allow the transmission of smoke from one smoke compartment to another.

Findings:

During the facility tour with Staff 1 on December 13, 2010, the facility smoke barriers were observed.

At 1:45 p.m. on 12-13-10, there was cap on a pipe penetration in the smoke barrier wall adjacent to 5D126 that had come loose. Staff 1 confirmed the cap was loose and had the cap resealed by facility maintenance staff.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that were not self closing. This affected 2 of 6 facility floors, and had the potential for the spread of smoke or fire, in the event of a fire.

Findings:

During the facility tour with Staff 1 on December 13 and 14, 2010, the smoke barrier doors were observed:

At 11:17 a.m. on 12-13-10, the smoke barrier door in the air conditioning chase adjacent to Damper 596 in the stairwell was not a self-closing door. Staff 1 confirmed the doors failed to self-close.

At 11:40 a.m. on 12-14-10, 2 of 2 doors in room 2C159A, an administration conference room, were obstructed from closing by hold open devices in the door closer. The doors had to be pulled to activate the self-closing device. Staff 1 confirmed the doors failed to self-close. On the maps provided by the facility, the two doors were located in a smoke barrier wall.

At 9:42 a.m. on 12-15-10, the smoke barrier double door 11, 5C, the leaf door leaf failed to positive latch when released from the magnetic hold-open device.

Based on observation and interview, the facility failed to protect hazardous areas as evidenced by hazardous storage areas that were open to the corridor, a door to a hazardous area that was not self-closing, and a door that failed to fully close and latch. This affected 2 of 6 floors of the facility, and had the potential to allow the spread of smoke and fire from hazardous areas to other areas.

Findings:

During a tour of the facility with Facility Staff 1 on December 13 and 14, 2010, the hazardous areas were observed.

At 9:56 a.m. on 12-13-10, there was an approximately 44 gallon container marked " Shred Safe " stored in the alcove to the dumbwaiter in the corridor adjacent to unit 6A. Staff 1 confirmed the container was stored in the alcove that was open to the corridor, and moved the container.

At 11:06 a.m. on 12-13-10, the corridor door for patient room 6C116, being used as an office, had approximately 25 cardboard boxes in the area. The door to the room was not a self-closing door. Staff 1 confirmed the storage of the boxes and that the door to the room was not self-closing.

At 2:31 p.m. on 12-13-10, the corridor door to the Unit 5C Soiled Utility room failed to fully close and latch.

Based on observation and interview, the facility failed to maintain exit access as evidenced by doors that were equipped with dead bolts that required more than one releasing operation to open the door. This affected 1 of 6 facility floors, and had the potential for delaying egress in an emergency.
NFPA 101 (2000 Edition) 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11
NFPA 101 (2000 Edition) 7.2.1.5 - Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
NFPA 101 (2000 Edition) 7.2.1.5.4 - A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm) above the finished floor. Doors shall be operable with not more than one releasing operation.
Findings:

During the facility tour with Staff 1 on December 14, 2010, the facility doors were observed.

At 10:39 a.m. on 12-14-10, the corridor door to Operating Room #8 and Operating Room #9 in labor and delivery were equipped with a dead bolt lock. When locked, it required to actions to unlock and open the door, a total of two releasing actions to exit the door. Staff 1 confirmed the doors were equipped with dead-bolts and required two releasing actions to exit the room.

Based on observation and interview, the facility failed to maintain exit access as evidenced by obstructed exit corridors. This affected 1 of 6 facility floors and had the potential for delaying egress in an emergency.
Finding:
During the facility tour with Staff 1 on December 14, 2010, the egress corridors were observed.

At 4:15 p.m. on 12-14-10, in the east corridor of the Emergency Room, on the west side of the corridor nurse call lights were installed on the wall, and emergency electrical strips were installed for patient equipment for additional beds in the corridor. There were three gurneys with patients on the gurneys along the wall. Staff 1 confirmed there were gurneys along the wall with the nurse call lights arranged for patient use.

At 4:20 p.m. on 12-14-10, in the Emergency Room registration corridor there was a total of 9 chairs in the corridor adjacent to the registration rooms. Staff 1 confirmed there were chairs in the corridor adjacent to the registration rooms.

Based on record review and interview, the facility failed to ensure that fire drills are conducted quarterly and at varying times and conditions as evidenced by no documentation for 1 of 4 AM fire drills, and 4 of 4 NOC fire drills conducted at the same time of day. This could result in any one staff member not accomplishing all of the tasks required in the event of an emergency, and an increased risk of injury to patients, visitors and staff in the event of an emergency.

Findings:

During record review and interview with facility staff on December 13, 2010 through December 15, 2010, the fire drills were reviewed and staff interviewed.

At 9:15 a.m. on December 13, 2010, documentation for 12 fire drills for one year were requested.

At 9:30 a.m. on December 15, 2010 the fire drills presented was for the 2nd quarter of 2010. There was no AM fire drill for the third quarter of 2010. The NOC drills showed the same time of day between 5:09 a.m., and 5:31 a.m.-5:21 a.m.-2/25/10 at 5:25 a.m., 4-20-10 at 5:21 a.m., 7-22-10 at 5:09 a.m. and 10/13/09 at 5:31 a.m. Staff 2 stated there were no additional fire drill records for review.

Based on observation and interview, the facility failed to maintain the fire alarm system as evidenced by batteries that were past due for replacement, and manual fire alarm boxes that were obstructed. This affected 3 of 6 facility floors, and had the potential for fire alarm system failure.


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

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

NFPA 72 (1999 Edition) Table 7-3.2 Testing Frequencies, Item 6(d)(1) Sealed lead acid batteries are to be replaced every 4 years.


Findings:

During the facility tour with Staff 1 and 2 between December 13 to 15, 2010, the fire alarm system was observed.

At 11:45 a.m., the two sealed lead acid (SLA) batteries in the fire alarm panel LEC6C-37 located in room 6B119B were dated 12-3-03, approximately 3 years past due for replacement. Staff 1 confirmed the batteries were dated 12-3-03.

At 2:30 p.m. on 12-13-10, at the Emergency Room Ambulance Entrance, the manual pull station was blocked by equipment. Staff 2 confirmed that the manual pull station was impeded from access.

At 4:18 p.m. on 12-14-10, in the 6C East corridor, the chime was barely audible and could not be heard in some areas. Staff 2 confirmed that the alarm was faint.

At 11:00 a.m. on 12-15-10, in the NICU, the alarm could not be heard during fire alarm testing, and there was no strobe. Staff 2 confirmed that there was no audible or visual notification in the unit.

At 11:15 a.m. on 12-15-10, in the 3A Zone, the Fire Alarm Sub-Control Panel did not communicate the signals to the Main Fire Alarm Control Panel. The panel was restored at 1:30 p.m.

Based on interview and document review, the facility failed to maintain the smoke detectors as evidenced by the failure to provide documentation for the sensitivity testing of the smoke detectors, and the failure to provide documentation for the removal of a duct detector. This affected 6 of 6 facility floors, and had the potential for smoke detector failure in the event of a fire.


NFPA 101 (2000 Edition) 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 (1999 Edition) 7-7.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

NFPA 72 (1999 Edition), 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.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.

Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.


Findings:

During the document review and facility tour with Staff 1 between December 13 to 15, 2010, the inspection and test record for the fire alarm systems was reviewed, and the fire alarm system was observed.

At 9:30 a.m. on 12-13-10, documents were requested for sensitivity testing for the system-based smoke detectors. At 1:15 p.m. on 12-15-10, the facility failed to provide sensitivity testing for the system-based smoke detectors. Staff 1 stated there were no documents available for review.

At 11:05 a.m. on 12-13-10, the facility failed to provide documentation for the removal of duct detector labeled 180 Zone 43 adjacent to room 6C121. Staff 1 confirmed the duct detector had been removed. On 12-15-10 at 2:00 p.m. Staff 1 stated the detector had been replaced and was in service

Based on observation, the facility failed to maintain the facility automatic sprinkler system as evidenced by sprinkler heads with foreign material on the sprinkler heads, sprinkler heads that were lacking the escutcheon rings, a fire department connection (FDC) that was missing a cap, a FDC that was not equipped with an identification sign, and post indicator valves (PIV) that were not secured. This affected 6 of 6 facility floors, and had the potential for the automatic sprinkler system failure in the event of a fire.


NFPA 13 (1999 Edition) 3-8.3* Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
NFPA 13 (1999 Edition) 5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.
NFPA 13 (1999 Edition) 5-15.2.3.4 Where a fire department connection services only a portion of a building, a sign shall be attached indicating the portions of the building served.

NFPA 25 (1998 Edition), 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

NFPA 25 (1998 Edition) 9-3.2.2 Each normally open valve shall be secured by means of a seal or a lock or shall be electrically supervised in accordance with the applicable NFPA standards.

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.


Findings:

During the facility tour with Staff 1 between December 13 to 15, 2010, the automatic sprinkler system was observed.

At 9:50 a.m. on 12-13-10, the FDC cap was missing on the north side of Penthouse 9. Staff 1 confirmed the FDC cap was missing.

At 10:25 a.m. on 12-13-10, there was dust build-up on 2 of 2 sprinkler heads in the unit 6A Dietary Prep area. Staff 1 confirmed there was dust build-up on the sprinkler heads.

At 10:27 a.m. on 12-13-10, there was dust build-up on the sprinkler head in room 6A124. Staff 1 confirmed there was dust build-up on the sprinkler head.

At 11:34 a.m. on 12-13-10, quick response sprinkler heads were observed in rooms 6B119, 6B119A and 6B119B in a smoke compartment which also contained standard sprinkler heads. Staff 1 confirmed there were quick response sprinkler head in the rooms and standard response sprinkler heads in the smoke compartment.

At 2: 45 p.m. on 12-13-10, in the Gift Shop, there were 3 of 4 sprinkler heads with holiday ornaments hanging from the sprinkler heads.

At 2: 50 p.m. on 12-13-2010, in the Cafeteria corridor next to the tray return, there was a build-up of debris on 2 of 3 sprinkler heads.

At 9:00 a.m. on 12-14-10, in the corridor to the Cafeteria, there was a build-up of debris on 5 of 7 sprinkler heads, 1 of 7 sprinkler heads were damaged and 1 of 7 was missing an escutcheon ring.

At 10:14 a.m. on 12-14-10, in Room 1B118, there was a build-up of debris on 3 of 4 sprinkler heads and 1 of 4 was missing an escutcheon ring.

At 10:45 a.m. on 12-14-10, Outside of Room 1B108, there was a sprinkler missing an escutcheon ring.

At 3:25 p.m. on 12-14-10, there was plastic wrap on the sprinkler head in the Biohazard room with door designation NW3184. Staff 1 confirmed there was plastic wrap on the sprinkler head and removed the plastic wrap.

At 9:20 a.m. on 12-14-10, there was plastic wrap on the sprinkler head in the corridor adjacent to the door designated NW2237. Staff 1 confirmed there was plastic wrap on the sprinkler head and removed the plastic wrap.

At 3:35 p.m. on 12-14-10, IS Room, there were 4 of 7 sprinklers missing escutcheon rings.

At 4:14p.m. on 12-14-10, 6th Floor Stairwell 3, there was 1 of 1 sprinklers missing an escutcheon ring.

At 10:15 a.m. on 12-15-10, the FDC identified by Staff 1 as serving the sprinkler riser for Stairwell #7 was not identified with a sign. Staff 1 confirmed there was no sign on the FDC advising the FDC served Stairwell #7.

At 10:25 a.m. on 12-15-10, Post Indicator Valves (PIV) #4 and #5 were not locked. Staff 1 confirmed the PIV ' s were not locked.

Based on observation, the facility failed to maintain the portable fire extinguishers, as evidenced by obstructed access to fire extinguishers, an extinguisher that was missing the tamper indicator, an extinguisher pressure gauge that read in the overcharge range, and fire extinguishers mounted more than 60 inches above the floor. This could result in delay in response to a fire, extinguisher failure and increase the risk of injury to patients, visitors and staff. This affected 6 of 6 facility floors.

NFPA 10 (1998 Edition) 1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

NFPA 10 (1998 Edition) 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.

NFPA 10 (1998 Edition), 4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.

NFPA 10 (1998 Edition) 4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During the facility tour with Facility Staff 1 between December 13 and 15, 2010, the fire extinguishers were observed.

At 1:23 p.m. on 12-13-10, the fire extinguisher at Unit 5A nurse station was missing the tamper indicator tag. Staff 1 confirmed the fire extinguisher was missing the tamper indicator tag.

At 10:17 a.m. on 12-14-10, in Medical Records, the fire extinguisher located by door NE1121, was blocked by a coat rack. Staff 2 confirmed that the fire extinguisher was blocked.

At 10:25 a.m. on 12-14-10, in the 1st Floor Electric Room G, the fire extinguisher was installed at approximately 68 inches from the top of the extinguisher to the floor. Staff 2 confirmed that the fire extinguisher was installed at 68 inches.

At 10:30 a.m. on 12-14-10, the fire extinguisher in the corridor adjacent to room 3C112 registered in the overcharged range on the pressure gauge. Staff 1 confirmed the extinguisher registered in the overcharge range.

At 10:40 a.m. on 12-14-10, in Central Supply Pick-up, the fire extinguisher was blocked by a trashcan. Staff 2 confirmed that the fire extinguisher was blocked.

At 11:30 a.m. on 12-14-10, at the PACU nurse station, the CO2 fire extinguisher access was impeded by a fax machine. To access the extinguisher required reaching over the fax machine. Staff 1 confirmed access to the extinguisher was obstructed.

At 11:45 a.m. on 12-14-10, at the west end of Administration, the fire extinguisher access was impeded by a fax machine. To access the extinguisher required reaching over the fax machine. Staff 1 confirmed access to the extinguisher was obstructed and moved the fax machine.

At 3:20 p.m. on 12-14-10, IS, the fire extinguisher was blocked by a trashcan. Staff 2 confirmed that the fire extinguisher was blocked.

At 9:25 a.m. on 12-15-10, the top of the fire extinguisher in the ENT clinic room 2C111, which weighed approximately 8 pounds 13 ounces, was installed approximately 68 inches above the floor and access to the extinguisher was obstructed by a trash can. To access the fire extinguisher required reaching over the trash can. Staff 1 confirmed the top of the extinguisher was approximately 68 inches above the floor and access was obstructed by a trash can.

At 1:40 p.m. on 12-15-10, access to the fire extinguisher in the corridor adjacent to Stairwell #6 on the first floor was obstructed. The sign identifying the extinguisher location was obstructed by the exit sign pointing to the stairwell. Staff 1 confirmed the location sign was obstructed.

Based on observation and interview, the facility failed to maintain the smoking areas as evidenced by the failure to provide self-closing containers into which to empty the ash trays. This affected 2 of 6 floors. This could result in a fire, and increase the risk of injury to patients, visitors and staff.

Findings:

During the facility tour with facility staff on December 13, 2010 through December 15, 2010, the smoking areas were observed.

At 10:50 a.m. on December 14, 2010, 1 of 3 ashtrays provided in the Cafeteria Patio Smoking Area was of an open design. There were 6 cigarette butts and paper on top. Staff 2 confirmed the open container.

At 1:00 p.m. on December 15, 2010, 1 of 1 ashtrays provided in the First Floor Smoking Area was of an open design. There were no self-closing containers into which to empty the ashtrays. The open ashtray was on top of the trashcan, and the butts were emptied inside the trashcan. Staff 2 confirmed there were no self-closing containers in the smoking area.

At 1:20 p.m. on December 14, 2010, 1 of 2 ashtrays provided in the Second Floor Smoking Area was of an open design. The open ashtrays were on top of the trashcans and the butts were emptied inside the trashcan. There were no self-closing containers into which to empty the ashtrays. Staff 2 confirmed there were no self-closing containers in the smoking area.

Based on observation, document review and interview, the facility failed to maintain the cooking facilities in accordance with NFPA 96, Section 7-2.2, by failing to provide a UL 300 fire suppression system. This could result in a kitchen fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

Findings:

During a tour of the facility with facility staff on December 13, 2010 through December 15, 2010, the kitchen cooking areas were observed, records reviewed and staff interviewed.

At 9:30 a.m. on 12-13-10, documents and records were requested for the testing and maintenance of the kitchen hood suppression systems. At 9:40 a.m. on 12-15-10, Staff I stated that the facility was in the process of receiving OSHPD (Office of Statewide Health Planning and Development) approval and stated the facility was in the process of upgrading the kitchen fire suppression systems. Staff I provided documentation for the upgrade of the kitchen fire suppression system. Staff I stated there were no current records for the extinguishing system maintenance.

Based on observation, the facility failed to ensure that means of egress are continuously free of all obstructions or impediments to full instant use in 2 of 6 floors as evidenced by paths of egress impeded by equipment. This find could delay egress in the event of an emergency, and increase the risk of injury to patients, visitors and staff.

Findings:

During the facility tour with facility staff on December 13, 2010 through December 15, 2010, the escape paths were observed.

Findings:

At 2:25 p.m. on 12-13-10, the exit corridor located in Demo 2, Rapid Screening was impeded by carts and equipment.

At 10:50 a.m. on 12-14-10, the exit double door located in the soiled area of Central Supply was impeded by a biohazard cart and equipment.

Based on observation, the facility failed to maintain the facility decorations as evidenced by the failure to provide documentation for the flame-retardent rating for Christmas trees and door decorations. This had the potential for the rapid spread of a fire, and affected 4 of 6 facility floors.

Findings:

During the facility tour with Staff 1 between December 13 and 15, 2010, the facility decorations were observed.

At 1:53 p.m. on 12-13-10, the facility failed to provide documentation as the flame resistance rating for the artificial Christmas Tree at the 5D nurse station. Staff 1 confirmed there was no documentation for the tree flame resistance rating.

At 2:23 p.m. on 12-13-10, the facility failed to provide documentation as the flame resistance rating for the artificial Christmas Tree at the 5C nurse station. Staff 1 confirmed there was no documentation for the tree flame resistance rating.

At 3:05 p.m. on 12-13-10, the facility failed to provide documentation as the flame resistance rating for the artificial Christmas Tree at the 4A nurse station. Staff 1 confirmed there was no documentation for the tree flame resistance rating.

At 3:25 p.m. on 12-13-10, the facility failed to provide documentation as the flame resistance rating for the artificial Christmas Tree at the 4D nurse station. Staff 1 confirmed there was no documentation for the tree flame resistance rating.

At 3:57 p.m. on 12-14-10, the facility failed to provide documentation as the flame resistance rating for the decorations used to decorate the corridor door to room 2B181. The door was covered with the decoration from the top of the door to the bottom of the door. Staff 1 confirmed there was no documentation for the flame resistance rating for the door decoration.

At 4:00 p.m. on 12-14-10, the facility failed to provide documentation as the flame resistance rating for the decorations used to decorate the corridor door to room 2C210. The door was covered with the decoration from the top of the door to the bottom of the door. Staff 1 confirmed there was no documentation for the flame resistance rating for the door decoration.

At 9:00 a.m. on 12-15-10, the facility failed to provide documentation as the flame resistance rating for the artificial Christmas Tree at the Community Health Lobby. Staff 1 confirmed there was no documentation for the tree flame resistance rating.

Based on observation and interview, the facility failed to maintain the compressed gas cylinders as evidenced by unsecured compressed gas cylinders, and by a patient observed smoking with oxygen attached to their wheelchair. This affected 3 of 6 smoke compartments, and had the potential for damage to the cylinders and harm to patients.


NFPA 99 (1999 Edition) Chapter 12 Hospital Requirements

12-1 Scope. This chapter addresses safety requirements of hospitals.

NFPA 99 (1999 Edition) 12-3.8 Gas Equipment Requirements.
12-3.8.1 Patient. Equipment shall conform to requirements for patient equipment in Chapter 8.

NFPA 99 (1999 Edition) 8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).

(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.

NFPA 99 (1999 Edition) 8-3.1.11.2 (h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

NFPA 99 (1999 edition), 4-3.5.2.1(b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During the facility tour with Staff 1 between December 13 and 15, 2010, the facility compressed gas cylinders were observed.

At 9:35 a.m. on 12-13-10, there was an H cylinder of Forane 22 and an H cylinder of compressed nitrogen in the roof penthouse number 5 that were secured by a chain around the neck of each cylinder. Staff 1 confirmed the cylinders were not secured properly.

At 3:32 p.m. on 12-13-10, there was an upright unsecured E oxygen cylinder in Soiled Utility room with the door designation of NW4157. Staff 1 confirmed the cylinder was not secured.

At 3:52 p.m. on 12-13-10, there was an unsecured oxygen E cylinder lying on a tray beneath the crib Bed B in room 4C109. Staff 1 confirmed the cylinder was lying on the crib tray and was not secured.

At 10:05 a.m. on 12-14-10, in the Kitchen by the back dock, there were 2 H Carbon Dioxide cylinders loosely secured. Staff 2 confirmed the cylinders were not secured.

At 12:00 p.m. on 12-14-10, there was an unsecured upright E oxygen cylinder in the Cath Lab prep room. Staff 1 confirmed the cylinder was not secured.

At 12:45 p.m. on 12-14-10, in the 1st Floor Smoking Area, there was a female patient smoking with an oxygen tank attached to the back of her wheel chair. There were two other patients also observed smoking. Staff 3 removed the oxygen tank from the wheel chair. Staff 2, Staff 3 and the Team Leader observed the event.

Based on observation, the facility failed to maintain access to the medical gas shutoff valves as evidenced by access to a valve box that was obstructed. This affected one floor in the facility, and could result in a delay in accessing the emergency shut-off valve.

NFPA 99 (1999 Edition) 4-3.1.2.3 Gas Shutoff Valves. i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings:

During the facility tour with Staff 1 between December 13 and 15, 2010, the facility medical gas system was observed.

At 11:32 a.m. on 12-14-10, access to the PACU emergency shutoff valves for rooms 1-6 was blocked by a table in front of the box. Staff 1 confirmed a table obstructed the access to the shutoff valve.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment as evidenced by the failure to identify the purpose or use of electrical breakers, damaged electrical receptacles, a refrigerator that was plugged into a surge protector instead of directly into an electrical receptacle and the use of a multi-plug extension cord. This affected 6 of 6 facility floors and had the potential for a fire or electrical shock.

NFPA 70 (1999 Edition), article 110-12(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 70 (1999 Edition) 384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

NFPA 70 (1999 Edition), 400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:

(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

NFPA 70 (1999 Edition) 400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

NFPA 70 (1999 edition) Section 410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.



Findings:

During the facility tour with Staff 1 between December 13 and 15, 2010, the facility electrical wiring and equipment were observed.

At 10:02 a.m. on 12-13-10, there was a toaster and coffee maker plugged into a multi-plug extension cord in room 6D101. The extension cord was used to extend power the items, and was used in place of providing fixed electrical receptacles. Staff 1 confirmed the multi-plug adapter extension cord was in use.

At 10:58 a.m. on 12-13-10, in electrical panel LN6AA on unit 6D, breakers 37, 39 and 41 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

At 11:30 a.m. on 12-13-10, the electrical receptacle in the corridor adjacent to room 6B112 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 11:41 a.m. on 12-13-10, the electrical receptacle in the corridor adjacent to the room with the door labeled SE6183 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 1:25 p.m. on 12-13-10, the red electrical receptacle in the corridor adjacent to the room 5A101 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 1:59 p.m. on 12-13-10, the electrical receptacle adjacent to Bed B in room 5D109 was not flush with the wall. Staff 1 confirmed the receptacle was not flush with the wall.

At 2:24 p.m. on 12-13-10, the red electrical receptacle in the corridor adjacent to the room 5C109 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 2:30 p.m. on 12-13-10, electrical receptacle on the left wall of the unit 5C Soiled Utility room was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 2:38 p.m. on 12-13-10, the red electrical receptacle in the corridor adjacent to the room 5B108 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 2:47 p.m. on 12-13-10, there was an open junction box adjacent to the air duct in Electrical Room C on unit 5B. Staff 1 confirmed there was an open junction box.

At 2:59 p.m. on 12-13-10, there was an open junction box above the drop ceiling adjacent to room 4D127. Staff 1 confirmed there was an open junction box and had a staff member replace the cover.

At 3:00 p.m. on 12-13-10, the red electrical receptacle in the corridor adjacent to the room 4A101 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 3:05 p.m. on 12-13-10, the red electrical receptacle in room 4A120 and room 4A110 were damaged around the ground port. Staff 1 confirmed the receptacles were damaged around the ground port.

At 3:20 p.m. on 12-13-10, the electrical receptacle in the corridor adjacent to the room 4D124 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 3:25 p.m. on 12-13-10, the electrical receptacle adjacent to Bed B in room 4D114 was not flush with the wall. Staff 1 confirmed the receptacle was not flush with the wall.

At 9:58 a.m. on 12-14-10, the electrical receptacle in the Same Day Surgery nurse station identified as LN3B4 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 10:13 a.m. on 12-14-10, the electrical receptacle in the corridor adjacent to the room 3D103 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 10:20 a.m. on 12-14-10, the red electrical receptacle in 3D Nursery identified as LEC3A5 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 10:27 a.m. on 12-14-10, the red electrical receptacle in Labor and Delivery room 3C113, bed 5 receptacle #6 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 10:27 a.m. on 12-14-10, the red electrical receptacle in Labor and Delivery room 3C113, bed 6 receptacle #5 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 10:40 a.m. on 12-14-10, breakers 7 and 8 in panel ORP10 E6 were in the on position and marked as spares. Staff 1 confirmed the breakers were marked as spare and were in the on position.

At 11:31 a.m. on 12-14-10, the #3 red electrical receptacle in PACU for bed 4 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 12:45 p.m. on 12-14-10, in the Ultrasound Break Room SW1105B, there was a microwave, toaster and two coffee makers plugged into a surge protector and not directly into the wall.

At 4:08 p.m. on 12-14-10, the electrical receptacle in the corridor adjacent to the room 2B136 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 4:10 p.m. on 12-14-10, the electrical receptacle in the corridor adjacent to Electrical Room G on the second floor was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 8:55 a.m. on 12-15-10, there was a refrigerator plugged into a surge protector instead of directly into an electrical receptacle in room 2D150. Staff 1 confirmed the refrigerator was plugged into a surge protector instead of directly into an electrical receptacle.

Based on observation, the facility failed to maintain the building construction as evidenced by unsealed penetrations through the ceilings and walls. This could result in the spread of smoke or fire to other smoke compartments, and affected 4 of 6 floors of the facility.

Findings:

During the facility tour with Staff 1 between December 13 and 15, 2010, the building construction was observed:

At 1:05 p.m. on 12-13-10, there was an approximately one-half inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 5A121 over bed A. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling. An escutcheon ring is a cover plate that cover the sprinker head.

At 1:23 p.m. on 12-13-10, there was an approximately one-half inch gap between the sprinkler escutcheon and the ceiling exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 5A115 over bed A. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 2:35 p.m. on 12-13-10, in Dem 2 (2B121), Bay 4, there were four approximately 1/4 inch penetrations in the center left of the wall.

At 2:45 p.m. on 12-13-10, in the Emergmncy Room, ENT 6, there were nine approximately 1/2 inch penetrations in the center left of the wall behind the patient bed.

At 3:12 p.m. on 12-13-10, there was one approximately one inch by three inch unsealed penetration in the corridor wall between rooms 4A110 and 4A109. Staff 1 confirmed there was a penetration in the wall.

At 3:22 p.m. on 12-13-10, there was an approximately three-quarter inch gap between the sprinkler escutcheon ring and the ceiling exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 4D117. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 3:50 p.m. on 12-13-10, there was an approximately three-quarter inch gap between 2 of 2 sprinkler escutcheon rings and the ceiling, exposing a three quarter inch gap around each sprinkler pipe where the pipe penetrated the ceiling in room 4C125. Staff 1 confirmed there was a three quarter inch unsealed gap around the two sprinkler pipes where the pipes penetrated the ceiling.

At 8:55 a.m. on 12-14-10, there was an approximately one-half inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in unit 4B clean utility room. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 8:55 a.m. on 12-14-10, there was an approximately one-half inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the corridor adjacent to room 4B128. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 9:08 a.m. on 12-14-10, there was an approximately one-half inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in unit 4B room with door labeled SE4208. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 10:08 a.m. on 12-14-10, there was an approximately one-half inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 3D116. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 10:50 a.m. on 12-14-10, there was an approximately three-quarter inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the NICU above bed 20. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 11:15 a.m. on 12-14-10, there was an approximately one-half inch gap between 1 of 3 sprinkler escutcheon rings and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the OR Sterile Supply room 3B103. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 4:20 p.m. on 12-14-10, in the room with the door frame labeled NE2271, there was a one-quarter inch unsealed gap around a pipe that penetrated the wall facing the door. Staff 1 confirmed the pipe was not sealed

At 8:40 a.m. on 12-15-10, there was an approximately three-quarter inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the room with the door designation of NW2116. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling and adjusted the escutcheon.

At 9:10 a.m. on 12-15-10, there was an approximately three-quarter inch gap between 1 of 2 sprinkler escutcheon rings and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the room with the door designation of 2D112. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 9:15 a.m. on 12-15-10, there was an approximately three-quarter inch gap between the sprinkler escutcheon ring and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in the Janitor room with the door designation of SW2233. Staff 1 confirmed there was a three quarter inch unsealed gap around the sprinkler pipe where the pipe penetrated the ceiling.

At 9:20 a.m. on 12-15-10, there was an approximately three-quarter inch gap between 2 of 3 south sprinkler escutcheon rings and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 2D139. Staff 1 confirmed there was a three quarter inch unsealed gap around the two sprinkler pipes where the pipes penetrated the ceiling.

At 9:27 a.m. on 12-15-10, there was an approximately three-quarter inch gap between 2 of 3 south sprinkler escutcheon rings and the ceiling, exposing a three quarter inch gap around the sprinkler pipe where the pipe penetrated the ceiling in room 2C120. Staff 1 confirmed there was a three quarter inch unsealed gap around the two sprinkler pipes where the pipes penetrated the ceiling.

Based on observation and interview, the facility failed to maintain the corridor doors, as evidenced by corridor doors that were obstructed from closing and by corridor doors that failed to positive latch upon closure. This had the potential to fail to contain the spread of smoke and fire throughout the facility, and affected 4 of 6 floors of the facility.

Findings:

During the facility tour with Staff 1 December 13 to 15, 2010, the corridor doors were observed.

At 11:00 a.m. on 12-13-10, the self-closing corridor door to Electrical Room A on Unit 6D failed to fully close and positive latch without assistance. Staff 1 confirmed the door failed to fully close and latch without assistance.

At 1:28 p.m. on 12-13-10, the self-closing corridor door to the Wheelchair Shower NW5206 failed to fully close and positive latch without assistance. Staff 1 confirmed the door failed to fully close and latch without assistance.

At 1:30 p.m. on 12-13-10, the self-closing corridor door to room 5A108 was obstructed from closing by a recycle bin. Staff 1 confirmed the recycle bin obstructed the door from closing.

At 2:33 p.m. on 12-13-10, the self-closing corridor door to room 5C106 was obstructed from closing by a chair. Staff 1 confirmed the chair obstructed the door from closing.

At 10:10 a.m. on 12-14-10, in Mailroom Storage NE1151, the door was blocked open with storage items.

At 10:10 a.m. on 12-14-10, the self-closing corridor door to room 3D105 failed to fully close and positive latch without assistance. Staff 1 confirmed the door failed to fully close and latch without assistance.

At 4:01 p.m. on 12-14-10, the self-closing corridor door to rooms 2B163 and 2B165 were obstructed from closing by a door wedge. Staff 1 confirmed a wedge obstructed the door to 2B163 and the door to 2B165 from closing.

At 8:53 a.m. on 12-15-10, the self-closing door from Patient Inquiry 2D101 to the Out-Patient Lobby was obstructed from closing by a door wedge. Staff 1 confirmed a wedge obstructed the door to 2D101 from closing.

At 9:07 a.m. on 12-15-10, the self-closing door corridor door to the copy room with the door designation of NW2291 was obstructed from closing by a door wedge. Staff 1 confirmed a wedge obstructed the door designated NW2291 from closing.

Based on observation and interview, the facility failed to maintain access to exits as evidenced by the failure to provide visible exit signs pointing to the path of egress. This affected 2 of 6 floors of the facility, and had the potential for occupants not to readily reach an exit.

Findings:

During the facility tour with Staff 1 on December 13, 2010, access to the exits were observed.

At 2:15 p.m., there was no exit sign visible on the 5th floor when looking south in the east corridor towards unit 5C. There was a sign over the door to unit 5C stating " Not and Exit. " When standing in the corridor, an exit sign was only visible when looking to the north end of the corridor. Staff 1 confirmed an exit sign was not visible when looking south in the corridor.

At 3:35 p.m., there was no exit sign visible on the 4th floor when looking from unit 4A down the corridor towards unit 4C. When standing in the corridor, an exit sign was only visible when looking to the north end of the corridor. Staff 1 confirmed an exit sign was not visible when looking south in the corridor.

Based on observation and interview, the facility failed to ensure that the integrity and maintenance of the smoke barrier walls as evidenced by a sealed cap in a pipe that was loose. This affected 1 of 6 floors of the facility, and had the potential to allow the transmission of smoke from one smoke compartment to another.

Findings:

During the facility tour with Staff 1 on December 13, 2010, the facility smoke barriers were observed.

At 1:45 p.m. on 12-13-10, there was cap on a pipe penetration in the smoke barrier wall adjacent to 5D126 that had come loose. Staff 1 confirmed the cap was loose and had the cap resealed by facility maintenance staff.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that were not self closing. This affected 2 of 6 facility floors, and had the potential for the spread of smoke or fire, in the event of a fire.

Findings:

During the facility tour with Staff 1 on December 13 and 14, 2010, the smoke barrier doors were observed:

At 11:17 a.m. on 12-13-10, the smoke barrier door in the air conditioning chase adjacent to Damper 596 in the stairwell was not a self-closing door. Staff 1 confirmed the doors failed to self-close.

At 11:40 a.m. on 12-14-10, 2 of 2 doors in room 2C159A, an administration conference room, were obstructed from closing by hold open devices in the door closer. The doors had to be pulled to activate the self-closing device. Staff 1 confirmed the doors failed to self-close. On the maps provided by the facility, the two doors were located in a smoke barrier wall.

At 9:42 a.m. on 12-15-10, the smoke barrier double door 11, 5C, the leaf door leaf failed to positive latch when released from the magnetic hold-open device.

Based on observation and interview, the facility failed to protect hazardous areas as evidenced by hazardous storage areas that were open to the corridor, a door to a hazardous area that was not self-closing, and a door that failed to fully close and latch. This affected 2 of 6 floors of the facility, and had the potential to allow the spread of smoke and fire from hazardous areas to other areas.

Findings:

During a tour of the facility with Facility Staff 1 on December 13 and 14, 2010, the hazardous areas were observed.

At 9:56 a.m. on 12-13-10, there was an approximately 44 gallon container marked " Shred Safe " stored in the alcove to the dumbwaiter in the corridor adjacent to unit 6A. Staff 1 confirmed the container was stored in the alcove that was open to the corridor, and moved the container.

At 11:06 a.m. on 12-13-10, the corridor door for patient room 6C116, being used as an office, had approximately 25 cardboard boxes in the area. The door to the room was not a self-closing door. Staff 1 confirmed the storage of the boxes and that the door to the room was not self-closing.

At 2:31 p.m. on 12-13-10, the corridor door to the Unit 5C Soiled Utility room failed to fully close and latch.

Based on observation and interview, the facility failed to maintain exit access as evidenced by doors that were equipped with dead bolts that required more than one releasing operation to open the door. This affected 1 of 6 facility floors, and had the potential for delaying egress in an emergency.
NFPA 101 (2000 Edition) 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11
NFPA 101 (2000 Edition) 7.2.1.5 - Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
NFPA 101 (2000 Edition) 7.2.1.5.4 - A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm) above the finished floor. Doors shall be operable with not more than one releasing operation.
Findings:

During the facility tour with Staff 1 on December 14, 2010, the facility doors were observed.

At 10:39 a.m. on 12-14-10, the corridor door to Operating Room #8 and Operating Room #9 in labor and delivery were equipped with a dead bolt lock. When locked, it required to actions to unlock and open the door, a total of two releasing actions to exit the door. Staff 1 confirmed the doors were equipped with dead-bolts and required two releasing actions to exit the room.

Based on observation and interview, the facility failed to maintain exit access as evidenced by obstructed exit corridors. This affected 1 of 6 facility floors and had the potential for delaying egress in an emergency.
Finding:
During the facility tour with Staff 1 on December 14, 2010, the egress corridors were observed.

At 4:15 p.m. on 12-14-10, in the east corridor of the Emergency Room, on the west side of the corridor nurse call lights were installed on the wall, and emergency electrical strips were installed for patient equipment for additional beds in the corridor. There were three gurneys with patients on the gurneys along the wall. Staff 1 confirmed there were gurneys along the wall with the nurse call lights arranged for patient use.

At 4:20 p.m. on 12-14-10, in the Emergency Room registration corridor there was a total of 9 chairs in the corridor adjacent to the registration rooms. Staff 1 confirmed there were chairs in the corridor adjacent to the registration rooms.

Based on record review and interview, the facility failed to ensure that fire drills are conducted quarterly and at varying times and conditions as evidenced by no documentation for 1 of 4 AM fire drills, and 4 of 4 NOC fire drills conducted at the same time of day. This could result in any one staff member not accomplishing all of the tasks required in the event of an emergency, and an increased risk of injury to patients, visitors and staff in the event of an emergency.

Findings:

During record review and interview with facility staff on December 13, 2010 through December 15, 2010, the fire drills were reviewed and staff interviewed.

At 9:15 a.m. on December 13, 2010, documentation for 12 fire drills for one year were requested.

At 9:30 a.m. on December 15, 2010 the fire drills presented was for the 2nd quarter of 2010. There was no AM fire drill for the third quarter of 2010. The NOC drills showed the same time of day between 5:09 a.m., and 5:31 a.m.-5:21 a.m.-2/25/10 at 5:25 a.m., 4-20-10 at 5:21 a.m., 7-22-10 at 5:09 a.m. and 10/13/09 at 5:31 a.m. Staff 2 stated there were no additional fire drill records for review.

Based on observation and interview, the facility failed to maintain the fire alarm system as evidenced by batteries that were past due for replacement, and manual fire alarm boxes that were obstructed. This affected 3 of 6 facility floors, and had the potential for fire alarm system failure.


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

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

NFPA 72 (1999 Edition) Table 7-3.2 Testing Frequencies, Item 6(d)(1) Sealed lead acid batteries are to be replaced every 4 years.


Findings:

During the facility tour with Staff 1 and 2 between December 13 to 15, 2010, the fire alarm system was observed.

At 11:45 a.m., the two sealed lead acid (SLA) batteries in the fire alarm panel LEC6C-37 located in room 6B119B were dated 12-3-03, approximately 3 years past due for replacement. Staff 1 confirmed the batteries were dated 12-3-03.

At 2:30 p.m. on 12-13-10, at the Emergency Room Ambulance Entrance, the manual pull station was blocked by equipment. Staff 2 confirmed that the manual pull station was impeded from access.

At 4:18 p.m. on 12-14-10, in the 6C East corridor, the chime was barely audible and could not be heard in some areas. Staff 2 confirmed that the alarm was faint.

At 11:00 a.m. on 12-15-10, in the NICU, the alarm could not be heard during fire alarm testing, and there was no strobe. Staff 2 confirmed that there was no audible or visual notification in the unit.

At 11:15 a.m. on 12-15-10, in the 3A Zone, the Fire Alarm Sub-Control Panel did not communicate the signals to the Main Fire Alarm Control Panel. The panel was restored at 1:30 p.m.

Based on interview and document review, the facility failed to maintain the smoke detectors as evidenced by the failure to provide documentation for the sensitivity testing of the smoke detectors, and the failure to provide documentation for the removal of a duct detector. This affected 6 of 6 facility floors, and had the potential for smoke detector failure in the event of a fire.


NFPA 101 (2000 Edition) 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 (1999 Edition) 7-7.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

NFPA 72 (1999 Edition), 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.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.

Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.


Findings:

During the document review and facility tour with Staff 1 between December 13 to 15, 2010, the inspection and test record for the fire alarm systems was reviewed, and the fire alarm system was observed.

At 9:30 a.m. on 12-13-10, documents were requested for sensitivity testing for the system-based smoke detectors. At 1:15 p.m. on 12-15-10, the facility failed to provide sensitivity testing for the system-based smoke detectors. Staff 1 stated there were no documents available for review.

At 11:05 a.m. on 12-13-10, the facility failed to provide documentation for the removal of duct detector labeled 180 Zone 43 adjacent to room 6C121. Staff 1 confirmed the duct detector had been removed. On 12-15-10 at 2:00 p.m. Staff 1 stated the detector had been replaced and was in service

Based on observation, the facility failed to maintain the facility automatic sprinkler system as evidenced by sprinkler heads with foreign material on the sprinkler heads, sprinkler heads that were lacking the escutcheon rings, a fire department connection (FDC) that was missing a cap, a FDC that was not equipped with an identification sign, and post indicator valves (PIV) that were not secured. This affected 6 of 6 facility floors, and had the potential for the automatic sprinkler system failure in the event of a fire.


NFPA 13 (1999 Edition) 3-8.3* Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
NFPA 13 (1999 Edition) 5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.
NFPA 13 (1999 Edition) 5-15.2.3.4 Where a fire department connection services only a portion of a building, a sign shall be attached indicating the portions of the building served.

NFPA 25 (1998 Edition), 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

NFPA 25 (1998 Edition) 9-3.2.2 Each normally open valve shall be secured by means of a seal or a lock or shall be electrically supervised in accordance with the applicable NFPA standards.

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.


Findings:

During the facility tour with Staff 1 between December 13 to 15, 2010, the automatic sprinkler system was observed.

At 9:50 a.m. on 12-13-10, the FDC cap was missing on the north side of Penthouse 9. Staff 1 confirmed the FDC cap was missing.

At 10:25 a.m. on 12-13-10, there was dust build-up on 2 of 2 sprinkler heads in the unit 6A Dietary Prep area. Staff 1 confirmed there was dust build-up on the sprinkler heads.

At 10:27 a.m. on 12-13-10, there was dust build-up on the sprinkler head in room 6A124. Staff 1 confirmed there was dust build-up on the sprinkler head.

At 11:34 a.m. on 12-13-10, quick response sprinkler heads were observed in rooms 6B119, 6B119A and 6B119B in a smoke compartment which also contained standard sprinkler heads. Staff 1 confirmed there were quick response sprinkler head in the rooms and standard response sprinkler heads in the smoke compartment.

At 2: 45 p.m. on 12-13-10, in the Gift Shop, there were 3 of 4 sprinkler heads with holiday ornaments hanging from the sprinkler heads.

At 2: 50 p.m. on 12-13-2010, in the Cafeteria corridor next to the tray return, there was a build-up of debris on 2 of 3 sprinkler heads.

At 9:00 a.m. on 12-14-10, in the corridor to the Cafeteria, there was a build-up of debris on 5 of 7 sprinkler heads, 1 of 7 sprinkler heads were damaged and 1 of 7 was missing an escutcheon ring.

At 10:14 a.m. on 12-14-10, in Room 1B118, there was a build-up of debris on 3 of 4 sprinkler heads and 1 of 4 was missing an escutcheon ring.

At 10:45 a.m. on 12-14-10, Outside of Room 1B108, there was a sprinkler missing an escutcheon ring.

At 3:25 p.m. on 12-14-10, there was plastic wrap on the sprinkler head in the Biohazard room with door designation NW3184. Staff 1 confirmed there was plastic wrap on the sprinkler head and removed the plastic wrap.

At 9:20 a.m. on 12-14-10, there was plastic wrap on the sprinkler head in the corridor adjacent to the door designated NW2237. Staff 1 confirmed there was plastic wrap on the sprinkler head and removed the plastic wrap.

At 3:35 p.m. on 12-14-10, IS Room, there were 4 of 7 sprinklers missing escutcheon rings.

At 4:14p.m. on 12-14-10, 6th Floor Stairwell 3, there was 1 of 1 sprinklers missing an escutcheon ring.

At 10:15 a.m. on 12-15-10, the FDC identified by Staff 1 as serving the sprinkler riser for Stairwell #7 was not identified with a sign. Staff 1 confirmed there was no sign on the FDC advising the FDC served Stairwell #7.

At 10:25 a.m. on 12-15-10, Post Indicator Valves (PIV) #4 and #5 were not locked. Staff 1 confirmed the PIV ' s were not locked.

Based on observation, the facility failed to maintain the portable fire extinguishers, as evidenced by obstructed access to fire extinguishers, an extinguisher that was missing the tamper indicator, an extinguisher pressure gauge that read in the overcharge range, and fire extinguishers mounted more than 60 inches above the floor. This could result in delay in response to a fire, extinguisher failure and increase the risk of injury to patients, visitors and staff. This affected 6 of 6 facility floors.

NFPA 10 (1998 Edition) 1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

NFPA 10 (1998 Edition) 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.

NFPA 10 (1998 Edition), 4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.

NFPA 10 (1998 Edition) 4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During the facility tour with Facility Staff 1 between December 13 and 15, 2010, the fire extinguishers were observed.

At 1:23 p.m. on 12-13-10, the fire extinguisher at Unit 5A nurse station was missing the tamper indicator tag. Staff 1 confirmed the fire extinguisher was missing the tamper indicator tag.

At 10:17 a.m. on 12-14-10, in Medical Records, the fire extinguisher located by door NE1121, was blocked by a coat rack. Staff 2 confirmed that the fire extinguisher was blocked.

At 10:25 a.m. on 12-14-10, in the 1st Floor Electric Room G, the fire extinguisher was installed at approximately 68 inches from the top of the extinguisher to the floor. Staff 2 confirmed that the fire extinguisher was installed at 68 inches.

At 10:30 a.m. on 12-14-10, the fire extinguisher in the corridor adjacent to room 3C112 registered in the overcharged range on the pressure gauge. Staff 1 confirmed the extinguisher registered in the overcharge range.

At 10:40 a.m. on 12-14-10, in Central Supply Pick-up, the fire extinguisher was blocked by a trashcan. Staff 2 confirmed that the fire extinguisher was blocked.

At 11:30 a.m. on 12-14-10, at the PACU nurse station, the CO2 fire extinguisher access was impeded by a fax machine. To access the extinguisher required reaching over the fax machine. Staff 1 confirmed access to the extinguisher was obstructed.

At 11:45 a.m. on 12-14-10, at the west end of Administration, the fire extinguisher access was impeded by a fax machine. To access the extinguisher required reaching over the fax machine. Staff 1 confirmed access to the extinguisher was obstructed and moved the fax machine.

At 3:20 p.m. on 12-14-10, IS, the fire extinguisher was blocked by a trashcan. Staff 2 confirmed that the fire extinguisher was blocked.

At 9:25 a.m. on 12-15-10, the top of the fire extinguisher in the ENT clinic room 2C111, which weighed approximately 8 pounds 13 ounces, was installed approximately 68 inches above the floor and access to the extinguisher was obstructed by a trash can. To access the fire extinguisher required reaching over the trash can. Staff 1 confirmed the top of the extinguisher was approximately 68 inches above the floor and access was obstructed by a trash can.

At 1:40 p.m. on 12-15-10, access to the fire extinguisher in the corridor adjacent to Stairwell #6 on the first floor was obstructed. The sign identifying the extinguisher location was obstructed by the exit sign pointing to the stairwell. Staff 1 confirmed the location sign was obstructed.

Based on observation and interview, the facility failed to maintain the smoking areas as evidenced by the failure to provide self-closing containers into which to empty the ash trays. This affected 2 of 6 floors. This could result in a fire, and increase the risk of injury to patients, visitors and staff.

Findings:

During the facility tour with facility staff on December 13, 2010 through December 15, 2010, the smoking areas were observed.

At 10:50 a.m. on December 14, 2010, 1 of 3 ashtrays provided in the Cafeteria Patio Smoking Area was of an open design. There were 6 cigarette butts and paper on top. Staff 2 confirmed the open container.

At 1:00 p.m. on December 15, 2010, 1 of 1 ashtrays provided in the First Floor Smoking Area was of an open design. There were no self-closing containers into which to empty the ashtrays. The open ashtray was on top of the trashcan, and the butts were emptied inside the trashcan. Staff 2 confirmed there were no self-closing containers in the smoking area.

At 1:20 p.m. on December 14, 2010, 1 of 2 ashtrays provided in the Second Floor Smoking Area was of an open design. The open ashtrays were on top of the trashcans and the butts were emptied inside the trashcan. There were no self-closing containers into which to empty the ashtrays. Staff 2 confirmed there were no self-closing containers in the smoking area.

Based on observation, document review and interview, the facility failed to maintain the cooking facilities in accordance with NFPA 96, Section 7-2.2, by failing to provide a UL 300 fire suppression system. This could result in a kitchen fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

Findings:

During a tour of the facility with facility staff on December 13, 2010 through December 15, 2010, the kitchen cooking areas were observed, records reviewed and staff interviewed.

At 9:30 a.m. on 12-13-10, documents and records were requested for the testing and maintenance of the kitchen hood suppression systems. At 9:40 a.m. on 12-15-10, Staff I stated that the facility was in the process of receiving OSHPD (Office of Statewide Health Planning and Development) approval and stated the facility was in the process of upgrading the kitchen fire suppression systems. Staff I provided documentation for the upgrade of the kitchen fire suppression system. Staff I stated there were no current records for the extinguishing system maintenance.

Based on observation, the facility failed to ensure that means of egress are continuously free of all obstructions or impediments to full instant use in 2 of 6 floors as evidenced by paths of egress impeded by equipment. This find could delay egress in the event of an emergency, and increase the risk of injury to patients, visitors and staff.

Findings:

During the facility tour with facility staff on December 13, 2010 through December 15, 2010, the escape paths were observed.

Findings:

At 2:25 p.m. on 12-13-10, the exit corridor located in Demo 2, Rapid Screening was impeded by carts and equipment.

At 10:50 a.m. on 12-14-10, the exit double door located in the soiled area of Central Supply was impeded by a biohazard cart and equipment.

Based on observation, the facility failed to maintain the facility decorations as evidenced by the failure to provide documentation for the flame-retardent rating for Christmas trees and door decorations. This had the potential for the rapid spread of a fire, and affected 4 of 6 facility floors.

Findings:

During the facility tour with Staff 1 between December 13 and 15, 2010, the facility decorations were observed.

At 1:53 p.m. on 12-13-10, the facility failed to provide documentation as the flame resistance rating for the artificial Christmas Tree at the 5D nurse station. Staff 1 confirmed there was no documentation for the tree flame resistance rating.

At 2:23 p.m. on 12-13-10, the facility failed to provide documentation as the flame resistance rating for the artificial Christmas Tree at the 5C nurse station. Staff 1 confirmed there was no documentation for the tree flame resistance rating.

At 3:05 p.m. on 12-13-10, the facility failed to provide documentation as the flame resistance rating for the artificial Christmas Tree at the 4A nurse station. Staff 1 confirmed there was no documentation for the tree flame resistance rating.

At 3:25 p.m. on 12-13-10, the facility failed to provide documentation as the flame resistance rating for the artificial Christmas Tree at the 4D nurse station. Staff 1 confirmed there was no documentation for the tree flame resistance rating.

At 3:57 p.m. on 12-14-10, the facility failed to provide documentation as the flame resistance rating for the decorations used to decorate the corridor door to room 2B181. The door was covered with the decoration from the top of the door to the bottom of the door. Staff 1 confirmed there was no documentation for the flame resistance rating for the door decoration.

At 4:00 p.m. on 12-14-10, the facility failed to provide documentation as the flame resistance rating for the decorations used to decorate the corridor door to room 2C210. The door was covered with the decoration from the top of the door to the bottom of the door. Staff 1 confirmed there was no documentation for the flame resistance rating for the door decoration.

At 9:00 a.m. on 12-15-10, the facility failed to provide documentation as the flame resistance rating for the artificial Christmas Tree at the Community Health Lobby. Staff 1 confirmed there was no documentation for the tree flame resistance rating.

Based on observation and interview, the facility failed to maintain the compressed gas cylinders as evidenced by unsecured compressed gas cylinders, and by a patient observed smoking with oxygen attached to their wheelchair. This affected 3 of 6 smoke compartments, and had the potential for damage to the cylinders and harm to patients.


NFPA 99 (1999 Edition) Chapter 12 Hospital Requirements

12-1 Scope. This chapter addresses safety requirements of hospitals.

NFPA 99 (1999 Edition) 12-3.8 Gas Equipment Requirements.
12-3.8.1 Patient. Equipment shall conform to requirements for patient equipment in Chapter 8.

NFPA 99 (1999 Edition) 8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).

(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.

NFPA 99 (1999 Edition) 8-3.1.11.2 (h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

NFPA 99 (1999 edition), 4-3.5.2.1(b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During the facility tour with Staff 1 between December 13 and 15, 2010, the facility compressed gas cylinders were observed.

At 9:35 a.m. on 12-13-10, there was an H cylinder of Forane 22 and an H cylinder of compressed nitrogen in the roof penthouse number 5 that were secured by a chain around the neck of each cylinder. Staff 1 confirmed the cylinders were not secured properly.

At 3:32 p.m. on 12-13-10, there was an upright unsecured E oxygen cylinder in Soiled Utility room with the door designation of NW4157. Staff 1 confirmed the cylinder was not secured.

At 3:52 p.m. on 12-13-10, there was an unsecured oxygen E cylinder lying on a tray beneath the crib Bed B in room 4C109. Staff 1 confirmed the cylinder was lying on the crib tray and was not secured.

At 10:05 a.m. on 12-14-10, in the Kitchen by the back dock, there were 2 H Carbon Dioxide cylinders loosely secured. Staff 2 confirmed the cylinders were not secured.

At 12:00 p.m. on 12-14-10, there was an unsecured upright E oxygen cylinder in the Cath Lab prep room. Staff 1 confirmed the cylinder was not secured.

At 12:45 p.m. on 12-14-10, in the 1st Floor Smoking Area, there was a female patient smoking with an oxygen tank attached to the back of her wheel chair. There were two other patients also observed smoking. Staff 3 removed the oxygen tank from the wheel chair. Staff 2, Staff 3 and the Team Leader observed the event.

Based on observation, the facility failed to maintain access to the medical gas shutoff valves as evidenced by access to a valve box that was obstructed. This affected one floor in the facility, and could result in a delay in accessing the emergency shut-off valve.

NFPA 99 (1999 Edition) 4-3.1.2.3 Gas Shutoff Valves. i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings:

During the facility tour with Staff 1 between December 13 and 15, 2010, the facility medical gas system was observed.

At 11:32 a.m. on 12-14-10, access to the PACU emergency shutoff valves for rooms 1-6 was blocked by a table in front of the box. Staff 1 confirmed a table obstructed the access to the shutoff valve.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment as evidenced by the failure to identify the purpose or use of electrical breakers, damaged electrical receptacles, a refrigerator that was plugged into a surge protector instead of directly into an electrical receptacle and the use of a multi-plug extension cord. This affected 6 of 6 facility floors and had the potential for a fire or electrical shock.

NFPA 70 (1999 Edition), article 110-12(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 70 (1999 Edition) 384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

NFPA 70 (1999 Edition), 400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:

(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

NFPA 70 (1999 Edition) 400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

NFPA 70 (1999 edition) Section 410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.



Findings:

During the facility tour with Staff 1 between December 13 and 15, 2010, the facility electrical wiring and equipment were observed.

At 10:02 a.m. on 12-13-10, there was a toaster and coffee maker plugged into a multi-plug extension cord in room 6D101. The extension cord was used to extend power the items, and was used in place of providing fixed electrical receptacles. Staff 1 confirmed the multi-plug adapter extension cord was in use.

At 10:58 a.m. on 12-13-10, in electrical panel LN6AA on unit 6D, breakers 37, 39 and 41 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

At 11:30 a.m. on 12-13-10, the electrical receptacle in the corridor adjacent to room 6B112 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 11:41 a.m. on 12-13-10, the electrical receptacle in the corridor adjacent to the room with the door labeled SE6183 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 1:25 p.m. on 12-13-10, the red electrical receptacle in the corridor adjacent to the room 5A101 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 1:59 p.m. on 12-13-10, the electrical receptacle adjacent to Bed B in room 5D109 was not flush with the wall. Staff 1 confirmed the receptacle was not flush with the wall.

At 2:24 p.m. on 12-13-10, the red electrical receptacle in the corridor adjacent to the room 5C109 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 2:30 p.m. on 12-13-10, electrical receptacle on the left wall of the unit 5C Soiled Utility room was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 2:38 p.m. on 12-13-10, the red electrical receptacle in the corridor adjacent to the room 5B108 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 2:47 p.m. on 12-13-10, there was an open junction box adjacent to the air duct in Electrical Room C on unit 5B. Staff 1 confirmed there was an open junction box.

At 2:59 p.m. on 12-13-10, there was an open junction box above the drop ceiling adjacent to room 4D127. Staff 1 confirmed there was an open junction box and had a staff member replace the cover.

At 3:00 p.m. on 12-13-10, the red electrical receptacle in the corridor adjacent to the room 4A101 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 3:05 p.m. on 12-13-10, the red electrical receptacle in room 4A120 and room 4A110 were damaged around the ground port. Staff 1 confirmed the receptacles were damaged around the ground port.

At 3:20 p.m. on 12-13-10, the electrical receptacle in the corridor adjacent to the room 4D124 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 3:25 p.m. on 12-13-10, the electrical receptacle adjacent to Bed B in room 4D114 was not flush with the wall. Staff 1 confirmed the receptacle was not flush with the wall.

At 9:58 a.m. on 12-14-10, the electrical receptacle in the Same Day Surgery nurse station identified as LN3B4 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 10:13 a.m. on 12-14-10, the electrical receptacle in the corridor adjacent to the room 3D103 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 10:20 a.m. on 12-14-10, the red electrical receptacle in 3D Nursery identified as LEC3A5 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 10:27 a.m. on 12-14-10, the red electrical receptacle in Labor and Delivery room 3C113, bed 5 receptacle #6 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 10:27 a.m. on 12-14-10, the red electrical receptacle in Labor and Delivery room 3C113, bed 6 receptacle #5 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 10:40 a.m. on 12-14-10, breakers 7 and 8 in panel ORP10 E6 were in the on position and marked as spares. Staff 1 confirmed the breakers were marked as spare and were in the on position.

At 11:31 a.m. on 12-14-10, the #3 red electrical receptacle in PACU for bed 4 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 12:45 p.m. on 12-14-10, in the Ultrasound Break Room SW1105B, there was a microwave, toaster and two coffee makers plugged into a surge protector and not directly into the wall.

At 4:08 p.m. on 12-14-10, the electrical receptacle in the corridor adjacent to the room 2B136 was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 4:10 p.m. on 12-14-10, the electrical receptacle in the corridor adjacent to Electrical Room G on the second floor was damaged around the ground port. Staff 1 confirmed the receptacle was damaged around the ground port.

At 8:55 a.m. on 12-15-10, there was a refrigerator plugged into a surge protector instead of directly into an electrical receptacle in room 2D150. Staff 1 confirmed the refrigerator was plugged into a surge protector instead of directly into an electrical receptacle.