HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the walls and ceilings. This affected two of six floors in the Main Building and could result in the spread of smoke or fire to other locations in the event of a fire.

Findings:

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

12/4/17

1. At 11:29 a.m., there were two approximately 18 inch by 18 inch unsealed penetrations in the ceiling in Room 3S-9. Room 3S-9 was located on the 3rd floor. Upon interview, SAA stated that the dialysis room was being updated.

12/5/17

2. At 10:00 a.m., there were two approximately 3 inch by 2 inch unsealed penetrations with Internet and phone cables protruding out of the wall in the back of the the Admitting department. The penetrations were near the copier machine. The Admitting department was located on the 1st floor. This finding was confirmed by SAA and ES2.

Based on observation and interview, the facility failed to maintain the means of egress. This was evidenced by the passageway that was not continuously maintained free of all obstruction to full use. This affected one of six floors in the Main Building and could result in a delay in evacuation in the event of an emergency.

Findings:

During a tour of the facility with staff, the means of egress was observed.

12/5/17

1. At 9:26 a.m., the passageway outside the exit door in the Emergency Room Department had an approximately 2 feet wide by 4 feet tall plastic sign. The sign was placed directly outside the exit door and obstructed the pathway. The exit was the back exit of the Emergency Room Department which lead to Civic Drive. The Emergency Room Department was located on the 1st floor. This finding was confirmed by SAA, SSS, and ES2.

Based on observation and interview, the facility failed to maintain their fire doors. This was evidenced by one fire door that failed to latch. This could result in the spread of smoke and fire in the event of a fire. This affected one of six floors in the Main Building.

NFPA 101, Life Safety Code, 2012 Edition
19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

19.7.6 Maintenance and Testing. See 4.6.12

NFPA 101, Life Safety Code 2012 Edition
4.6.12 Maintenance, Inspection, and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

7.2.1.8 Self-Closing Devices.
7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with
7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing,
or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National
Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the holdopen mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair.

Findings:

During the facility tour with Staff, the fire doors were observed.

12/5/17

1. At 10 a.m., the 1-hour fire door to the Core Storage located in OR on the First Floor failed to latch when manually tested. The 1-hour fire door was held open to the fullest extent and released. Two attempts were made. Upon interview the ES 3 staff stated there was a loose screw.

Based on observation, the facility failed to maintain the battery back-up combination emergency exit sign with lights. This was evidenced by the emergency exit sign/light combo that failed to illuminate when tested. This affected one of six floors in the Main Building and Building 04. This could result in delayed evacuation in the event of an emergency.


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

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

Findings:

During a tour of the facility with staff, the battery back-up combination emergency exit sign with light was observed.

12/5/17

1. At 11:40 a.m., the battery back-up emergency exit sign with light combo located in the Hydrotherapy room in the Rehab department was observed. The light to the battery back-up emergency exit sign/light combo failed to illuminate when test button was depressed by staff. The Hydrotherapy room was located on the Ground floor.

Based on observation and interview, the facility failed to maintain the installation of their exit signs. This was evidenced by directional indicator signs that were pointed to a non-exit. This could delay egress in the event of an emergency. This affected two of six floors in the Main Building and Building 04.

NFPA 101, Life Safety Code, 2012 Edition

19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

7.10 Marking of Means of Egress.
7.10.1 General.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 43.

7.10.2 Directional Signs.
7.10.2.1* A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
7.10.2.2 Directional exit signs shall be provided within horizontal components of the egress path within exit enclosures as required by 7.10.1.2.2.


Findings:

During a tour of the facility and interview with staff, the exit signs were observed and staff interviewed.

12/4/17

1. At 11:06 a.m., the exit sign near Room 5W-3 had the right directional indicator arrow illuminated and pointed to a non-direction of travel to the nearest exit. The arrow was pointed to the wall. The exit sign was located on the 5th floor. Upon interview, ES2 stated that the cover to the arrow fell off.

12/5/17

2. At 11:40 a.m., the exit sign above the South Stairwell door had the left directional indicator arrow illuminated and pointed to a non-direction of travel to the nearest exit. The arrow was pointed to the wall. The exit sign was located on the Ground floor. This finding was confirmed by SAA, ES2, and SSS.



31070

12/6/17

3. At 11:42 a.m., the emergency lighting exit combo located in Building 04 Conference room failed to illuminate when the ES 1 staff pressed the test button.

4. At 11:43 a.m., the emergency lighting exit combo located in Building 04 Employee Lounge failed to illuminate when the ES 1 staff pressed the test button.

5. At 11:47 a.m., the emergency lighting exit combo located in Building 04 near the RN Interview room failed to illuminate when the ES 1 staff pressed the test button.

6. At 11:51 a.m., the emergency lighting exit combo located in Building 04 above the Main Entrance failed to illuminate when the ES 1 staff pressed the test button.

Based on observation and interview, the facility failed to ensure the Tamper Valve for the automatic sprinkler system activated an audible and visual trouble signal to the annunciator panel, fire alarm control panel, and the monitoring central station when tested. This could result in the tamper valve being closed without staff knowledge and the potential for sprinkler system failure. This affected all residents in six of six floors in the Main Building.

NFPA 101, Life Safety Code, 2012 Edition
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, waterflow alarms shall be transmitted to an approved, proprietary alarm-receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.3

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.4 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
Table 14.4.2.2
(i) Initiating devices, supervisory
(1) Control valve switch Valve shall be operated and signal receipt shall be verified to be within the
first two revolutions of the handwheel or within one-fifth of the travel distance, or per the manufacturer ' s published instructions

Findings:

During fire alarm testing with Staff, the Tamper Valve for the automatic sprinkler system was observed.

12/4/17

1. At 11:20 a.m., the Tamper Valve for the automatic sprinkler system located in the Third Floor Stairwell failed to send an audible and visual trouble signal to the annunciator panel located at the Nurses Station when the ES 3 staff turned the handwheel. There was no notification to staff that the water valve was turned off to the sprinkler system during fire alarm testing.

2. 11:34 a.m., the Tamper Valve for the automatic sprinkler system located in the Third Floor Stairwell was retested. The ES 3 staff turned the handwheel, and there was a audible signal received at the annunciator panel for 5 seconds and then it shut off but there was no visual signal received. Upon interview the ES 3 stated they were not sure what was wrong with the panel. There was an audible and visual signal received at the fire alarm control panel located at the PBX station and the monitoring central station.

Based on observation and interview, the facility failed to maintain the sprinkler system and components. This was evidenced by the failure to maintain the sprinkler heads. This affected two of six floors in the Main Building and could result in an ineffective operation of the automatic sprinkler system in the event of a fire.


NFPA 101 Life Safety Code, 2012 Edition
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.

9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems


NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

6.2.7 Escutcheons and Cover Plates.
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.


NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).




Findings:

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

12/4/17

1. At 11:52 a.m., one of two sprinkler in Kitchen near Room 3N-43 had debris on the deflector. The Kitchen was located on the 3rd floor. This finding was confirmed by SAA and ES2.

2. At 11:55 a.m., two of five sprinklers in Room 3N-43 had debris build up. Room 3N-43 was located on the 3rd floor. This finding was confirmed by SAA and ES2.

3. At 11:56 a.m., the sprinkler in the alcove near 3N-40 had debris build up. Room 3N-40 was located on the 3rd floor. This finding was confirmed by SAA and ES2.

12/5/17

4. At 10:32 a.m., the sprinkler in the Dietician office was missing an escutcheon cover. The Dietician office was located on the Ground floor. This finding was confirmed by ES2.



31070

5. At 10:41 a.m., the escutcheon ring located in the Sterile Processing on the First Floor was not flush to the ceiling wall and the sprinkler had retracted down. The ES 3 staff tried to push the retracted sprinkler back into place but was unable to.

6. At 11:09 a.m., the escutcheon cover for the sprinkler in the Respiratory Therapy Manager office did not have the correct size. The escutcheon cover has an approximately 3 inch long by 1/4 inch wide penetration at one side of the escutcheon. The Respiratory Therapy Manager office was located on the Ground floor. This finding was confirmed by ES2.

7. At 2:00 p.m., the sprinkler along the corridor near the Nursing Staff office had debris build up. The Nursing Staff office was located on the Ground floor. This finding was confirmed by ES2 and SAA.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by a fire extinguisher that was obstructed from access, by a fire extinguisher that was mounted greater than 60 inches from floor level, and by an unsecured fire extinguisher. This affected two of six floors in the Main Building. This could result in staff's inability to readily access the fire extinguishers in the event of a fire and could result in the fire extinguisher being knocked over and damaged.


NFPA 101, Life Safety Code, 2012 Edition

19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

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


NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition

6.1.3 Placement.
6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.

6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses
6.1.3.5 Wheeled fire extinguishers shall be located in designated locations.
6.1.3.6 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed for this problem.
6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.
6.1.3.8 Installation Height.
6.1.3.8.1 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.
6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm).


Findings:

During a tour of the facility and interview with staff, the portable fire extinguishers were observed and staff was interviewed.

12/4/17

1. At 2:01 p.m., the access to the fire extinguisher in the Labor and Delivery Operating Room 1 was obstructed by a linen hamper with an instrument tray placed on top of the hamper. Labor and Delivery was located on the 2nd floor. This finding was confirmed by ES2.

12/5/17

2. At 9:20 a.m., the extinguisher in the ED Clinic was mounted at approximately 71 inches from floor level to the top handle. The ED Clinic was located on the 1st floor. This was confirmed by ES2.

3. At 10:05 a.m., the fire extinguisher in the Medical Records department was observed stored freestanding and unsecured. The Medical Records department was located on the 1st floor. Upon interview, SSS stated that they are in the process of removing the fire extinguisher because there was another fire extinguisher close by.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke and/or fire. This was evidenced by doors that failed to latch. This affected three of six floors in the Main Building, and could result in the passage smoke and flames in the event of a fire.


Findings:

During a tour of the facility with staff, the corridor doors were observed and staff interviewed.

12/4/17

1. At 10:39 a.m., the door to the Electrical room near Room 6W-7 was equipped with a self-closing device. The door failed to latch when tested. The Electrical room was located on the 6th floor. This finding was confirmed by ES2 and SAA.

2. At 10:50 a.m., the door to the Electrical room near the Employee Lounge was equipped with a self-closing device. The door failed to latch when tested several times. The Electrical room was located on the 5th floor. This finding was confirmed by ES2 and SAA.

3. At 1:40 p.m., the door to the Nurse Director office near Room 2S-34 was equipped with a self-closing device. The door failed to latch when tested several times. The Nurse Director office was located on the 2nd floor. This finding was confirmed by ES2 and SAA.

4. At 1:43 p.m., the door to the Storage room near Room 2S-32 was equipped with a self-closing device. The door failed to latch when tested several times. The Storage room was located on the 2nd floor. This finding was confirmed by ES2 and SAA.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by an unsealed penetration in a smoke barrier wall. This could result in the spread of smoke and fire in the event of a fire, and increase the risk of injury to all residents and staff. This affected one of six floors in the Main Building.

NFPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(ac).
(B) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.


Findings:

During the facility tour with Staff, the smoke barrier walls were observed.

12/5/17

1. At 11:45 a.m., there was an approximately 12 by 8 circular penetration around eight pipes in the smoke barrier wall located on the 3rd Floor near 3 North Nursing Station that ran through the wall to the other side. This finding was confirmed by ES 1 and ES 3 staff.

Based on observation and interview, the facility failed to maintain their fire doors. This was evidenced by a smoke barrier door that was not clear of obstructions. This could result in delayed evacuation in the event of an emergency and affected one of six floors in the Main Building.


NFPA 101, Life Safety Code, 2012 Edition
19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8 Self-Closing Devices.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.

7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

7.2.1.15.6 Door assemblies shall be visually inspected from both sides of the opening to assess the overall condition of the assembly.

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


Findings:

During a tour of the facility with staff, the smoke barrier door was observed.

12/4/17

1. At 2:07 p.m., the left leaf to the double fire rated smoke barrier doors in the Special Care Nursery had two work stations parked in front of the door. The two work stations were directly in front of the push bar. The Special Care Nursery was located on the 2nd floor. The finding was confirmed by SAA and ES2.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by circuit breakers that were not legibly identified to specific purpose or use, by receptacle faceplates that were not maintained, and by electrical panels that were obstructed from access. This affected five of six floors in the Main Building. This could result in the ignition of an electrical fire, could result in delay of access, and could result in staff inability to identify the circuit breaker in the event of an emergency.


NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.


NFPA 70, National Electrical Code, 2011 Edition
314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminaire canopy, except where the installation complies with 410.24(B).
406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.
110.22 Identification of Disconnecting Means.
(A) General. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved. 408.4 Field Identification Required.
(A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy.
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.
(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater.In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels


Findings:

During a tour of the facility and interview with staff, the electrical equipment were observed and staff was interviewed.

12/4/17

1. At 11:11 a.m., the electrical panel in Electrical room 4 West had circuit breaker number 12 that was not labeled and not identified on the directory list. The circuit breaker was in the "ON" position. The electrical panel room was located near the elevator on the 4th floor. Upon interview, ES2 stated that they were unsure what it served.

2. At 11:29 a.m., there were approximately six electrical outlets that were missing faceplates and some with wires exposed in Room 3S-9. Room 3S-9 was located on the 3rd floor. Upon interview, SAA stated that the dialysis room was being updated.

3. At 11:42 a.m., the electrical panel "Panel 1C3E" had circuit breakers number 14 and 23 not labeled and not identified on the directory list. The circuit breakers were in the "ON" position. The electrical panel was located on the 3rd floor. Upon interview, ES2 stated that they were unsure what they served.

4. At 11:50 a.m., the electrical panel "Panel 1B1J" had circuit breaker number 6 not labeled and not identified on the directory list. The circuit breaker was in the "ON" position. The electrical panel was located on the 3rd floor near Room 3N-41. This finding was confirmed by ES2.

5. At 1:00 p.m., the electrical panel "Panel 1C8" was obstructed by a 6 foot tall laundry cart. The laundry cart was parked directly in front of the panel. ES2 moved the cart to gain access to the panel. The electrical panel was located on the 2nd floor.

6. At 2:11 p.m., the electrical panel "Panel 1A2A" was obstructed by a 6 foot tall linen cart. The linen cart was parked directly in front of the panel. Staff moved the cart to gain access to the panel. The electrical panel was located on the 2nd floor near Room 2W-17.

7. At 2:12 p.m., the electrical panel "Panel 1A2A" had circuit breakers number 27, 28, and 30 not labeled and identified on the directory list as "used". The circuit breakers were in the "ON" position. The electrical panel was located on the 2nd floor near Room 2W-17. Upon interview, ES2 stated that they were unsure what they were used for.

12/5/17

8. At 9:08 a.m., the electrical panel had circuit breaker number 28 not labeled and not identified on the directory list. The circuit breaker was in the "ON" position. The electrical panel was near the Operating room back hallway on the 1st floor. This finding was confirmed by ES2.

9. At 9:18 a.m., the electrical panel "Panel 1C3F" had circuit breaker number 40 not labeled and not identified on the directory list. The circuit breaker was in the "ON" position. The electrical panel was located on the 1st floor near Room 24. This finding was confirmed by ES2.

10. At 10:16 a.m., the faceplate for the emergency receptacle outlet in the Surgery Lounge was not flush with wall. The Surgery Lounge was located on the 1st floor. This finding was confirmed by SAA and ES2.

11. At 10:36 a.m., the electrical panel "3D1" was obstructed by a printer. The printer was placed in front of the panel access door. ES2 moved the printer to gain access to the panel. The electrical panel was in the Sterile Processing department in the Manager's office. The Sterile Processing department was located on the Ground floor.

12. At 10:38 a.m., the electrical panel "3D1" had combined circuit breakers number 37/39/41 not labeled and not identified on the directory list. The circuit breakers were in the "ON" position. The electrical panel was in the Sterile Processing department in the Manager's office. The Sterile Processing department was located on the Ground floor. This finding was confirmed by ES2.

Based on observation, the facility failed to maintain the medical gas system. This was evidenced by a piped-in medical gas valve box that was obstructed. This affected one of six floors in the Main Building, and could result in staff's inability to readily access the shut-off valves in the event of an emergency.


NFPA 99, Health Care Facilities Code, 2012 Edition
5.1.4.8.4 Zone valve boxes shall be installed where they are visible and accessible at all times.


Findings:

During a tour of the facility, the piped-in medical gas valve box was observed.

12/4/17

1. At 1:53 p.m., the medical gas shut off valves near the OBPACU was obstructed by a moving work station. The moving work station was approximately 5 feet tall and was parked in front of the shut off valves. The OBPACU was located on the 3rd floor. This finding was confirmed by SAA.

Based on observation and interview, the facility failed to maintain the storage of oxygen gas cylinders. This was evidenced by cylinders that were not supported in a cylinder stand or cart, by storage of combustible materials near the cylinders, and by electric wall switches installed less than 5 feet above the floor in the Oxygen Storage room. This could result in damage to the medical gas cylinders and could result in the increased risk of fire. This affected four of six floors in the Main Building.


NFPA 99, Health Care Facilities Code, 2012 Edition

11.3 Cylinder and Container Storage Requirements.
11.3.1* Storage for nonflammable gases equal to or greater than 85 m3 (3000 ft3) at STP shall comply with 5.1.3.3.2 and 5.1.3.3.3.
5.1.3.3.2* Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:
(1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the location on hand trucks complying with 11.4.3.1.1.
(2) They shall be secured with lockable doors or gates or otherwise secured.
(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits.
(4) If indoors, they shall be constructed and use interior finishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating.
(5)*They shall be compliant with NFPA 70, National Electrical Code, for ordinary locations.
(6) They shall be heated by indirect means (e.g., steam, hot water) if heat is required.
(7) They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty.
(8)*They shall be supplied with electrical power compliant with the requirements for essential electrical systems as described in Chapter 6.
(9) They shall have racks, shelves, and supports, where provided, constructed of noncombustible materials or limited-combustible materials.
(10) They shall protect electrical devices from physical damage.

11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour

11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.


Findings:

During a tour of the facility and interview with staff, the oxygen storage locations were observed and staff interviewed.

12/4/17

1. At 11:18 a.m., the oxygen storage location was observed. There were four partial full E-cylinders and five E-full cylinders stored approximately 18 inches from the light switch. The light switch was installed approximately 4 feet above the floor. The oxygen cylinders were stored in the Clean Utility room near Room 4W-4 located on the 4th floor. This finding was confirmed by SAA and ES2.

2. At 11:31 a.m., the oxygen storage location was observed. There were two partial full E-cylinders and four full E-cylinders stored approximately 18 inches from the light switch. The light switch was installed approximately 4 feet above the floor. The oxygen cylinders were stored in the Biohazard room near Room 3S-8 located on the 3rd floor. This finding was confirmed by SAA and ES2.



31070

3. At 2:07 p.m., the Oxygen Storage room located on the Second Floor across from Room 2W-23 had a oxygen storage rack that contained seven full E-Oxygen cylinders stored directly under the light switch. The light switch was installed approximately 4 feet 3 inches above the floor.

4. At 2:12 p.m., the Oxygen Storage room located on the Second Floor across from Room 2W-21 had a oxygen storage rack that contained one empty E-Oxygen cylinder stored directly under the light switch. The light switch was installed approximately 4 feet 2 inches above the floor.


12/5/17

5. At 11:22 a.m., the oxygen storage location was observed. There was one empty E-cylinder and one air compressor placed laying on top of four air compressors, four empty E-cylinders, and four nitrous oxide cylinders. There was one air compressor placed laying on top of two empty E-cylinders, eight nitrous oxide cylinders, and two air compressors. There was also one nitrous oxide placed laying on top of six empty E-cylinders, five carbon dioxide, and one air compressor.

The oxygen Storage location was also observed to have combustible materials. There were combustible materials stored within 12 inches from the cylinders. There were approximately three dozen cardboard boxes of respiratory supplies and three shelving of respiratory supplies.

The oxygen storage location was in the Respiratory Care Storage room South on the Ground floor. Upon interview, the DOR stated that the cylinders were just moved into the storage from the outside due to construction.

Based on observation, the facility failed to maintain the hyperbaric room. This was evidenced by the failure to provide precautionary signage at the chamber entrance. This affected one of four floors in the Outpatient Services- Hyperberic Medicine. This could result in the increased risk of fire.

NFPA 99, Health Care Facilities Code, 2012 Edition
14.2.6.1 Signs prohibiting the introduction of flammable liquids, gases, and other articles not permitted by this chapter into the chamber shall be posted at the chamber entrance(s).

Findings:

During a tour of the facility with staff, the hyperbaric chamber entrance was observed.

12/6/17

1. At 12:22 p.m., there was no sign prohibiting the introduction of flammable liquids, gases, and other articles not permitted observed at the hyperbaric chamber entrance. The chamber entrance had a sign that read "OXYGEN IN USE, NO SMOKING". This finding was confirmed by the HSC.