HospitalInspections.org

The facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

On June 22 and 23 the surveyors, accompanied by the Director of Facilities Services, Faculties Supervisor, Electrician 2 staff and Maintenance Technician observed the following corridor doors were either wedged open, would not tightly close or not smoke resistant.

6th floor C Tower

Door C657 will not latch
Door C60658 will not latch
Door C654 will not latch

4th floor C and D Tower fire rated separation doors will not latch

3rd floor B Tower
Door 326 will not latch

2nd floor 2A

Door 23083A not smoke resistant four 1/4 inch holes went through the entire door around the corridor door handle.

Door A 215 no positive latching hardware installed.

1st floor

Door 12161 will not latch
Doors 15018 and 15502 chalked open with rubber stops

Doors to Special Procedures will not latch

Double doors marked 12097A to the main kitchen the smoke seals were torn/ripped

Pharmacy Storage supplies room was missing its self closing hardware

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

The facility did not keep exits readily accessible and unobstructed at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel." NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency". Section 7.1.10.2.1 "No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof."

On June 23, 2010 the surveyor, accompanied by the Facilities Supervisor and the Maintenance Technician observed storage of various Medical and Therapy Equipment and Medical Surgical Supplies stored within the exit corridors of the 2nd floor Surgery back hall corridor, 4th Floor 4 West corridor adjacent to the Isolation Room in the Psychiatric Unit and the 5th floor C Tower Acute Rehab Gym. The storage of equipment and medical supplies was reducing the corridor width and obstructing the exit access located in these locations.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and cause harm to the patients.

The facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

On June 22, 2010 the surveyor, accompanied by the Director of Facilities Services and Electrician 2 staff reviewed the facility's fire drill records. The surveyor noted there were no fire drill report for the 4th quarter 2009 third shift, this was a false alarm and the 1st Quarter 2010 third shift. No documentation was provided to the surveyor while on site that the fire drill was completed.

Failure to train and drill the staff on fire procedures will result in harm to the patients.

The facility failed to maintain the electric fire pump.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1, " Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." " NFPA 25, Chapter 5, Section 5-3.2.1 and Section 5-3.3.1 , requires weekly and annual testing of the fire pump. Section 5-3.2.4.1 Pump System Procedures (b) Check the pump packing glands for slight leaking.

On June 23, 2010 the surveyor, accompanied by the Director of Facilities Services and Electrician 2 observed the main fire pump. The main fire pump was leaking excessively a steady flow of water was leaking from what appeared to be the fire pump packing glands. The Electrician also turned on the fire pump manually and while it was running the fire pump packing glands continued to leak excessively.

Failure to maintain the fire pump could allow the fire pump to fail during a fire emergency. This could cause harm to the patients.


The facility failed to maintain the sprinkler heads.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..."

On June 22 and 23 the surveyors, accompanied by the Director of Facilities Services, Facilities Supervisor, Electrician 2 and the Maintenance Technician observed the sprinkler heads were either corroded had paint, grease and lint or lint on the sprinklers or missing escutcheon plates from the sprinklers in the following rooms or locations within the hospital.


6th Floor C Tower

Rooms C653, C654, C649, C645, C646, C637, C639, C652, 60663A

5th floor A Tower A 505

3rd floor Rooms 32134B, 32114, 32116,

2nd floor Rooms 22033

1st floor

Cardio Rehab, Housekeeping
Rooms 12108, 12120, Cardio Pulmonary Education, Adjacent to room 14013 in the corridor.
Main Kitchen cooking area

Failing to maintain sprinkler heads could allow a fire to burn longer before the sprinkler head will activate. This could cause harm to the patients.

The facility failed to provide a medical gas cylinder storage rooms free of combustible materials and failed to mount electrical light switches and receptacles five feet above the floor in the oxygen storage rooms.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (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. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

On June 22 and 23, the surveyors, accompanied by the Director of Facilities Services, Facilities Supervisor, Electricians and Maintenance Technician observed the oxygen storage rooms on floors one through six. Multiple oxygen storage locations throughout the hospital had storage of plastics, cardboard boxes etc within five feet of the oxygen bottles.

In addition,the following locations had oxygen storage next to or adjacent to light switches or receptacle wall outlets. The wall receptacles and light switches were approximately two to three and a half feet (3.5ft) above the floor

1. Room 4054A, 41061A, 41163, D 3054A, Labor and Delivery in the nursery.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients. Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.


The facility failed to secure medical gas and compressed gas cylinders.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."

On June 23, 2010 the surveyor accompanied by the Director of Facilities Services and Electrician 2 observed unsecured medical gas cylinders or helium cylinders in the following locations.

1. MRI Computer room Two helium tanks unsecured
2. Bio Engineering E tank unsecured

Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.


The facility failed to provide protection for the exterior oxygen cylinder storage.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. NFPA 99, Chapter 4, Section 4-3.5.2.2, (3) "Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter; cylinders stored in the open shall be protected against accumulations of ice or snow. In summer; cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail."

On June 23, 2010 the surveyor, accompanied by the Director of Facilities Services and Electrician 2 observed the exterior oxygen cylinder storage by the hospital helipad. A total of four H tanks were not protected by a sun shade.

Failing to protect exterior stored medical gas cylinders from rust, snow/ice or sun may cause harm to the patients.

The facility failed to provide battery operated emergency lighting in the operating rooms, anesthetizing locations.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2 "Electric wiring and equipment shall be in accordance with NFPA 70 National Electrical Code... Article 517 Health Care Facilities, Section 517-63 Grounded Power systems in Anesthetizing Locations. 517-63(a), 'Battery-Powered Emergency Lighting Units." "One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e)." NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.2.1.2, (5) Wiring in Anesthetizing Locations. (e) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, Section 700-12 (e).

On June 21, 2010 the surveyor accompanied by the Director of Facilities Services, and Electrician 2 staff had asked the Staff if the Operating Rooms in the Hospital had battery powered emergency lighting. The surveyor was advised none of the operating rooms were protected with battery powered emergency lighting.

Failing to provide battery-powered emergency lighting in the operating rooms will harm patients during a power outage and failure of the emergency generator.


The facility failed to test the operating room isolated electrical panels.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.3"Anesthetizing Locations, NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.3.4.2 Line Isolation Monitor tests. Line Isolation tests shall be preformed at intervals of not more than 12 months.

On June 22, 2010 the surveyor asked the Director of Facilities Services and Electricians staff if the facility had documentation on testing of the isolated electrical panels in the operating rooms? The staff could not provide any current documentation of the testing to the surveyor while on site.

Failure to test and document the isolated electrical panels could cause harm to the patients in an emergency.


The facility failed to allow access to the electrical equipment/panels.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

On June 23, 2010 the surveyor, accompanied by the Director of Facilities Services and Electrician 2 observed storage in front of the electrical panels located in the following locations.

1. 1st floor room 14016 and the Old ED by the South Entrance first floor. There were several boxes stored in front of the electrical panels.

2. 1st floor Womens Center, Infection Control tent stored in front of the electrical panels

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.


The facility failed to provide protection from electrical shock.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19-5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code. NEC, 1999, ARTICLE 110, SECTION 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

On June 22, 2010 the surveyor, accompanied by the Facilities Supervisor and Maintenance Technician observed the electrical panel located in the 6th floor C Tower room 60665 Panel 6chx had unused unprotected openings.

Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.


The facility failed to identify panel board circuits.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1."Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code.... " NEC, 1999, Article 384, Section 384-13 General "All panel board 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."

On July 23, 2010 the surveyor, accompanied by the Director of Facilities Services and Electrician 2 observed the circuit breaker panels located in the PBX Room did not have the breakers identified.

Failing to identified electrical circuits in an emergency could cause a fire or electrical shock, which may cause harm to patients.


The facility allowed the use of a multiple outlet adapters and extension cords.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

On June 22, and 23, 2010 the surveyor, accompanied by Director of Facilities services, Electrician 2 staff, Facility Supervisor and the Maintenance Technician observed the following locations had the use of multiple outlet adapters being connected together and extension cord were being used connected to appliances.

(Extension cords)

1. Associate Administrators Office 1st floor
2. Room IT 004 1st floor
3. Main Pharmacy 1st floor
4. 2nd floor Surgery Room 23052

Power strips plugged into another power strip

1. 5th floor A Tower Room 51167
2. 5th floor C tower Room 51227
3. 3rd floor A tower Room 31209
4. 3rd floor Cardio 32121

The use of multiple outlet adapters and extension cords could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.


The facility failed to provide a guard on the light bulb or bulbs.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

On June 22, and 23, the surveyor, accompanied by the Facility Supervisor Maintenance Technician, observed light bulbs located in the following locations were not protected from physical damage.

1. 5th Floor A Tower Room 51217A
2. B Tower 51167

4th floor

1. B Tower Rooms 41107 and 41153

3rd floor

1. A Tower Room 31165
2. B Tower 31107

Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.

The facility failed to test the fire fighter service, Monthly, on all the elevators.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.3, "Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4. Section 9.4.6 "Elevator Testing." "Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators."

On June 22, 2010 the surveyor accompanied by the Director of Facilities Services and Electrician 2 staff asked for documentation to review the monthly elevator fire fighter service test documentation. The facility did not test the fire fighter service on a monthly schedule. No documentation of testing was given to the surveyor while on site.

Fire fighter service is critical during an emergency and failing to test the elevators which may cause harm to the patients, staff and visitors.

The facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

On June 22 and 23 the surveyors, accompanied by the Director of Facilities Services, Faculties Supervisor, Electrician 2 staff and Maintenance Technician observed the following corridor doors were either wedged open, would not tightly close or not smoke resistant.

6th floor C Tower

Door C657 will not latch
Door C60658 will not latch
Door C654 will not latch

4th floor C and D Tower fire rated separation doors will not latch

3rd floor B Tower
Door 326 will not latch

2nd floor 2A

Door 23083A not smoke resistant four 1/4 inch holes went through the entire door around the corridor door handle.

Door A 215 no positive latching hardware installed.

1st floor

Door 12161 will not latch
Doors 15018 and 15502 chalked open with rubber stops

Doors to Special Procedures will not latch

Double doors marked 12097A to the main kitchen the smoke seals were torn/ripped

Pharmacy Storage supplies room was missing its self closing hardware

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

The facility did not keep exits readily accessible and unobstructed at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel." NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency". Section 7.1.10.2.1 "No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof."

On June 23, 2010 the surveyor, accompanied by the Facilities Supervisor and the Maintenance Technician observed storage of various Medical and Therapy Equipment and Medical Surgical Supplies stored within the exit corridors of the 2nd floor Surgery back hall corridor, 4th Floor 4 West corridor adjacent to the Isolation Room in the Psychiatric Unit and the 5th floor C Tower Acute Rehab Gym. The storage of equipment and medical supplies was reducing the corridor width and obstructing the exit access located in these locations.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and cause harm to the patients.

The facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

On June 22, 2010 the surveyor, accompanied by the Director of Facilities Services and Electrician 2 staff reviewed the facility's fire drill records. The surveyor noted there were no fire drill report for the 4th quarter 2009 third shift, this was a false alarm and the 1st Quarter 2010 third shift. No documentation was provided to the surveyor while on site that the fire drill was completed.

Failure to train and drill the staff on fire procedures will result in harm to the patients.

The facility failed to maintain the electric fire pump.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1, " Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." " NFPA 25, Chapter 5, Section 5-3.2.1 and Section 5-3.3.1 , requires weekly and annual testing of the fire pump. Section 5-3.2.4.1 Pump System Procedures (b) Check the pump packing glands for slight leaking.

On June 23, 2010 the surveyor, accompanied by the Director of Facilities Services and Electrician 2 observed the main fire pump. The main fire pump was leaking excessively a steady flow of water was leaking from what appeared to be the fire pump packing glands. The Electrician also turned on the fire pump manually and while it was running the fire pump packing glands continued to leak excessively.

Failure to maintain the fire pump could allow the fire pump to fail during a fire emergency. This could cause harm to the patients.


The facility failed to maintain the sprinkler heads.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..."

On June 22 and 23 the surveyors, accompanied by the Director of Facilities Services, Facilities Supervisor, Electrician 2 and the Maintenance Technician observed the sprinkler heads were either corroded had paint, grease and lint or lint on the sprinklers or missing escutcheon plates from the sprinklers in the following rooms or locations within the hospital.


6th Floor C Tower

Rooms C653, C654, C649, C645, C646, C637, C639, C652, 60663A

5th floor A Tower A 505

3rd floor Rooms 32134B, 32114, 32116,

2nd floor Rooms 22033

1st floor

Cardio Rehab, Housekeeping
Rooms 12108, 12120, Cardio Pulmonary Education, Adjacent to room 14013 in the corridor.
Main Kitchen cooking area

Failing to maintain sprinkler heads could allow a fire to burn longer before the sprinkler head will activate. This could cause harm to the patients.

The facility failed to provide a medical gas cylinder storage rooms free of combustible materials and failed to mount electrical light switches and receptacles five feet above the floor in the oxygen storage rooms.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (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. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

On June 22 and 23, the surveyors, accompanied by the Director of Facilities Services, Facilities Supervisor, Electricians and Maintenance Technician observed the oxygen storage rooms on floors one through six. Multiple oxygen storage locations throughout the hospital had storage of plastics, cardboard boxes etc within five feet of the oxygen bottles.

In addition,the following locations had oxygen storage next to or adjacent to light switches or receptacle wall outlets. The wall receptacles and light switches were approximately two to three and a half feet (3.5ft) above the floor

1. Room 4054A, 41061A, 41163, D 3054A, Labor and Delivery in the nursery.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients. Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.


The facility failed to secure medical gas and compressed gas cylinders.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."

On June 23, 2010 the surveyor accompanied by the Director of Facilities Services and Electrician 2 observed unsecured medical gas cylinders or helium cylinders in the following locations.

1. MRI Computer room Two helium tanks unsecured
2. Bio Engineering E tank unsecured

Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.


The facility failed to provide protection for the exterior oxygen cylinder storage.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. NFPA 99, Chapter 4, Section 4-3.5.2.2, (3) "Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter; cylinders stored in the open shall be protected against accumulations of ice or snow. In summer; cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail."

On June 23, 2010 the surveyor, accompanied by the Director of Facilities Services and Electrician 2 observed the exterior oxygen cylinder storage by the hospital helipad. A total of four H tanks were not protected by a sun shade.

Failing to protect exterior stored medical gas cylinders from rust, snow/ice or sun may cause harm to the patients.

The facility failed to provide battery operated emergency lighting in the operating rooms, anesthetizing locations.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2 "Electric wiring and equipment shall be in accordance with NFPA 70 National Electrical Code... Article 517 Health Care Facilities, Section 517-63 Grounded Power systems in Anesthetizing Locations. 517-63(a), 'Battery-Powered Emergency Lighting Units." "One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e)." NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.2.1.2, (5) Wiring in Anesthetizing Locations. (e) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, Section 700-12 (e).

On June 21, 2010 the surveyor accompanied by the Director of Facilities Services, and Electrician 2 staff had asked the Staff if the Operating Rooms in the Hospital had battery powered emergency lighting. The surveyor was advised none of the operating rooms were protected with battery powered emergency lighting.

Failing to provide battery-powered emergency lighting in the operating rooms will harm patients during a power outage and failure of the emergency generator.


The facility failed to test the operating room isolated electrical panels.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.3"Anesthetizing Locations, NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.3.4.2 Line Isolation Monitor tests. Line Isolation tests shall be preformed at intervals of not more than 12 months.

On June 22, 2010 the surveyor asked the Director of Facilities Services and Electricians staff if the facility had documentation on testing of the isolated electrical panels in the operating rooms? The staff could not provide any current documentation of the testing to the surveyor while on site.

Failure to test and document the isolated electrical panels could cause harm to the patients in an emergency.


The facility failed to allow access to the electrical equipment/panels.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

On June 23, 2010 the surveyor, accompanied by the Director of Facilities Services and Electrician 2 observed storage in front of the electrical panels located in the following locations.

1. 1st floor room 14016 and the Old ED by the South Entrance first floor. There were several boxes stored in front of the electrical panels.

2. 1st floor Womens Center, Infection Control tent stored in front of the electrical panels

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.


The facility failed to provide protection from electrical shock.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19-5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code. NEC, 1999, ARTICLE 110, SECTION 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

On June 22, 2010 the surveyor, accompanied by the Facilities Supervisor and Maintenance Technician observed the electrical panel located in the 6th floor C Tower room 60665 Panel 6chx had unused unprotected openings.

Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.


The facility failed to identify panel board circuits.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1."Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code.... " NEC, 1999, Article 384, Section 384-13 General "All panel board 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."

On July 23, 2010 the surveyor, accompanied by the Director of Facilities Services and Electrician 2 observed the circuit breaker panels located in the PBX Room did not have the breakers identified.

Failing to identified electrical circuits in an emergency could cause a fire or electrical shock, which may cause harm to patients.


The facility allowed the use of a multiple outlet adapters and extension cords.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

On June 22, and 23, 2010 the surveyor, accompanied by Director of Facilities services, Electrician 2 staff, Facility Supervisor and the Maintenance Technician observed the following locations had the use of multiple outlet adapters being connected together and extension cord were being used connected to appliances.

(Extension cords)

1. Associate Administrators Office 1st floor
2. Room IT 004 1st floor
3. Main Pharmacy 1st floor
4. 2nd floor Surgery Room 23052

Power strips plugged into another power strip

1. 5th floor A Tower Room 51167
2. 5th floor C tower Room 51227
3. 3rd floor A tower Room 31209
4. 3rd floor Cardio 32121

The use of multiple outlet adapters and extension cords could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.


The facility failed to provide a guard on the light bulb or bulbs.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

On June 22, and 23, the surveyor, accompanied by the Facility Supervisor Maintenance Technician, observed light bulbs located in the following locations were not protected from physical damage.

1. 5th Floor A Tower Room 51217A
2. B Tower 51167

4th floor

1. B Tower Rooms 41107 and 41153

3rd floor

1. A Tower Room 31165
2. B Tower 31107

Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.

The facility failed to test the fire fighter service, Monthly, on all the elevators.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.3, "Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4. Section 9.4.6 "Elevator Testing." "Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators."

On June 22, 2010 the surveyor accompanied by the Director of Facilities Services and Electrician 2 staff asked for documentation to review the monthly elevator fire fighter service test documentation. The facility did not test the fire fighter service on a monthly schedule. No documentation of testing was given to the surveyor while on site.

Fire fighter service is critical during an emergency and failing to test the elevators which may cause harm to the patients, staff and visitors.