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

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "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 19. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed the corridor doors or elevator doors would not tightly close when tested or were not smoke resistant. The following corridor or elevator doors listed below are by the numbers posted on the these doors.

1. IT room, room VLH 1018
2. Lab hall next to Pathology VLH 2198
3. LHH 2710 2nd floor door knob missing
4. Elevator doors CTR 367 smoke seals torn
5. Elevator doors CTR 290 by Surgery ICU seals torn
6. Elevator doors CTR 575 seals torn
7. CTR 518 5th floor
8. Room 625 the door closure arm was taken off of the door assembly to the room
9. Elevators by the 6th floor Patient Visitors was missing the smoke seal.
10. VLH 750 7th floor
11. Elevator doors CTR 476 Center Tower
12. Radiology double doors North side missing smoke seals.
13. Elevator doors marked #9
14. Elevator doors VLH 1031
15. Satellite Pharmacy dutch door was missing the astragal/smoke seal on corridor door.

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

The facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles. Section A-8.3.4.1 The clearance for proper operation of smoke doors is defined as 1/8 inch.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6. ( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3, "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Section 7.2.1.8.1 (1) "Upon release of the hold-open mechanism, the door becomes self-closing."

On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed the he smoke barrier doors either did not close all the way when tested or there was more than an 1/8 inch gap between the doors when closed some smoke seals worn torn, ripped or missing.

1. Smoke barrier doors CTR -142/143
2. Smoke barrier doors VLH 2306
3. Emergency Department 2003 East/West
Note it was also observed these doors are on 15 second release on alarm the sign was not posted on the doors.
4. Smoke barrier doors VLH 2178
5. Smoke barrier doors VLH 679
6. Smoke barrier doors VLH 561-1
7. Smoke barrier doors CTR 437 and 461
8. Smoke doors by Volunteer Services storage

Failure to properly adjust or repair the smoke doors could cause harm to the patients. Non closing smoke doors will allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

The facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

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..."

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.1.5, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."


On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed Escutcheon plates missing from the sprinkler assembly or the sprinklers had either lint, lint and grease, paint or was corroded in the following locations in the building.


Escutcheon plates missing:

1. VLH 115-2 Clinical education
2. VLH 1113 Security Director's office
3. ELH 650 ELH office
4. CNO office
5. VLH 1085 Admin IDF
6. Main Chapel CTR 102
7. Department Supply Chain
8. Managers office Environmental Services office
9. Outside first floor corridor by the Elevators in the Women's Center
10. Outside of the corridor of the Volunteer Services Department.
11. North Stairwell by LH 706
12. VLH 456, 553 and 644

Lint, lint and grease, paint or corroded sprinkler

1. Main Kitchen and dining room and Java Junction
2. PACU Lint on sprinkler (s)
3. Corroded sprinkler apparent by the green color on the entire sprinkler on the 5 th floor stairwell landing North East side of the building.

Failing to maintain sprinkler heads could allow a fire to burn longer before the sprinkler head will activate. Sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

The facility failed to provide a medical gas cylinder storage room free of combustible materials.

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..."

On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed oxygen storage locations in the building. The oxygen bottles were being stored next to combustibles in the Clean utility rooms/Medical supply storage rooms or in the following locations:

In addition, these areas did not have signs posted to indicating which oxygen bottle racks were the empty or full bottles.

1. VLH 2051 by PACU
2. CTR 320
3. CTR 259
4. CTR 275
5. CTR 508
6. CTR 408
7. CTR 418
8. Exterior main oxygen storage supply no signs posted empty or full.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.

The facility allowed the use of multiple outlet adapters

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 November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed the use of a multiple outlet adapters two U.L. listed power strips being connected together into one receptacle outlet in the following locations:

1. Audiology room in the Women's Center
2. 1st floor room DCH 1072
3. Wound Center

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


The facility failed to provide or replace broken/cracked receptacle face plates.

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 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."

On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed the receptacle face plates where not installed or were broken in the following areas:

1. Bio-med 1157
2. Housekeeping room ULH 2061

Failing to repair or replace missing or broken receptacle face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. A fire in the facility may cause harm to the patients.


The facility failed to provide 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, auxillary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed the following electrical J boxes were missing the covers on the boxes:

1. VLH 459 Electrical room
2. ED 2904 Electrical room
3. VLH 642 Electrical room

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

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

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "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 19. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed the corridor doors or elevator doors would not tightly close when tested or were not smoke resistant. The following corridor or elevator doors listed below are by the numbers posted on the these doors.

1. IT room, room VLH 1018
2. Lab hall next to Pathology VLH 2198
3. LHH 2710 2nd floor door knob missing
4. Elevator doors CTR 367 smoke seals torn
5. Elevator doors CTR 290 by Surgery ICU seals torn
6. Elevator doors CTR 575 seals torn
7. CTR 518 5th floor
8. Room 625 the door closure arm was taken off of the door assembly to the room
9. Elevators by the 6th floor Patient Visitors was missing the smoke seal.
10. VLH 750 7th floor
11. Elevator doors CTR 476 Center Tower
12. Radiology double doors North side missing smoke seals.
13. Elevator doors marked #9
14. Elevator doors VLH 1031
15. Satellite Pharmacy dutch door was missing the astragal/smoke seal on corridor door.

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

The facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles. Section A-8.3.4.1 The clearance for proper operation of smoke doors is defined as 1/8 inch.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6. ( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3, "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Section 7.2.1.8.1 (1) "Upon release of the hold-open mechanism, the door becomes self-closing."

On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed the he smoke barrier doors either did not close all the way when tested or there was more than an 1/8 inch gap between the doors when closed some smoke seals worn torn, ripped or missing.

1. Smoke barrier doors CTR -142/143
2. Smoke barrier doors VLH 2306
3. Emergency Department 2003 East/West
Note it was also observed these doors are on 15 second release on alarm the sign was not posted on the doors.
4. Smoke barrier doors VLH 2178
5. Smoke barrier doors VLH 679
6. Smoke barrier doors VLH 561-1
7. Smoke barrier doors CTR 437 and 461
8. Smoke doors by Volunteer Services storage

Failure to properly adjust or repair the smoke doors could cause harm to the patients. Non closing smoke doors will allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

The facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

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..."

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.1.5, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."


On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed Escutcheon plates missing from the sprinkler assembly or the sprinklers had either lint, lint and grease, paint or was corroded in the following locations in the building.


Escutcheon plates missing:

1. VLH 115-2 Clinical education
2. VLH 1113 Security Director's office
3. ELH 650 ELH office
4. CNO office
5. VLH 1085 Admin IDF
6. Main Chapel CTR 102
7. Department Supply Chain
8. Managers office Environmental Services office
9. Outside first floor corridor by the Elevators in the Women's Center
10. Outside of the corridor of the Volunteer Services Department.
11. North Stairwell by LH 706
12. VLH 456, 553 and 644

Lint, lint and grease, paint or corroded sprinkler

1. Main Kitchen and dining room and Java Junction
2. PACU Lint on sprinkler (s)
3. Corroded sprinkler apparent by the green color on the entire sprinkler on the 5 th floor stairwell landing North East side of the building.

Failing to maintain sprinkler heads could allow a fire to burn longer before the sprinkler head will activate. Sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

The facility failed to provide a medical gas cylinder storage room free of combustible materials.

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..."

On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed oxygen storage locations in the building. The oxygen bottles were being stored next to combustibles in the Clean utility rooms/Medical supply storage rooms or in the following locations:

In addition, these areas did not have signs posted to indicating which oxygen bottle racks were the empty or full bottles.

1. VLH 2051 by PACU
2. CTR 320
3. CTR 259
4. CTR 275
5. CTR 508
6. CTR 408
7. CTR 418
8. Exterior main oxygen storage supply no signs posted empty or full.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.

The facility allowed the use of multiple outlet adapters

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 November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed the use of a multiple outlet adapters two U.L. listed power strips being connected together into one receptacle outlet in the following locations:

1. Audiology room in the Women's Center
2. 1st floor room DCH 1072
3. Wound Center

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


The facility failed to provide or replace broken/cracked receptacle face plates.

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 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."

On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed the receptacle face plates where not installed or were broken in the following areas:

1. Bio-med 1157
2. Housekeeping room ULH 2061

Failing to repair or replace missing or broken receptacle face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. A fire in the facility may cause harm to the patients.


The facility failed to provide 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, auxillary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

On November 05/08 the surveyors accompanied by the Director of Facilities Services, Manager of Facilities Services and Electrician observed the following electrical J boxes were missing the covers on the boxes:

1. VLH 459 Electrical room
2. ED 2904 Electrical room
3. VLH 642 Electrical room

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