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Based on observation, written document review, and staff interview North Shore Medical Center - Florida Medical Center Campus located at 5000 West Oakland Park Blvd., Lauderdale Lakes, FL failed to comply with NFPA LSC 101-(2000) 4.2.1, 4.5.7, 4.6.1.1 exiting requirements. NFPA 1 (2000) 7.5.1.1 requires exits shall be located and exit egress shall be arranged so that exits are readily accessible at all times. This deficient practice could affect all of the occupants, staff and visitors, if exit egress is not maintained as clear and unobstructed as required by code.

Findings include:
(1) On March 4, 2013 between 8 a.m. and 2 p.m. when touring with the maintenance director, code violations were discovered in that the facility was storing beds, which were being used to diagnose, and treat patients, in the corridors. These items are stored in the corridors of the emergency room patient care areas for more than 30 minute time frames on a regular basis. At this time there was no mass casualty treatment occurrence requiring emergency actions. Also at this same time, at least ten rooms and other spaces were vacant in the area, which is for overflow and was completely vacant. Some areas required maneuvering due to excessive storage in violation of code requirements to maintain clear egress. An interview with the maintenance director at the times of observation revealed he was not aware of the storage and treatment of patients in the corridors which did not meet the code requirements of clear egress.

(2) On March 8, 2013 at 9:15 a.m. when touring with the maintenance director, code violations were discovered in that the facility was storing beds in the corridor of four West; at least seven beds completely blocked the egress through the exit door and the corridor was completely blocked with the beds. An interview with the maintenance director at the times of observation revealed he was not aware of the storage of the beds in the corridors which did not meet the code requirements of clear egress.

These findings were verified by the maintenance director the times of observation and the administrator at the exit conference on March 8, 2013.

Based on observation and interview North Shore Medical Center - Florida Medical Center Campus located at 5000 West Oakland Park Blvd., Lauderdale Lakes, FL failed to comply with NFPA 101 LSC (2000) 4.5.3.2, 7.1.10.1; 7.3.2.2., 19.2.3.3. Nurse charting stations or boxes. These will be allowed to protrude into the clear corridor width by 3.5 inches in the closed position. The tables must return automatically when not actively in use. There are some other type wall stations that are being considered by some facilities that project 4.25 inches into the clear width of the corridor. These too will be accepted if they are not placed directly opposite to each other and close automatically when not actively in use. Additionally, CMS reference S & C-04-41 dated August 12, 2004 addresses corridor obstructions. The maintenance director acknowledged that the facility did not maintain the nurse charting stations to be within code requirements. This deficient practice could affect all of the occupants as well as all staff and visitors, if the corridor exit paths are not maintained as required by code.

Findings include:

On March 4-8, 2013 between 8 a.m. and 2:30 p.m. during the observation tour accompanied by the maintenance director on the second and third floors of the facility numerous wall mounted charting stations were found to be damaged and when tested many did not close automatically in violation of code requirements. Based on projections within the means of egress of not more than 114 mm (4 ? in.) on each side shall be permitted at a height of 965 mm (38 in.) and below, the facility was found not in compliance with code requirements. The maintenance director acknowledged that the facility installed items in the corridors exceeding the allowed 4 1/2 inch maximum projection allowed by code.

These findings were verified by the maintenance director the times of observation and the administrator at the exit conference on March 8, 2013.

Based on observation, written document review, and staff interview the North Shore Medical Center - Florida Medical Center Campus located at 5000 West Oakland Park Blvd., Lauderdale Lakes, FL failed to comply with NFPA LSC 101-(2000) 4.2.1 Occupant Protection. 4.5.7 Maintenance. 4.6.1.1 The authority having jurisdiction shall determine whether the provisions of the code are met. Special locking arrangements - 7.5.1.1 Exits shall be located and exit egress shall be arranged so that exits are readily accessible at all times. 19.2.2.2.5.2 (4). This deficient practice could affect all of the occupants, staff and visitors, if keys to locked exit egress is not maintained as functional as required by code.

Findings include:

On March 8, 2013 at 9 a.m. on the fourth floor East locked unit when checking that all staff working in this unit had keys to open locked doors, fire extinguishers, and fire alarm pull stations it was discovered that at least one staff member did not have the keys required to open the locked fire extinguisher cabinet, and also did not have a key to unlock the locked fire alarm pull stations. All staff are required to carry keys to be used in an emergency event. Based on interview at this same time, the maintenance director acknowledged that the staff member did not have keys to unlock the locked fire safety features of the locked unit in violation of the code requirements

These findings were verified by the maintenance director at the times of document review and the administrator at the exit conference on March 8, 2013.

Based on observation, written document review, and staff interview the North Shore Medical Center - Florida Medical Center Campus located at 5000 West Oakland Park Blvd., Lauderdale Lakes, FL failed to comply with NFPA LSC 101 (2000) 7.9.3 which requires periodic testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Code requires written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all of the occupants as well as all staff and visitors, if the battery operated emergency lights are not maintained as functional as required by code.

Findings include:

On March 7, 2013 at 11 a.m. during paperwork review the facility failed to provide written documentation in support of the performance of maintaining emergency lighting. The facility was not able to confirm that they maintained written documentation of the required annual 90 minute testing which documented the start and ending times for testing. Based on interview at this same time, the maintenance director acknowledged that the documentation for testing of the battery operated emergency lighting annually was not being done. The maintenance director was not able to produce the requested paperwork at the time of exit.

These findings were verified by the maintenance director at the times of observation and the administrator at the exit conference on March 8, 2013.

Based on observation and staff interview North Shore Medical Center failed to comply with NFPA 101 (2000) 9.7, 19.3.5 and NFPA 13 8.3.2.5 installation of sprinkler heads in walk-in coolers and freezers. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings:

During a tour of the facility on 03/06/2013 at 3:05 pm with the Director of Facilities Management & Safety Officer it was observed that a sprinkler head was not installed in the walk-in cooler located in the Lab on the 1st floor.

During a tour of the facility on 03/06/2013 at 3:08 pm with the Director of Facilities Management & Safety Officer it was acknowledged that a sprinkler head was not installed in the walk-in cooler located in the Lab on the 1st floor.

NFPA 101 (2009) edition 9.7, 19.3.5
NFPA 13, 8.3.2.5

Based on observation and staff interview the North Shore Medical Center - Florida Medical Center Campus located at 5000 West Oakland Park Blvd., Lauderdale Lakes, FL failed to comply with the NFPA LSC 101 (2000) 9.2.3; 19.3.2.6 and NFPA 96 9-1.2.2 requires the effectiveness of an automatic extinguishing system is affected by the placement of the nozzles. For this reason, it is essential that cooking appliances be situated in the area in which they were when the extinguishing equipment was designed and installed. If an appliance is moved from under the equipment for cleaning or any other reason, it should be replaced to its original position prior to initiating a cooking operation. NFPA 96. 4.6 Drawings. A drawing(s) of the exhaust system installation along with a copy of operating instructions for subassemblies and components used in the exhaust system, including electrical schematics, shall be kept on the premises. If the cooking hood suppression system is not maintained as per code requirements, in the event of a fire, occupants, staff, and visitors will be affected.

Findings include:

(1) On March 4, 2013 at 930 a.m. accompanied by the maintenance director when inspecting the kitchen food preparation areas it was revealed that the cooking appliances were not properly covered or protected by the kitchen pre-engineered hood suppression system. The discharge nozzles were improperly aligned to protect the cooking surfaces of the appliances in the event of a fire. An interview was conducted at this time with the maintenance director who acknowledged that the discharge nozzles were improperly aligned to protect the cooking surfaces of the appliances.

(2) On March 4, 2013 at 9:35 a.m. accompanied by the maintenance director when inspecting the kitchen food preparation areas it was revealed that the drawing(s) of the exhaust system installation along with a copy of operating instructions for subassemblies and components used in the exhaust system, including electrical schematics, were not available on the premises. An interview was conducted at this time with the maintenance director who acknowledged that the documentation was not available. No additional documentation was presented at the exit conference to substantiate compliance.

(3) On March 4, 2013 at 9:50 a.m. accompanied by the maintenance director when inspecting the kitchen food preparation areas it was revealed that the grease collection filters had been installed horizontally. Manufacture and code requirements are that filters shall be installed vertically to allow the grease to collect in the predesigned grease collection pans. An interview was conducted at this time with the maintenance director who acknowledged that the filters were not installed properly.

(4) On March 4, 2013 at 9:55 a.m. accompanied by the maintenance director when inspecting the kitchen food preparation areas it was revealed that the suppression system was not UL 300 compliant. An interview was conducted at this time with the maintenance director who was unaware that the system was not UL 300 compliant. No additional documentation was presented at the exit conference to substantiate compliance.

These findings were verified by the maintenance director the times of observation and the administrator at the exit conference on March 8, 2013.

Based on observation and staff interview North Shore Medical Center failed to comply with NFPA 99 (2005) edition, 9.4.3.3, 9.7.2.3. When small-size (A,B,D,E) cylinders are in use, they shall be attached to a cylinder stand or to a therapy apparatus of sufficient size to render the entire assembly stable. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings:

During a tour of the facility on 03/06/13 at 11:40 am with Director of Facilities Management & Safety Officer it was observed that a "E" cylinder Oxygen tank was unsecured in the clean storage room on the 2nd floor Hospice.

During a tour of the facility on 03/06/13 at 11:45 am with Director of Facilities Management & Safety Officer it was acknowledged that a "E" cylinder Oxygen tank was unsecured in the clean storage room on the 2nd floor Hospice.

During a tour of the facility on 03/06/13 at 11:55 am with Director of Facilities Management & Safety Officer it was observed that a "E" cylinder Oxygen tank was unsecured in the Sleep Lab Monitoring room on 2nd floor.

During a tour of the facility on 03/06/13 at 11:58 am with Director of Facilities Management & Safety Officer it was acknowledged that a "E" cylinder Oxygen tank was unsecured in the Sleep Lab Monitoring room on 2nd floor.

NFPA 101 (2000) edition
NFPA 99 (2005) 9.4.3.3, 9.7.2.3

Based on staff interview and record review the North Shore Medical Center - Florida Medical Center Campus located at 5000 West Oakland Park Blvd., Lauderdale Lakes, FL failed to meet NFPA LSC 101 (2000) 19.3.2.3 and NFPA 99 (1999) 5-4.1.1 which requires the mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 % or greater. The facility did not maintain any written documentation of the relative humidity in the operating rooms. This deficient practice could affect patients if the humidity levels are not in accordance to code requirements.

Findings include:

On March 4, 2013 at about 11:45 a.m. through a computer based program screen record review of the humidity levels in the operating rooms at least two functional operating rooms were found to have 28 % humidity readings on this date. When requested the facility was unable to produce any written documentation of maintaining humidity levels equal to or greater than 35% in the operating rooms. No additional documentation was provided in support of humidity levels at the time of exit. The facility director acknowledged that the facility could not produce humidity logs and the readings based on the computerized program showed humidity readings below 35%.

This finding was verified by the maintenance director at the time(s) of observation and the administrator at the exit conference on March 8, 2013.

Based on observation, and staff interview it was determined that North Shore Medical Center failed to comply with NFPA 101 (2000) edition, NFPA 70, NFPA 99 (2005) edition. Major appliances must be plugged directly into wall receptacle. Extension cords are prohibited.

Findings:

During a tour of the facility on 03/06/2013 at 11:50 pm with the Director of Facilities Management & Safety Officer it was observed that on the 2nd floor Sleep Lab monitoring room a refrigerator, microwave, coffee pot, and a television were plugged into a surge protector.

During a tour of the facility on 03/06/2013 at 11:53 pm with the Director of Facilities Management & Safety Officer it was acknowledged that on the 2nd floor Sleep Lab monitoring room a refrigerator, microwave, coffee pot, and a television were plugged into a surge protector.

During a tour of the facility on 03/06/2013 at 1:45 pm with the Director of Facilities Management & Safety Officer it was observed that on the 1st floor Radiology special procedure room 11 an IV pump was plugged into a surge protector.

During a tour of the facility on 03/06/2013 at 1:48 pm with the Director of Facilities Management & Safety Officer it was acknowledged that on the 1st floor Radiology special procedure room 11 an IV pump was plugged into a surge protector.


NFPA 101 (2009) edition
NFPA 70
NFPA 99 (2005) edition

Based on observation and staff interview the North Shore Medical Center - Florida Medical Center Campus located at 5000 West Oakland Park Blvd., Lauderdale Lakes, FL failed to comply with 42 CFR 482 and NFPA LSC 101 (2000) the facility failed to install alcohol-based hand-rub dispensers as required by code. Failure to correctly install alcohol - based dispensers may result in danger to occupants, visitors, and staff.

Findings include:

On March 4, 2013 between 8 a.m. and 2 p.m. while touring the facility with the facility maintenance director in the various areas including PACU, Alcohol-based hand-rub dispensers were installed directly over or adjacent to electrical ignition sources. The maintenance director acknowledged the facility had installed Alcohol-based hand-rub dispensers directly over or adjacent to electrical ignition sources based on interview during the tour.

These findings were verified by the maintenance director at the times of survey and the administrator at the exit conference on March 8, 2013.

Based on observation and staff interview the North Shore Medical Center - Florida Medical Center Campus located at 5000 West Oakland Park Blvd., Lauderdale Lakes, FL failed to comply with 42 CFR 482 and NFPA LSC 101 (2000) the facility failed to install alcohol-based hand-rub dispensers as required by code. Failure to correctly install alcohol - based dispensers may result in danger to occupants, visitors, and staff.

Findings include:

On March 4, 2013 between 8 a.m. and 2 p.m. while touring the facility with the facility maintenance director in the various areas including PACU, Alcohol-based hand-rub dispensers were installed directly over or adjacent to electrical ignition sources. The maintenance director acknowledged the facility had installed Alcohol-based hand-rub dispensers directly over or adjacent to electrical ignition sources based on interview during the tour.

These findings were verified by the maintenance director at the times of survey and the administrator at the exit conference on March 8, 2013.