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Based on observations, record review, and staff interview, the facility failed to maintain exit signs in accordance with (National Fire Protection Association) NFPA 101. Failure to identify exits and direction of travel could result in building occupants becoming confused or unable to exit at a safe level to the exit discharge.

The findings included:

On 08/06/2019 between 1:37 p.m. and 2:02 p.m. and on 08/07/2019 at 8:59 a.m. exit signs were observed. Following are the areas of non-compliance:
1. At the APCP building, 6th floor, the exit sign configuration did not identify the direction to the stairwell at stair TS3
2. At the APCP building, 5th floor, the exit sign was not configured as shown on the construction drawings.
3. At the Bed Tower Building in the first floor lobby, the exit sign direction indication was not visible in the path of travel.

Concurrent with the observation and review of construction drawings, the Director of Plant Operations acknowledged the findings. He also said that an audit of egress and exit signs was currently in progress.

(National Fire Protection Association) NFPA 101 (2012 edition) 7.1.2, 7.2.1

Based on observation and staff interview, the facility failed to provide storage of flammable materials in the laboratory in accordance with (National Fire Protection Association) NFPA 30. This in the event of a fire could accelerate and contribute to the rapid development of fire, endangering the occupants of the building.

The findings included:

On 08/08/2019 at 1:43 p.m. in the lab corridor closet, 3 flammable materials cabinets were observed. Two of the three cabinets were not fully closed and their latching mechanisms were inoperable. One of the two cabinets had a broken door roller guide. Concurrent with the observation, the Director of Plant Operations acknowledged the findings. Cabinets for the storage of flammable materials is a requirement of (National Fire Protection Association) NFPA 30.

NFPA 101 (2015 edition) 19.3.3.2, 8.7.3.1; NFPA 30 (2015 edition) 9.5.3(2)(c)

Based on observations and staff interview, the automatic sprinkler system was not installed in accordance with (National Fire Protection Association) NFPA 13. This in the event of fire could delay or deny extinguishment of a fire.

Findings include:

On 08/07/2019 at 12:49 p.m. while on tour in the emergency department RMS/corridor, (8) quick response type sprinkler heads were observed in the same compartment as standard response type heads. Concurrent with the observations, the Director of Plant Operations acknowledged the findings.

According to (National Fire Protection Association) NFPA 13, when converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

NFPA 101 (2015 edition) 19.3.5, 9.7; NFPA 13 (2013 edition) 8.3.3.4

Based on observations, record review, and interview, the facility failed to ensure that the fire sprinkler system was tested and maintained in accordance with (National Fire Protection Association)NFPA 101(2015 edition) and NFPA 72 (2013 edition) which requires supervision of the system. This would deny notification to the fire alarm control panel and those who monitor it in when a non-supervised control valve is put into the closed position thereby disabling the sprinkler system with no one knowing.

The findings included:

On 08/09/2019 at 7:53 a.m. the fire alarm system was put into test mode. At 8:03 a.m. at the main fire sprinkler control valves and backflow preventer's across from the Emergency Department, a post indicator valve and the OS&Y control valves were observed. The Director of Plant Operations closed the first OS&Y valve. The fire alarm panel was observed by a facility maintenance supervisor and it was reported that no signal indicating the valve had been moved from its fully open position. The Director of Plant Operations confirmed the observations at the time of the test.

On 08/09/2019 at 9:45 a.m. the fire sprinkler inspection reports were reviewed. The annual inspection reports dated 12/18/18 and 1/11/19 did not indicate any deficiencies with the supervisory devices.

According to (National Fire Protection Association) NFPA 101, all control valves in the fire sprinkler system shall be electronically supervised.

NFPA 101(2015 edition) 9.7.2.1; NFPA 72 (2013 edition) 17.16.1

Based on staff interview and observations, the automatic sprinkler system was not maintained and tested in accordance with (National Fire Protection Association) NFPA 25. This in the event of fire could delay or deny extinguishment of a fire, endangering the occupants of the building.

Findings include:

1.On 08/07/2019 at 9:46 a.m. in the "Main Building", the fire sprinkler heads in 3 elevator pits were observed. The pits had accumulations of debris consisting of paper, plastic and dust. The fire sprinkler heads in the pits have accumulations of dust, debris and paper. Concurrent with the observation, the Director of Plant Operations acknowledged the findings.

NFPA 25 (2011 edition) 5.2.1.1.2

On 08/07/2019 at 11:13 a.m. in the pharmacy and areas throughout the the "Northeast Building", quick response fire sprinkler heads were observed in the pharmacy, corridors, and common areas. A sample of three heads were observed to be dated 1992, 1996, and 1994. The Director of Plant Operations confirmed the findings at that time. Replacement or testing of quick response fire sprinkler heads that have been in service for 20 years is a requirement of (National Fire Protection Association) NFPA 25.

NFPA 101 (2012 edition) 9.7.5, 9.7.7, 9.7.8, NFPA 25 (2011 edition) 5.3.1.1.1.3

On 08/08/2019 at 10:50 a.m. in the "Variety Behavioral Health Unit", recessed fire sprinkler heads were observed. The trim covers for the heads had been painted throughout the unit. Concurrent with the observations, the Director of Plant Operations acknowledged the findings.

On 08/09/2019 at 9:24 a.m. in the chapel, recessed fire sprinkler heads were observed. The trim covers for the heads had been painted throughout the room. Concurrent with the observations, the Director of Plant Operations acknowledged the findings.

Painting of sprinkler components reduces the efficiency and may delay or deny the activation of the sprinkler head in a fire event.
NFPA 25 (2011 edition) 5.2.1.1.2

Based on observation, record review and staff interview, the facility failed to provide evidence of generator maintenance and testing in accordance with (National Fire Protection Association) NFPA 110. The facility failed to provide documentation of the generator battery electrolyte testing which is required to assure the ability of the prime mover to start. Batteries not able to start the prime mover will result in a loss of power to the facility thus endangering the patients and occupants of the facility.

Findings include:

On 08/09/2019 at 8:24 a.m. in the main generator room, the generator batteries were of the maintenance free type. Concurrent with the observation the Director of Plant Operations acknowledged the findings.

On 08/09/2019 at 9:34 a.m. while conducting records review, evidence of testing and recording of the generator battery electrolyte could not be produced. Concurrent with the review, the Director of Plant Operations said that they would purchase a conductance tester in order to perform monthly battery testing. According to (National Fire Protection Association) NFPA 110, maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

NFPA 110 (2010 edition) 8.3.7.1

Based on observation and interview, the facility failed to use RPT's (Relocatable Power Taps) in accordance with their listing and in the patient care vicinity. This could result in the RPT failing to perform as designed and utilization equipment connected to the RPT's to lose power which could cause potential harm to patients.

The findings included:

On 08/07/2019 at 10:27 a.m. in O.R. #6, two RPT's were observed on the floor. One of the RPT's was plugged into the other and was located less than 6 ft. from the operating table.

On 08/07/2019 at 10:29 a.m. in O.R. #3, two RPT's were observed. Neither were mounted on carts, racks, or poles. One of the RPT's was observed to have a replacement plug end.

Concurrent with the observations, the Director of Plant Operations acknowledged the findings.
RPT's are to permitted be used in the patient care vicinity in accordance with their listing which includes mounting to pole, rack, or cart mounted equipment, prohibits modification of the RPT, and connecting the RPT's in series.

(National Fire Protection Association) NFPA 99 (2012 edition) 10.2.3.6