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Based on observation, document review, and interview, the facility failed to maintain building construction and fire-rated occupancy separations. This was evidenced by a building construction that is not permitted for health care occupancies, by one fire-rated door into an offsite suite that failed to latch, and by one fire-rated separation with a non-rated door. This failed to provide the appropriate protection that could result in the faster spread of smoke and fire. This affected 1938 Building, the Pavilion, and the Raymond Building.

NFPA 101, Life Safety Code, 2000 Edition.
18.1.1.4.2 Communicating openings in dividing fire barriers required by 18.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)
18.1.1.4.3 Doors in barriers required by 18.1.1.4.1 shall normally be kept closed.
Exception: Doors shall be permitted to be held open if they meet the requirements of 18.2.2.2.6.
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations:
Construction Type II (000): 4 or More Stories - Not Permitted.

Findings:

During a facility tour with the Director of Facilities (DFS1) and the Plant Operations Manager (POM1) from 11/30/15 to 12/4/15, the building construction and the fire-rated separations of the offsite suites were observed.

1938 Building:
1. On 12/4/15, at 8 a.m., the DFS1 provided building construction information for the 1938 Building. The 1938 Building was 5 stories in height. The document identified the 1938 Building as construction Type II (000) and it included the following note: healthcare occupancy located in a portion of the 4th Floor. The floor plans identified a portion of the Pediatric Unit in the 1938 Building. The 1938 Building was observed to be non-sprinklered on the 4th Floor. The Type II (000) was not a permitted construction type for health care occupancies five stories in height.


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Pavilion, Suite 355:
2. On 12/2/15, at 11:16 a.m., the door into Suite 355 from the Pavilion hallway was held open by a magnetic hold-open device. Upon activation of the fire alarm system, the door released from its hold-open device but failed to latch upon closure.

Raymond Building, Suite 120:
3. On 12/2/15, at 2:43 p.m., there were two doors going into the outpatient rehabilitation suite from the building lobby. The main entrance door was 90-minute fire-rated. The door into Speech Pathology was a non-rated glass panel door without a latch.

During an interview at 2:44 p.m., Raymond Building Manager stated that the previous tenant of the suite changed the original door, which was fire-rated and had a latch, to this glass panel door.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in a facility wall. This could result in the spread of fire and smoke, increasing the risk of injury to patients. This affected one of five Floors in Valentine Building.

NFPA 101, Life Safety Code, 2000 Edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
19.1.6.3 All interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.
8.2.3.1.1 Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the facility's walls and ceilings were observed with the Plant Operations Manager (POM1), the Plant Maintenance Mechanic (PMM3), and the Coordinator Orthopedic Joint Program (Scribe1).

Valentine Building, Fourth Floor:
1. On 12/3/15, at 10:20 a.m., the wall to the patient sleeping room in Room 4218, located in the Valentine Building on the 4th Floor, was observed to have penetrations going through the wall. The penetrations included two that measured approximately 1-inch and two that measured approximately 1/2-inch.

Based on observation, the facility failed to maintain doors opening into corridors. This was evidenced by doors with penetrations, doors held open by unapproved methods, and by doors that failed to positive latch. This had the potential to allow the migration of smoke and result in injury to patients. This affected one of five Floors in La Vina Building, two of eight floors in the West Tower, one of four suites in the Pavilion, and one of five floors in the Wingate Building.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous
areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the doors were observed with the Plant Operations Manager (POM1), the Director of Facilities (DFS1), the Plant Maintenance Mechanic (PMM2), and the Coordinator Orthopedic Joint Program (Scribe1).

La Vina Building, Fourth Floor:
1. On 12/1/15, at 3:48 p.m., the door to the patient sleeping room in Room 4114, located in the La Vina Building on the 4th Floor, had two holes going through the door. The holes measured approximately 1/2-inch each. PMM2 stated that it appeared that the door handle had been replaced with the incorrect type.


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West Tower, Ground Floor:
2. On 12/1/15, at 9:55 a.m., the 60-minute fire-rated door into the pharmacy office suite was held open by a rubber wedge and obstructed from closing.

West Tower, Fourth Floor:
3. On 12/1/15, at 2:36 p.m., the door to the W487 Ante Room was held open with a rubber wedge and obstructed from closing.

Pavilion, Suite 345:
4. On 12/2/15, at 11:03 a.m., the 1-hour fire-rated door to Conference Room 1 was held open by a rubber wedge and obstructed from closing.

Wingate Building, Second Floor:
5. On 12/3/15, at 3:24 p.m., the door to the Cardiac Rehab (Door 2434) was held open by a magnetic hold-open device. The door released upon activation of the fire alarm system but failed to latch upon closure.

Based on observation and interview, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls. This was evidenced by penetrations in the smoke barrier walls. This failure affected three of eight floors in the East Tower.

NFPA 101, Life Safety Code, 2000 Edition
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 1/2 hour.

8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the smoke barrier walls were observed with the Plant Operations Managers (POM1 and POM2), the Hospital Safety Officer (HPSO), and the Plant Maintenance (PMM4).

East Tower, First Floor:
1. On 12/1/15, at 10:06 a.m., there was an unsealed conduit with blue communication wires running through it in the smoke barrier wall above door 1E115 located in the maternity suite. This was confirmed by HPSO and PMM4.

East Tower, Second Floor:
2. On 12/1/15, at 10:56 a.m., there was a unsealed conduit with white communication wires running through in the smoke barrier wall above door 2D104 entering the Intensive Care Unit (ICU) suite. This was confirmed by HPSO and PMM4.

3. On 12/1/15, at 11:08 a.m., there were a unsealed conduit and an approximately 2 inch circular penetration in the wall above door 2B130 located in same day surgery. This was confirmed by HPSO and PMM4.

East Tower, Fifth Floor:
4. On 12/1/15, at 1:11 p.m., there was a unsealed conduit with communication wires running through in the smoke barrier wall above door 5EB25 in the surgical unit suite. This was confirmed by HPSO and PMM4 during survey.

Based on observation and interview, the facility failed to maintain the smoke barrier doors to operate without interference and to prevent the passage of smoke or fire. This was evidenced by smoke barrier doors that failed to close and positive latch upon activation of the fire alarm system. This could delay evacuation and could result in the spread of smoke and fire. This affected two of eight floors in the West Tower, four of eight floors in the East Tower, one of five floors in the La Vina Building, and one of five floors in the Hahn Building.

NFPA 101, Life Safety Code (2000) Edition
19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the smoke barrier doors were observed with the Plant Operations Managers (POM1 and POM2), the Hospital Safety Officer (HPSO), the Plant Maintenance (PMM4), the Director of Facilities (DFS1), and the Coordinator Orthopedic Joint Program (Scribe1).

West Tower, Second Floor:
1. On 12/2/15, at 1:24 p.m., smoke barrier door 2WH24 in the DOU, failed to close and positive latch during fire alarm testing. This was confirmed by HPSO.

East Tower, Ground Floor:
2. On 12/2/15, at 2:13 p.m., the smoke barrier door GD111 in the radiology registration failed to close and positive latch during fire alarm testing. This was confirmed by HPSO.

3. On 12/2/15, at 2:16 p.m., the smoke barrier door located in the north/east corridor by the fire alarm control panel room failed to close and latch. One of the double door leafs was dragging on the floor and would not fully close. This was confirmed by HPSO and POM1.

4. On 12/2/15, at 2:30 p.m., the smoke barrier doors GC230, GC218 and GC225 located in the emergency department failed to fully close and latch. This was confirmed by HPSO during the survey.


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East Tower, Sixth Floor:
5. On 12/2/15, at 9:36 a.m., the cross corridor doors 6EB01, located by the Nurse Station and Elevator #2 in the East Tower 6th Floor, failed to fully close and latch 1 of 2 doors. The door was observed to be dragging on the carpet and it was acknowledged by Scribe1 during the survey.

East Tower, Fifth Floor:
6. On 12/2/15, at 9:49 a.m., the cross corridor doors 5EB63, located by Module 4 in the East Tower 5th Floor, failed to fully close and latch 1 of 2 doors. The finding was acknowledged by Scribe1 during the survey.

East Tower, Second Floor:
7. On 12/2/15, at 10:43 a.m., the cross corridor doors 2A116.1, located by Elevator 4 in the East Tower 2nd Floor, failed to fully close and latch 1 of 2 doors. The finding was acknowledged by Scribe1 during the survey.

8. On 12/2/15, at 10:45 a.m., the cross corridor doors 2A100, located by Elevator 10 in the East Tower 2nd Floor, failed to fully close and latch 2 of 2 doors. The finding was acknowledged by Scribe1 during the survey.

West Tower, Second Floor:
9. On 12/2/15, at 1:25 p.m., the cross corridor doors 2WH42, located by Room W257 in the West Tower 2nd Floor, failed to fully close and latch 1 of 2 doors. The finding was acknowledged by Scribe1 during the survey.

La Vina Building, Second Floor:
10. On 12/3/15, at 1:38 p.m., the cross corridor doors 05227, located by Cath Lab 3 in the Lavina Building 2nd Floor, failed to fully close and latch 1 of 2 doors. The door was observed to have its rod latching mechanism not retracting and it was acknowledged by Scribe1 during the survey.


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Hahn Building, Ground Floor:
11. On 12/1/15, at 4:03 p.m., there was a cross-corridor door frame, outside the Perinatal Health Education/Breastfeeding Center, and there were fire alarm magnetic hold-open devices on either side of the door frame. The cross-corridor door was removed.

During an interview at 4:04 p.m., the Director of Facilities (DFS1) stated that the door was removed a few years ago because it was continuously getting hit by carts. He stated that the doors were removed without approval from the authority having jurisdiction (AHJ).

The blueprints showing the fire-rating of the removed door were requested but not provided.

Based on observation and interview, the facility failed to protect their hazardous area enclosures. This was evidenced by the failure to ensure the doors protecting hazardous areas latched upon self closure, by doors that were obstructed from closing, and by a penetration in one hazardous area enclosure. This could result in the increased risk of fire and or smoke to spread from one area to another. This affected one of eight floors in the East Tower and two of five floors in the Wingate Building, two of seven floors in the West Tower and one of four offsite suites in the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
18.3.2.1 Hazardous Areas. Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to the following:
(1) Boiler and fuel fired heater rooms
(2) Central/bulk laundries larger than 100 ft. (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft. (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
8.4.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.
8.4.1.2 In new construction, where protection is provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4.
Exception No. 1: This requirement shall not apply to mercantile occupancy general storage areas and stockrooms protected by automatic sprinklers in accordance with Section 9.7.
Exception No. 2: This requirement shall not apply to hazardous areas in industrial occupancies protected by automatic extinguishing systems in accordance with 40.3.2.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the hazardous areas were observed with the Plant Operations Manager (POM1), the Hospital Safety Officer (HPSO), the Plant Maintenance (PMM4), and the Director of Facilities (DFS1).

East Tower, Ground Floor:
1. On 12/1/15, at 9:59 a.m., the door to the trash collection room, located in the north east side of the emergency department, failed to latch upon self closure. During interview, POM1 stated the door was in the process of being repaired at the time of survey.

Wingate Building, Third Floor:
2. On 12/3/15, at 10:15 a.m., the dirty utility room door #3411 failed to latch upon self closure. This was confirmed by HPSO during the survey.

Wingate Building, Second Floor:
3. On 12/3/15, at 10:24 a.m., the dirty utility room door 2412.1 failed to latch upon self closure. The doors were open to the fullest extent and released. This was confirmed by HPSO during the survey.


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West Tower, Ground Floor:
4. On 11/30/15, at 4:05 p.m., the 60-minute fire-rated door into the pathology laboratory was held open by a rubber wedge and obstructed from closing.

West Tower, First Floor:
5. On 12/1/15, at 1:28 p.m., there was an approximately 6 inch by 3 inch penetration in the wall of the trash chute room, directly across from the chute.

Pavilion, Suite 345:
6. On 12/2/15, at 11:06 a.m., the door to the soiled linen room (Door 3124) was held open by a rubber wedge and obstructed from closing.

Based on record review and interview, the facility failed to maintain their battery-powered emergency lights. This was evidenced by missing and incomplete records of testing the battery-powered emergency lights. This could result in a delay in evacuation due to limited visibility, in the event of an emergency. This affected the Raymond Building and the Senior Care Network.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.1.1 Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the
following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator
that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and
vestibule emergency lighting power supply For the purposes of this requirement, exit access shall
include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

7.9.3 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. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with the Director of Facilities (DFS1) from 11/30/15 to 12/4/15, the emergency lights were observed and maintenance logs were requested.

Raymond Building:
1. On 12/2/15, at 3:10 p.m., records for the monthly 30-second and annual 90-minute testing of the battery-powered emergency lights were requested.

During an interview at 3:11 p.m., Raymond Building Maintenance Staff (Maint1) stated that the emergency lights and exit signs were not tested.

Senior Care Network (SCN):
2. On 12/3/15, at 9:40 a.m., records indicated that SCN Maintenance Staff (Maint2) was conducting monthly tests on the battery-powered emergency lights.

During an interview at 9:41 a.m., Maint2 stated that he checks the emergency lights by pushing the test buttons for a few seconds. He stated that he does not test them for 30 seconds monthly and 90 minutes annually.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by one exit sign that was not fully mounted, by one exit sign that was removed, and by two exit signs that were not illuminated. This could result in less visibility of the exit signs and a delay in evacuation. This affected one of five floors in the 1938 Building, the penthouse of the West Tower, and one of four offsite suites in the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
18.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

7.10.5.1 General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a facility tour with the Director of Facilities (DFS1), the Plant Operations Managers (POM1), the Plant Maintenance Mechanic (PMM2), and the Coordinator Orthopedic Joint Program (Scribe1) from 11/30/15 to 12/4/15, the exit signs were observed.

1938 Building, Second Floor:
1. On 12/1/15, at 1:26 p.m., the exit sign by the cross corridor doors 2247, located on the 2nd Floor in the 1938 Building, was not fully secured and hanging on by one screw. The finding was acknowledged by Scribe1 during the survey.


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West Tower, Seventh Floor Penthouse:
2. On 12/1/15, at 3:54 p.m., the base of an exit sign was observed on the wall outside Stairwell 10 (Door 7WHST10) but the actual exit sign was missing. The exit sign was observed on the floor near the stair landing.

Pavilion, Suite 100:
3. On 12/2/15, at 10:04 a.m., the LED exit sign by Room 1103 was not illuminated.

4. On 12/2/15, at 10:16 a.m., the LED exit sign outside the Equipment Room was not illuminated.

Based on document review and interview, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by quarterly fire drills held around the same time, by no activation of an audible fire alarm device during fire drills held after 6:00 a.m. and before 9:00 p.m., and by a staff who was not aware of her responsibilities and the use life safety devices in accordance with the facility's fire plan. This could result in staff to not properly respond to a fire and cause harm to patients. This affected the West Tower, the East Tower, and the Della Martin Center.

NFPA 101, Life Safety Code 2000 Edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.2* Fire 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2 Procedure in Case of Fire.
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During a tour of the facility and document review with the Plant Operations Managers (POM1 and POM2) and the Hospital Patient Safety Officer (HPSO) from 11/30/15 through 12/4/15, the quarterly fire drill reports were reviewed and the staff were interviewed to determine their knowledge of facility's fire emergency procedures.

West Tower:
1. On 12/3/15, between 3:30 p.m., and 4:30 p.m., the fire drills reports were provided. The fire drill reports for the West Tower PM shift (second shift), documented 4 of 10 drills were held between 7:40 p.m., and 7:45 p.m., all the fire drills were held before 9:00 p.m., and only two drills documented activation of a fire alarm device. The NOC shift (third Shift) fire drills documented 7 of 7 drills were held between 1:25 a.m., and 1:40 a.m.

East Tower:
2. On 12/3/15, between 3:30 and 4:30 p.m., the fire drill reports for East Tower documented the PM shift (second shift) were held between 7:40 p.m., and 7:45 p.m., there was no documentation for the activation of a fire alarm device during 5 of 5 drills. The NOC shift drills (third shift) documented 5 of 6 drills were held between 1:20 a.m. and 1:40 a.m.

Della Martin Center:
3. On 12/3/15, between 3:00 and 4:30 p.m., the fire drill reports for Della Martin Center documented 4 of 8 drills were held after 6 a.m., and before 9:00 p.m., there was no activation of a fire alarm device during any of the 4 fire drills. During an interview, the HPSO stated the fire drills are conducted by hospital security.


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East Tower, Ground Floor:
4. On 12/2/15, at 2:33 p.m., the environmental service staff working in the Emergency Department near the Patient Waiting Area was interviewed to determine her knowledge of the facility's fire emergency procedures and usage of life safety equipment. The staff stated that she had not received training and was not familiar with the facility's fire and disaster plan.

Based on observation, record review, and interview, the facility failed to ensure that their fire alarm system was in reliable operating condition. This was evidenced by the modification of the fire alarm system without approval from the authority having jurisdiction (AHJ). This was also evidenced by fire alarm notification appliances that could only be activated by a manual means. This could result in delayed notification and response, and possible harm to patients, in the event of a fire. This affected one of four patient care units at the Della Martin Center.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

4.1.1 Fire and Similar Emergency. The goal of this Code is to provide an environment for the occupants that is reasonably safe from fire and similar emergencies by the following means:
(1) Protection of occupants not intimate with the initial fire development
(2) Improvement of the survivability of occupants intimate with the initial fire development.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.1.3 System Design. Fire alarm system plans and specifications shall be developed in accordance with this code by persons who are experienced in the proper design, application, installation, and testing of fire alarm systems. The system designer shall be identified on the system design documents. Evidence of qualifications shall be provided when requested by the authority having jurisdiction.

1-5.5.2.1 All systems shall be installed in accordance with the specifications and standards approved by the authority having jurisdiction.

1-5.7.1.1 The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. All required annunciation means shall be readily accessible to responding personnel and shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.

1-6.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. At its request, complete information regarding the system or system alterations, including specifications, wiring diagrams, battery calculation, and floor plans shall be submitted for approval.

Findings:

During a facility tour with the Director of Facilities (DFS1) from 11/30/15 to 12/4/15, the fire alarm system at the DMC 400 Locked Unit was observed.

Della Martin Center (DMC), First Floor:
1. On 12/3/15, at 10:00 a.m., there were three pull stations in DMC 400 that had key inserts in the middle above the pull station handles. Per the Fire Alarm Training policy, keys can be inserted into the pull stations to unlock the exit doors. The policy stated that there were two stages to unlock the doors. The policy stated that the first stage (Phase 1) was to remove the pull station protective cover, pull the lever, and this should activate the strobes, bells, and notify PBX (operator). The second stage (Phase 2) was to insert the fire pull box key and rotate 1/4 turn clockwise to unlock the doors.

During an interview at 10:03 a.m., the DMC Interim Manager of Behavioral Services (IMBS) and the DMC Psych Services Supervisor (PSS) stated that this system was put in place approximately 1 year ago. The Director of Facilities (DFS1) stated that the facility did not obtain approval from the Office of Statewide Health Planning and Development (OSHPD) for these modifications to the fire alarm system.

An invoice from the fire alarm vendor indicated that the three pull stations were installed on 5/27/14.

On 12/4/15, at 1:20 p.m., a Fire Life Safety Officer (FLSO) and an Area Compliance Officer (ACO) from OSHPD were onsite at the facility. After observing the modified pull stations at DMC 400, the ACO confirmed that a permit/approval would have been required for installation of these pull stations.

2. On 12/3/15, at 10:04 a.m., the pull station outside Room 401 in DMC 400 was tested (Phase 1: pull station cover removed and pull station handle was pulled down). Alarm notification devices outside DMC 400 were activated but the three notification devices (horn/strobe combination) in DMC 400 failed. The alarms from outside DMC 400 could not be heard in the Day Room and towards the east end of the unit.

During an interview at 10:10 a.m., the DFS1 stated that a fire watch would be implemented in DMC 400 immediately.

3. On 12/3/15, at 10:13 a.m., the smoke detector in Room 401 was tested. Alarm notification devices outside DMC 400 were activated but the three notification devices in DMC 400 failed.
Facility staff were asked to demonstrate Phase 2 of their fire plan (insertion of the pull station key to unlock the exit doors) while the smoke detector was still in alarm. The three notification devices in DMC 400 only activated after turning of the key in the pull station.

During an interview at 10:16 a.m., the DFS1 stated that this was a programing error with the fire alarm system and fire alarm notification devices should have activated before Phase 2.

4. On 12/3/15, at 10:27 a.m., the Inspector's Test Valve (ITV) at DMC was tested. Alarm notification devices outside DMC 400 activated within 43 seconds but the three notification devices in DMC 400 failed to activate after two minutes of opening the ITV. The notification devices only activated after staff implemented Phase 2 of their fire plan (turning the key in the pull station).

On 12/4/15, at 9:00 a.m., the fire alarm system at DMC 400 was tested again after the vendor informed the facility that the programming issue was fixed. Activation of the pull station outside Room 401 (Phase 1) activated the notification devices in DMC 400. Activation of the smoke detector in 401 and the ITV failed to activate the notification devices in DMC 400 until Phase 2 (turning of the pull box key) was implemented by staff.

During an interview at 9:12 a.m., the DFS1 stated that they will continue to implement a fire watch at DMC 400 until the issue was fixed.

Based on observation and interview, the facility failed to maintain their fire alarm system. This was evidenced by visual alarms that fail to function, by strobe lights that were not synchronized, by one fire alarm panel that was out of service, one fire alarm subpanel that required updated device addresses, by one smoke detector that was dirty, and by one smoke detector that was obstructed. This was also evidenced by the failure of an Inspector's Test Valve to initiate an alarm throughout the third floor of the Pavilion, and by sealed-lead acid batteries that were due to be replaced. These deficiencies could result in a delay in notification and staff response, in the event of a fire or abnormal condition with the fire alarm system. This affected two of five Floors in Valentine Building, one of five floors in the Wingate Building, the West Tower, the smoke/fire dampers in the East Tower, three of four offsite suites in the Pavilion, and the Senior Care Network.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.
4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.7.1.1 The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. All required annunciation means shall be readily accessible to responding personnel and shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.
4-4.4.1.1 (4) More than two visible notification appliances in the same room or adjacent space within the field of view that flash on synchronization. This requirement shall not preclude synchronization of appliances that are not within the
same field of view.
7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.
Table 7-3.2 Testing Frequencies, requires annual testing of:
1. Control Equipment - Building Systems Connected to Supervising Station
a. Functions
b. Fuses
c. Interfaced Equipment
d. Lamps and LEDs
e. Primary (Main) Power Supply
f. Transponders
6. Batteries - Fire Alarm Systems
d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years.)
2. Discharge Test (30 minutes)
9. Control Unit Trouble Signals
14. Remote Annunciators
15. Initiating Devices
19. Alarm Notification Appliances
7-4.1 Fire alarm system equipment shall be maintained in accordance with the manufacturer's instructions. The frequency of maintenance shall depend on the type of equipment and the local ambient conditions.

Findings:

During a facility tour with the Director of Facilities (DFS1), the Plant Operations Managers (POM1), and the Coordinator Orthopedic Joint Program (Scribe1) from 11/30/15 to 12/4/15, the fire alarm system was observed.

Valentine Building, Fourth Floor:
1. On 12/3/15, at 2:08 p.m., the visual fire alarm device in the corridor outside of Room 4206, located in Valentine Building on the 4th Floor, failed to illuminate when a smoke detector was activated in the room. The device was red and labeled "fire."

Valentine Building, Third Floor:
2. On 12/3/15, at 2:16 p.m., the visual fire alarm device in the corridor outside of Room 3203, located in Valentine Building on the 3rd Floor, failed to illuminate when a smoke detector was activated in the room. The device was red and labeled "fire." The POM1 was interviewed and he stated that those devices in the Valentine Building are not currently working and that a project will be opened to make repairs.

Wingate Building, Second Floor:
3. On 12/3/15, at 2:16 p.m., the strobe light fire alarm device in the Cardiac Rehabilitation, located in the Wingate Building on the 2nd Floor, was not synchronized to flash at the same time with the strobe lights in the field of view and located in the corridor. The finding was acknowledged by Scribe1 during the survey.


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West Tower, Ground Floor:
4. On 11/30/15, at 4:00 p.m., Fire Alarm Control Panels (FACP) 47 and 48 were in the electrical room. The LED panel on FACP 48 was not lit and the panel did not exhibit the trouble signals shown in FACP 47.

On 12/3/15, at 1:15 p.m., FACP 48 was still inactive.
During an interview at 1:16 p.m., the Director of Facilities (DFS1) stated that the vendor needs to replace a module on this panel so it can be operational.

Hahn Building, Ground Floor:
5. On 11/30/15, at 5:15 p.m., there were fire alarm panels in the maintenance shop that showed the status of the fire smoke dampers connected to the fire alarm system. The panels indicated if the dampers were opened or closed. There were 42 dampers located in the East Tower that did not exhibit an "open" or "closed" status on the panel. Their status indicators were not lit.

During an interview at 5:16 p.m., the Plant Operations Manager (POM2) stated that he will have a vendor investigate and verify the status of the dampers that were not lit on the panel. He was unsure if those 42 dampers had issues with their relays or if there was an issue with the panel itself.

On 12/1/15, at 4:11 p.m., the damper panels in the maintenance shop were relabeled.

During an interview at 4:12 p.m., Technician 1 from the fire alarm vendor stated that the dampers that were not illuminated on the panel were removed or relocated during a 2010 Emergency Department remodel. He stated that technicians were still working on re-labeling the panels to make it accurate.

West Tower, First Floor:
6. On 12/1/15, at 1:27 p.m., the smoke detector in the trash chute room was covered in dirt, debris, and dust.

Pavilion:
7. On 12/2/15, at 10:48 a.m., the Inspector's Test Valve (ITV) on the third floor of Stairwell 2 was tested by a fire alarm vendor technician. The fire alarm notification devices on the first floor activated within 35 seconds but failed to activate on the third floor after the valve was opened for two minutes. No alarms could be heard on the third floor. The ITV was tested again at 11:12 a.m., and only the fire alarm notification devices on the first floor were activated.

Pavilion Building, Suite 345:
8. On 12/2/15, at 10:55 a.m., the smoke detector outside the IDF Room was entirely covered with a plastic cap.

Senior Care Network:
9. On 12/2/15, at 3:34 p.m., the two sealed-lead acid batteries in the fire alarm control panel were dated 3/30/10. The batteries were due to be replaced in 2014.

Based on observation, the facility failed to maintain their sprinkler system control valves. This was evidenced by supervised control valves that failed to initiate remote trouble signals at the fire alarm panel when closed. This affected the Pavilion and the Raymond Building and could result in a delay in response, in the event of closure of the valves.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

19.3.5.2 Where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.2 Supervision.
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-9 Supervisory Signal-Initiating Devices.
2-9.1 Control Valve Supervisory Signal-Initiating Device.
2-9.1.1 Two separate and distinct signals shall be initiated: one indicating movement of the valve from its normal position and the other indicating restoration of the valve to its normal position. The off-normal signal shall be initiated during the first two revolutions of the hand wheel or during one-fifth of the travel distance of the valve control apparatus from its normal position. The off-normal signal shall not be restored at any valve position except normal.

Findings:

During a facility tour with the Director of Facilities (DFS1) 11/30/15 to 12/4/15, the supervised sprinkler control valves were observed.

Pavilion:
1. On 12/2/15, at 9:40 a.m., two of two outside screw and yoke (OS&Y) valves were tested. Both were supervised by tamper switches designed to send a trouble signal to the fire alarm panel upon closure of the valves. Pavilion Facilities Staff 1 and 2 closed the OS&Y valves all the way and they failed to send supervisory trouble signals to the fire alarm panel.

Raymond Building:
2. On 12/2/15, at 2:36 p.m., the supervised outside screw and yoke (OS&Y) valve (west valve) was closed all the way by fire alarm vendor technician. Closure of the valve failed to send a supervisory trouble signal to the fire alarm panel.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinkler escutcheon rings that were missing, by sprinklers that were not flush with the ceiling and by sprinkler spray patterns that were obstructed. This had the potential for the sprinkler system failure to contain or extinguish a fire. This affected three of eight floors in the East Tower, three of five floors in the Hahn Building, one of eight floors in the West Tower, the Pavilion Building, and the Raymond Building.

NFPA 101, Life Safety Code (2000) Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 13, Installation of Sprinkler Systems 1999, edition
Chapter 12 System Inspection, Testing, and Maintenance
12-1 General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water- Base Fire Protection Systems, 1998 edition
Chapter 2 Sprinkler Systems
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 (e.g. upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the sprinkler system was observed throughout the facility with the Plant Operations Managers (POM1 and POM2), the Hospital Safety Officer (HPSO), the Plant Maintenance (PMM4), and the Director of Facilities (DFS1).

East Tower, Ground Floor:
1. On 12/1/15, at 9:15 a.m., there was tape hanging from a sprinkler deflector in the central sterile room. This was confirmed by HPSO during the survey.

East Tower, First Floor:
2. On 12/1/15, at 9:38 a.m., there were sprinklers in NICU pod A and C that were not flush with the ceiling. This was confirmed by HPSO during the survey.

East Tower, Second Floor:
3. On 12/1/15, at 10:51 a.m., the sprinkler escutcheon ring inside of housekeeping room 2D106 was missing. This was confirmed by HPSO during the survey.

4. On 12/1/15, at 11:04 a.m., the sprinkler escutcheon ring, located inside the Same Day Surgery treatment room 12, was missing. This was confirmed by HPSO during the survey.

Hahn Building, Third Floor:
5. On 12/3/15, at 8:47 a.m., the sprinkler escutcheon ring was missing inside the corridor alcove located next to room 3514. This was confirmed by HPSO during the survey.

6. At 12/3/15, at 8:59 a.m., the sprinkler deflector inside the alcove across from room 3517 was obstructed by cardboard boxes. This was confirmed by HPSO during the survey.

Hahn Building, First Floor:
7. On 12/3/15, at 9:09 a.m., the sprinkler escutcheon ring was missing inside the conference room 1514.2.

Hahn Building, Ground Floor:
8. On 12/3/15, at 9:31 a.m., the sprinkler deflector in ambulatory care unit #2 closet was obstructed by storage. The closet is between room 2-9 and 2-10. This was confirmed by HPSO during the survey.


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Hahn Building, Ground Floor:
9. On 12/3/15, at 9:37 a.m., the sprinkler head with escutcheon ring in the Employee Health Physician Room G521, located in the Hahn Building Ground Floor, was not flush with the ceiling. This exposed a penetration around the sprinkler that measured approximately 2-inches. This finding was acknowledged by PMM3 during the survey.

10. On 12/3/15, at 9:53 a.m., the sprinkler head with escutcheon ring by the cross corridor doors G595, located in the Hahn Building Ground Floor, was not flush with the ceiling. This finding was acknowledged by PMM3 during the survey.


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West Tower, First Floor:
11. On 12/1/15, at 10:22 a.m., the recessed sprinkler head in the kitchen, near the main hood, was missing its cover.

12. On 12/1/15, at 10:25 a.m., the recessed sprinkler head in the kitchen catering dry storage room was missing its cover.

13. On 12/1/15, at 10:56 a.m., the sprinkler head in the gift shop storage room, near the work station, was missing an escutcheon ring.

Pavilion Building:
14. On 12/2/15, at 9:39 a.m., two of two outside screw and yoke (OS&Y) control valves were leaking at the stem.

Raymond Building:
15. On 12/2/15, at 2:34 p.m., two of two OS&Y control valves were leaking at the stem.

16. On 12/2/15, at 3:00 p.m., quarterly, annual, and five-year sprinkler system testing and inspection records were requested but not provided.

Based on observation, the facility failed to maintain their fire extinguishers. This was evidenced by fire extinguishers that were obstructed and by fire extinguishers with pressure gauges that indicated they were not in operable range. This could result in a delay in extinguishing a fire. This affected one of seven floors in the West Tower and the Senior Care Network.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

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

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
4-3.2 Procedures. Periodic inspection of fire extinguishers
shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During a facility tour with the Director of Facilities (DFS1) from 11/30/15 to 12/4/15, the fire extinguishers were observed.

West Tower, First Floor:
1. On 12/1/15, at 10:56 a.m., the needle of the pressure gauge on the Class ABC fire extinguisher in the admitting room indicated that it needed to be recharged.

Senior Care Network:
2. On 12/2/15, at 3:40 p.m., access to the fire extinguisher in the Xerox Room was obstructed by a copy machine.

Based on observation, record review, and interview, the facility failed to maintain their heating, ventilating, and air-conditioning system (HVAC) system. This was evidenced by no documentation for the repairing of two failed fire dampers, by a fire panel that identified two smoke dampers in trouble, by air filters that were not free of excessive dust and dirt, by inoperable static pressure gauges, and by incomplete records of testing fire dampers. The dirty filters can cause the HVAC system to overheat and result in fire, and the failure to maintain dampers could result in the faster spread of smoke and fire through the HVAC system. This affected one of five Floors in La Vina Building, the East Tower, the Raymond Building, and the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
Exception: As modified in 19.5.2.2.
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
4.61.2 Any requirement that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.
2-1.3 Equipment shall be guarded for personnel protection and against the intake of foreign matter into the system.
3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct system.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During document review and the facility tour with the Plant Operations Manager (POM2), the Hospital Patient Safety Officer (HPSO), and the Director of Facilities (DFS1) from 11/30/15 through 12/4/15, the fire damper reports were reviewed and the HVAC system was observed.

La Vina Building, First Floor:
1. On 12/1/15, at 2:01 p.m., the damper inspection reports dated 3/22/13, from an outside vendor documented two fire dampers (Identification numbers 1-05 and 1-06) failed in the La Vina Building, first floor Rehab office. In the action required/comments noted Faulty Actuator/No Access. During interview, POM2 stated the dampers were not repaired because there was no access to the dampers.


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East Tower, Ground Floor:
2. On 12/2/15, at 9:02 a.m., the Fire Alarm Control Panel (FACP) in the Emergency Department, located in the East Tower on the Ground Floor, listed two devices in trouble (address 01-001-02130454 and 01-001-03090177). The fire alarm vendor technician pulled up the devices and identified them as smoke dampers that were labeled ED_MAIN_DMCG-241 and ED_MAIN_DMCG-257. The fire alarm vendor technician did not know why the damper devices were in trouble and stated that they would need to investigate.


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East Tower, Ground Floor:
3. On 12/1/15, at 1:02 p.m., the static pressure gauge for the final filters in air handler unit (AHU) 1A was reading at approximately 2 inches of water.

During an interview at 1:03 p.m., the Director of Facilities (DFS1) stated that the filters are supposed to be changed at a pressure of 1 inch of water.

At 1:08 p.m., AHU 1A was turned off and the pressure needle for the final filters went beyond 2 inches of water while the other gauges read 0 after air flow stopped.

During an interview at 1:09 p.m., the DFS1 stated that the gauge for the AHU 1A final filters was broken.

On 12/2/15, at 8:46 a.m., Plant Maintenance Mechanic (PMM5) stated that the facility does not maintain the gauges because they have a central automated system. The system did not give exact static pressure readings but instead monitored air flow. On 12/3/15, at 8:45 a.m., he stated that it was the facility's policy to change the filters when the static pressure was between 0.75 and 1.00.

On 12/3/15, at 8:30 a.m., the header on the Facility Management Filter Log stated "recommended change out is 1.0" of static pressure." The logs showed that Plant Maintenance Staff 7 was conducting monthly inspections on the air handler filters. The documentation showed that the static pressure was documented during the inspections. For AHU 2, the acronym "V.I." was documented in lieu of a static pressure since 3/27/15 for the final filters. For AHU 2B, the acronym "V.I." was documented in lieu of a static pressure since 3/24/15 for the final filters and in all the months of 2015 for the pre-filters.

During an interview at 8:39 a.m., Plant Maintenance Mechanic (PMM7) stated that when the static pressure gauges are not working, he conducts visual inspections of the filter and documents "V.I." on the logs. PMM7 stated that the gauges for AHU 2 and 2B were not working.

The facility failed to maintain the static pressure pressure gauges used by the facility as an indicator for changing the air filters.

4. On 12/1/15, at 1:10 p.m., the final filters for AHU 1A were observed to be dirty with an excess accumulation of dust.

5. On 12/2/15, at 8:36 a.m., the exterior air intakes for AHU 1 and 1A were covered with dust and debris.

During an interview at 8:37 a.m., the DFS1 stated that the intakes are not cleaned because they are difficult to reach.

6. On 12/2/15, at 8:58 a.m.,the pre-filters and final filters for AHU 1 were covered with an excess accumulation of dust and dirt.

East Tower, Third Floor:
7. On 12/2/15, at 9:01 a.m., the pre-filters and final filters for AHU 2A were covered with an excess accumulation of dust and dirt.

8. On 12/2/15, at 9:12 a.m., the pre-filters and final filters for AHU 2 were covered with and excess accumulation of dust and dirt.

9. On 12/2/15, at 9:16 a.m., the pre-filters and final filters for AHU 2B were covered with an excess accumulation of dust and dirt.

Raymond Building:
10. On 12/2/15, at 2:51 p.m., records of testing the fire dampers were requested.

During an interview at 2:52 p.m., Raymond Building Manager stated that the building was equipped with fire dampers but they were not tested.

Pavilion Building:
11. On 12/4/15, at 10:01 a.m., records indicated that the fire dampers at the Pavilion were most recently tested on 5/6/10. The dampers were due to be tested in May 2014.

Based on observation, the facility failed to ensure that their chutes be maintained with the appropriate protection. This was evidenced by chute discharge doors that did not maintain automatic closing function. This could result in the rapid spread of fire and smoke and had the potential of harming patients, visitors, and staff with burns and/or smoke inhalation in the event of a fire. This affected one of five Floors in La Vina Building.

NFPA 101, Life Safety Code, 2000 Edition
19.5.4.2 Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with Section 9.7. (See Section 9.5.)
9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, 1999 Edition
3-2.2.9 Chute Discharge Doors. Gravity chutes shall be constructed so that the base opening of the chute or shaft, or both, shall be protected by an approved automatic-closing or self-closing 1-hour fire door suitable for a Class B opening.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the laundry and trash chutes were observed with the Plant Operations Managers (POM2), the Plant Maintenance Mechanics(PMM2), and the Coordinator Orthopedic Joint Program (Scribe1).

La Vina Building, Ground Floor:
1. On 12/1/15, at 9:42 a.m., the trash chute in Room G112, located in the La Vina Building on the Ground Floor, had its discharge door that was obstructed by trash and the door was held open by an unapproved method. The discharge door was held open by metal wire instead of using an approved method that would allow the door to close automatically during a fire. This finding was acknowledged by POM2 and PMM2 during the survey.

2. On 12/1/15, at 9:46 a.m., the laundry chute in Room G111, located in the La Vina Building on the Ground Floor, had its discharge door that was held open by an unapproved method. The discharge door was held open by metal wire instead of using an approved method that would allow the door to close automatically during a fire. This finding was acknowledged by POM2 and PMM2 during the survey.

Based on observation and interview, the facility failed to ensure that means of egress are maintained free from any obstructions. This was evidenced by items blocking the egress paths. This could result in the delay in the evacuation of the facility and the increased risk of injury to the patients and staff. This affected one of eight floors in the East Tower, one of two floors of the Della Martin Center, and one of four outpatient suites in the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.1.10.1 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.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the means of egress were observed with the Plant Operations Manager (POM1), the Hospital Safety Officer (HPSO), the Plant Maintenance (PMM4), and the Director of Facilities (DFS1).

East Tower, Ground Floor:
1. On 11/30/15 at 3:38 p.m., four beds were observed obstructing both sides of the north east corridor located outside of the emergency department.

On 12/2/15, at 2:21 p.m., during fire alarm testing there were three beds observed in the north east corridor outside of the emergency department obstructing both sides of the corridor. During interview, HPSO acknowledged the beds were obstructing both sides of the egress corridor.


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Pavilion Building, Suite 345:
2. On 12/2/15, at 10:54 a.m., there were two soiled linen bags and a cart blocking the exit door outside the soiled utility room.

Della Martin Center (DMC), First Floor:
3. On 12/3/15, at 2:35 p.m., the paved and gated exit pathway, outside the east end exit door of DMC 300, was obstructed by patio furniture. The paved pathway was approximately 7 feet 9 inches wide and was obstructed by a round table and chairs spanning approximately 5 feet 3 inches in width. The width of the egress path was reduced to approximately 2 1/2 feet.

During an interview at 2:36 p.m., DMC Interim Manager of Behavioral Services (IMBS) and the DMC Psych Services Supervisor (PSS) stated that the area was used as an outside patio.

Based on observation, document review, and interview, the facility failed to maintain humidity in anesthetizing locations in accordance with NFPA 99. This was evidenced by facility policy and procedure indicating humidity level range is 30% to 60%, and by the facility building automation system (BAS) humidity range set at 20% - 60%. This affected the operating rooms on the first floor and the second floor in the East Tower.

NFPA 101, Life Safety Code (2000) Edition
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities (1999) Edition
5-4.1 Ventilation - Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During observation, document review, and interview on 11/30/15 through 12/4/15 with Plant Operations Manager (POM2), Plant Maintenance Supervisor (PMM6) and Hospital Patient Safety Officer (HPSO), the humidity reports were reviewed and the building automation system (BAS) was observed.

Central Plant:
1. On 12/2/15, at 3:38 p.m., the Building Automation System (BAS) was observed to have the alarm parameters for humidity set at 20 to 60%. During interview, PMM6 stated the BAS monitors humidity in all the operating rooms including labor and delivery.

On 12/3/15, at 11:00 a.m., during document review, HPSO provided Policy and Procedure No. 596, for the monitoring of the temperature and humidity in clinical areas. The policy states the humidity parameters are set at 30 to 60% and is monitored and controlled by BAS. During interview, HPSO stated the facility did not have a categorical waiver for humidity and stated the humidity parameters in the BAS have been changed and are now set at 35 to 60%.

Based on observation and interview, the facility failed to ensure that their anesthetizing locations were provided with functional battery-powered emergency lighting units. This was evidenced by the catheterization laboratories (Cath Lab) and Operating Rooms (ORs) with battery-powered emergency lighting units that failed to illuminate when tested. This could result in no illumination in the ORs during a power outage and during the generator start-up period, and could result in harm to patients during the period of no illumination. This affected the Cath Labs in the La Vina Building and the Labor and Delivery (L&D) ORs in the East Tower.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
7.9.3 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. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.2 All Patient Care Areas. 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, National Electrical Code, Section 700-12(e).

NFPA 70, National Electrical Code, 1999 Edition.
700-12. (e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment
The batteries shall be of suitable rating and capacity to supply and maintain at not less than 87.5 percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 1.5 hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 1.5 hours. Storage batteries, whether of the acid or alkali type,
shall be designed and constructed to meet the requirements of emergency service
Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the
normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the anesthetizing locations were observed with the Plant Operations Managers (POM1), the Plant Maintenance Mechanics (PMM2 and PMM3), and the Coordinator Orthopedic Joint Program (Scribe1).

La Vina Building, Second Floor:
1. On 12/1/15, at 3:10 p.m., Cath Lab 2, located in the La Vina Building on the 2nd Floor, failed to illuminate 4 of 6 battery-powered emergency lighting units when tested via its test button. This finding was acknowledged by PMM2 during the survey.

2. On 12/1/15, at 3:20 p.m., Cath Lab 3, located in the La Vina Building on the 2nd Floor, failed to illuminate 5 of 6 battery-powered emergency lighting units when tested via its test button. This finding was acknowledged by PMM2 during the survey.

East Tower, First Floor:
3. On 12/3/15, at 11:43 a.m., L&D OR 2 (Room 1B180), located in the East Tower on the 1st Floor, failed to illuminate its battery-powered emergency lighting unit when tested via its test button. This finding was acknowledged by PMM3 during the survey.

Based on observation and interview, the facility failed to maintain their emergency generators. This was evidenced by inoperable remote alarm annunciators. This could result in a delay in staff notification and response to troubles with the generator and the increased risk of injury to the patients. This affected eight of eight patient care buildings on the main campus.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
(a) Type I and Type II essential electrical system power (107C) or the engine water-jacket temperature at not less than sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (See NFPA 70, National Electrical Code, Section 700-12)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency power source is operating to supply power to load
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

Findings:

During tour of facility with staff from 11/30/15 to 12/4/15, the generator and generator components were observed.

West Tower, Ground Floor:
1. On 11/30/15, at 3:47 p.m., there was a remote annunciator panel in PBX for the hospital's four generators. There were no status indicators lit on the panel and it failed the lamp test.

During an interview at 3:48 p.m., the Director of Facilities (DFS1) stated that it seemed like there was no power going to the annunciator.

Central Plant:
2. On 11/30/15, at 4:54 p.m., there was a remote annunciator panel in Central Plant for the hospital's four generators. The module labeled "Emergency System Remote Annunciator" on the panel had two status indicators that were lit: "Horn Alarm Silenced" and "PLC Failure". Status indicators for the four generators were not lit and the annunciator panel failed a lamp test.

During an interview at 4:55 p.m., Plant Maintenance Mechanic (PMM4) stated that the panel has not been working for approximately one month.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by failing to ensure weatherproofing of an area containing circuit switches, by failing to properly secure conductor cables, by missing cover plates, by multi-outlet power strips and adapters used in methods not permitted, and by blocked electrical panels. This had the potential for increasing the risk of electrical fire and electrical shock that may result in the injury to patients, visitors, and staff. This affected two of five floors in the Hahn Building, two of eight floors in the East Tower, the Basement and one of five floors in the Valentine Building, one of five floors in the La Vina Building, three of eight floors in the West Tower, and the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (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.
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.
110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.
Table 210-21(b)(2). Maximum Cord- and Plug-Connected Load to Receptacle
Circuit Rating (Amperes): 20
Receptacle Rating (Amperes): 20
Maximum Load (Amperes): 16
210-23. Permissible Loads. In no case shall the load exceed the branch-circuit ampere rating. An individual circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) through (d) and as summarized in Section 210-24 and Table 210-24.
370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.
380-9. Provisions for Snap Switch Faceplates. (a) Position. Snap switches mounted in boxes shall have faceplates installed so as to completely cover the opening and seat against the finished surface.
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
380-4. Wet Locations. A switch or circuit breaker in a wet location or outside of a building shall be enclosed in a weatherproof enclosure or cabinet that shall comply with Section 373-2(a). Switches shall not be installed within wet locations in tub or shower spaces unless installed as part of
a listed tub or shower assembly.
For information on lockout/tagout procedures, see Standard for Electrical Safety Requirements for Employee Workplaces, NFPA 70E-1995.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the electrical wiring and equipment was observed with the Plant Operations Managers (POM1 and POM2), the Hospital Safety Officer (HPSO), the Plant Maintenance Mechanics (PMM1, PMM2 and PMM4), and the Director of Facilities (DFS1).

East Tower, Ground Floor:
1. On 11/30/15, at 3:30 p.m., the refrigerator inside the social worker/care coordinator office GC135 was plugged into a power strip and not directly into the wall receptacle. This was confirmed by HPSO and POM1 during the survey.

2. On 11/30/15, at 3:26 p.m., the refrigerator in room GC140 was plugged into a power strip and not directly into the wall receptacle. This was confirmed by HPSO and POM1 during the survey.

3. On 12/1/15, at 9:09 a.m., there was a white extension cord used inside the radiology room GE137. The extension cord did not have overcurrent protection. This was confirmed by HPSO and POM1 during the survey.

East Tower, Fourth Floor:
4. On 12/01/15, at 11:30 a.m., a white three outlet wall adapter was observed in the corridor across from module 2 nurse station. The adapter was in use and had no overcurrent protection. This was confirmed by HPSO and POM1.

Hahn Building, Third Floor:
5. On 12/3/15, at 8:51 a.m., a power strip was observed to be plugged into another power strip under the desk in room 3520. This was confirmed by HPSO and POM1.


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Valentine Building, Basement Floor:
6. On 12/1/15, at 9:12 a.m., the electrical room containing high voltage switch gears, located in the Valentine Building on the Basement Floor, had a puddle of water in the corridor approximately 6-feet away from the door entrance. The water puddle measured approximately 3-feet in diameter. PMM1 stated that the water appeared to be coming from outside the building. PMM2 then stated that the building's seams between the wall and the floor needed some repair.

Valentine Building, Second Floor:
7. On 12/1/15, at 1:42 p.m., the IT Room, located in the Valentine Building on the 2nd Floor, had cables with exposed conductors coming out of the wall. POM1 stated that he believed that the electrical panel for the cables was located on the same wall adjacent to the cables. All the circuit switches to the panel (V2HEA) were in the off position. The panel was not locked and did not have the appropriate lockout/tagout procedures in place.

La Vina Building, Third Floor:
8. On 12/1/15, at 2:30 p.m., in the corridor by Room 3117, located in the La Vina Building on the 3rd Floor, there was white three outlet adapter connected to the dual wall outlet. The adapter had medical equipment plugged into it. This finding was confirmed by POM1 during the survey.

West Tower, Ground Floor:
9. On 12/2/15, at 2:04 p.m., in the corridor by Room GWH33, located in the West Tower on the Ground Floor, there was a dual wall outlet with scorched markings at the top of the outlet. This finding was confirmed by POM1 during the survey.

Hahn Building, Ground Floor:
10. On 12/3/15, at 9:32 p.m., in the Outpatient Clinic Area Room G525, located in the Hahn Building on the Ground Floor, there was no cover plate over a junction box.


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West Tower, Ground Floor:
11. On 11/30/15, at 4:25 p.m., there was a slide warmer and portable fume hood plugged into a six-plug power strip on the Cytology Bench in the laboratory.

12. On 11/30/15, at 4:26 p.m., there was an electrical box with no cover near the Cytology Bench in the laboratory.

West Tower, First Floor:
13. On 12/1/15, at 11:05 a.m., there was an extension cord plugged into a four-plug power strip near the work station in the gift shop storage room.

West Tower, Fifth Floor:
14. On 12/1/15, at 3:10 p.m., there was a four-plug power strip plugged into an eight-plug power strip in the Signal Room. The power strips were used for phone chargers.

Pavilion Building, Suite 100:
15. On 12/2/15, at 10:02 a.m., the light switch in Room 1104 was missing a cover plate.

16. On 12/2/15, at 10:08 a.m., access to Panel L136A was blocked by storage in the Equipment Room.

Based on observation and interview, the facility failed to have an appropriate life safety measure when devices for the fire alarm system were disabled. This was evidenced by failing to have a fire watch or other appropriate life safety measures when the smoke detectors were disabled for more than 4 hours in a 24-hour period. This could result in the delay in notifying occupants and responders during a fire, increasing the risk of injury to the patients and staff. This failure affected one of eight floors in the East Tower.

Findings:

During a facility tour with the Plant Operations Manage (POM1) from 11/30/15 to 12/4/15, the fire alarm system was observed.

East Tower, First Floor:
1. On 12/2/15, at 8:15 a.m., the Director of Facilities (DFS1) had informed the surveyor that four smoke detectors were disabled in an area that was undergoing a construction project and confirmed that no fire watch was conducted.

At 9:05 a.m., the Fire Alarm Control Panel (FACP) located in the Emergency Department listed four smoke detectors as disabled (address 01-001-2040008, 01-001-2040009, 01-001-2040010, and 01-001-2040011).

At 11:02 a.m., the smoke detector 2040010, located in the corridor by the soiled utility room in the Neonatal Intensive-Care Unit (NICU) on the 1st Floor East Tower, failed to alarm when attempting to activate it with canned smoke. The corridor containing the four smoke detectors were not separated from the egress path that was open to the NICU.

At 11:10 a.m., the Project Manager who identified himself as the Superintendent was interviewed. He stated that four smoke detectors (labeled 2040008, 2040009, 2040010, and 2040011) located in the corridor were disabled everyday from 7 a.m. to 2 p.m. while working on a construction project adjacent to the corridor. The Project Manager stated that there was no fire watch initiated during the times the four smoke detectors were disabled.

Based on observation and interview, the facility failed to ensure the Alcohol Based Hand Rub (ABHR) dispensers were not installed above or adjacent to an ignition source. This was evidenced by ABHR dispensers that were installed above or adjacent to electrical switches or outlets. This could increase the risk of an electrical fire and affected three of eight floors in the East Tower.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the Alcohol Based Hand Rub (ABHR) dispensers were observed throughout the facility with the Plant Operations Manager (POM1), the Hospital Safety Officer (HPSO), and the Plant Maintenance Mechanic (PMM4).

East Tower, Ground Floor:
1. On 12/1/15, at 8:58 a.m., the ABHR dispenser inside the trash collection room that is located in the North East corridor outside of the emergency department was installed above a light switch. There was evidenced of spill pattern on the wall below the dispenser. This was confirmed by HPSO and POM1.

East Tower, Second Floor-Surgery Suite:
2. On 12/2/15, at 10:22 a.m., 1 of 2 ABHR dispensers observed to be installed approximately 3 feet above an electrical outlet inside of operating room 6. This was confirmed by HPSO during the survey.

3. On 12/2/15, at 10:31 a.m., 1 of 2 ABHR dispensers observed to be installed approximately 3 feet above an electrical outlet inside of operating room 12. This was confirmed by HPSO during the survey.

East Tower, First Floor-Labor and Delivery:
4. On 12/2/15, at 11:17 a.m., the ABHR dispenser was observed to be installed approximately 3 feet above an electrical outlet inside of labor delivery room 3. This was confirmed by HPSO during the survey.

5. On 12/2/15, at 11:25 a.m., the ABHR dispenser was observed to be installed approximately 3 feet above an electrical outlet inside of labor delivery room 2. This was confirmed by HPSO during the survey.

Based on observation, document review, and interview, the facility failed to maintain building construction and fire-rated occupancy separations. This was evidenced by a building construction that is not permitted for health care occupancies, by one fire-rated door into an offsite suite that failed to latch, and by one fire-rated separation with a non-rated door. This failed to provide the appropriate protection that could result in the faster spread of smoke and fire. This affected 1938 Building, the Pavilion, and the Raymond Building.

NFPA 101, Life Safety Code, 2000 Edition.
18.1.1.4.2 Communicating openings in dividing fire barriers required by 18.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)
18.1.1.4.3 Doors in barriers required by 18.1.1.4.1 shall normally be kept closed.
Exception: Doors shall be permitted to be held open if they meet the requirements of 18.2.2.2.6.
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations:
Construction Type II (000): 4 or More Stories - Not Permitted.

Findings:

During a facility tour with the Director of Facilities (DFS1) and the Plant Operations Manager (POM1) from 11/30/15 to 12/4/15, the building construction and the fire-rated separations of the offsite suites were observed.

1938 Building:
1. On 12/4/15, at 8 a.m., the DFS1 provided building construction information for the 1938 Building. The 1938 Building was 5 stories in height. The document identified the 1938 Building as construction Type II (000) and it included the following note: healthcare occupancy located in a portion of the 4th Floor. The floor plans identified a portion of the Pediatric Unit in the 1938 Building. The 1938 Building was observed to be non-sprinklered on the 4th Floor. The Type II (000) was not a permitted construction type for health care occupancies five stories in height.


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Pavilion, Suite 355:
2. On 12/2/15, at 11:16 a.m., the door into Suite 355 from the Pavilion hallway was held open by a magnetic hold-open device. Upon activation of the fire alarm system, the door released from its hold-open device but failed to latch upon closure.

Raymond Building, Suite 120:
3. On 12/2/15, at 2:43 p.m., there were two doors going into the outpatient rehabilitation suite from the building lobby. The main entrance door was 90-minute fire-rated. The door into Speech Pathology was a non-rated glass panel door without a latch.

During an interview at 2:44 p.m., Raymond Building Manager stated that the previous tenant of the suite changed the original door, which was fire-rated and had a latch, to this glass panel door.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in a facility wall. This could result in the spread of fire and smoke, increasing the risk of injury to patients. This affected one of five Floors in Valentine Building.

NFPA 101, Life Safety Code, 2000 Edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
19.1.6.3 All interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.
8.2.3.1.1 Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the facility's walls and ceilings were observed with the Plant Operations Manager (POM1), the Plant Maintenance Mechanic (PMM3), and the Coordinator Orthopedic Joint Program (Scribe1).

Valentine Building, Fourth Floor:
1. On 12/3/15, at 10:20 a.m., the wall to the patient sleeping room in Room 4218, located in the Valentine Building on the 4th Floor, was observed to have penetrations going through the wall. The penetrations included two that measured approximately 1-inch and two that measured approximately 1/2-inch.

Based on observation, the facility failed to maintain doors opening into corridors. This was evidenced by doors with penetrations, doors held open by unapproved methods, and by doors that failed to positive latch. This had the potential to allow the migration of smoke and result in injury to patients. This affected one of five Floors in La Vina Building, two of eight floors in the West Tower, one of four suites in the Pavilion, and one of five floors in the Wingate Building.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous
areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the doors were observed with the Plant Operations Manager (POM1), the Director of Facilities (DFS1), the Plant Maintenance Mechanic (PMM2), and the Coordinator Orthopedic Joint Program (Scribe1).

La Vina Building, Fourth Floor:
1. On 12/1/15, at 3:48 p.m., the door to the patient sleeping room in Room 4114, located in the La Vina Building on the 4th Floor, had two holes going through the door. The holes measured approximately 1/2-inch each. PMM2 stated that it appeared that the door handle had been replaced with the incorrect type.


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West Tower, Ground Floor:
2. On 12/1/15, at 9:55 a.m., the 60-minute fire-rated door into the pharmacy office suite was held open by a rubber wedge and obstructed from closing.

West Tower, Fourth Floor:
3. On 12/1/15, at 2:36 p.m., the door to the W487 Ante Room was held open with a rubber wedge and obstructed from closing.

Pavilion, Suite 345:
4. On 12/2/15, at 11:03 a.m., the 1-hour fire-rated door to Conference Room 1 was held open by a rubber wedge and obstructed from closing.

Wingate Building, Second Floor:
5. On 12/3/15, at 3:24 p.m., the door to the Cardiac Rehab (Door 2434) was held open by a magnetic hold-open device. The door released upon activation of the fire alarm system but failed to latch upon closure.

Based on observation and interview, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls. This was evidenced by penetrations in the smoke barrier walls. This failure affected three of eight floors in the East Tower.

NFPA 101, Life Safety Code, 2000 Edition
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 1/2 hour.

8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the smoke barrier walls were observed with the Plant Operations Managers (POM1 and POM2), the Hospital Safety Officer (HPSO), and the Plant Maintenance (PMM4).

East Tower, First Floor:
1. On 12/1/15, at 10:06 a.m., there was an unsealed conduit with blue communication wires running through it in the smoke barrier wall above door 1E115 located in the maternity suite. This was confirmed by HPSO and PMM4.

East Tower, Second Floor:
2. On 12/1/15, at 10:56 a.m., there was a unsealed conduit with white communication wires running through in the smoke barrier wall above door 2D104 entering the Intensive Care Unit (ICU) suite. This was confirmed by HPSO and PMM4.

3. On 12/1/15, at 11:08 a.m., there were a unsealed conduit and an approximately 2 inch circular penetration in the wall above door 2B130 located in same day surgery. This was confirmed by HPSO and PMM4.

East Tower, Fifth Floor:
4. On 12/1/15, at 1:11 p.m., there was a unsealed conduit with communication wires running through in the smoke barrier wall above door 5EB25 in the surgical unit suite. This was confirmed by HPSO and PMM4 during survey.

Based on observation and interview, the facility failed to maintain the smoke barrier doors to operate without interference and to prevent the passage of smoke or fire. This was evidenced by smoke barrier doors that failed to close and positive latch upon activation of the fire alarm system. This could delay evacuation and could result in the spread of smoke and fire. This affected two of eight floors in the West Tower, four of eight floors in the East Tower, one of five floors in the La Vina Building, and one of five floors in the Hahn Building.

NFPA 101, Life Safety Code (2000) Edition
19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the smoke barrier doors were observed with the Plant Operations Managers (POM1 and POM2), the Hospital Safety Officer (HPSO), the Plant Maintenance (PMM4), the Director of Facilities (DFS1), and the Coordinator Orthopedic Joint Program (Scribe1).

West Tower, Second Floor:
1. On 12/2/15, at 1:24 p.m., smoke barrier door 2WH24 in the DOU, failed to close and positive latch during fire alarm testing. This was confirmed by HPSO.

East Tower, Ground Floor:
2. On 12/2/15, at 2:13 p.m., the smoke barrier door GD111 in the radiology registration failed to close and positive latch during fire alarm testing. This was confirmed by HPSO.

3. On 12/2/15, at 2:16 p.m., the smoke barrier door located in the north/east corridor by the fire alarm control panel room failed to close and latch. One of the double door leafs was dragging on the floor and would not fully close. This was confirmed by HPSO and POM1.

4. On 12/2/15, at 2:30 p.m., the smoke barrier doors GC230, GC218 and GC225 located in the emergency department failed to fully close and latch. This was confirmed by HPSO during the survey.


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East Tower, Sixth Floor:
5. On 12/2/15, at 9:36 a.m., the cross corridor doors 6EB01, located by the Nurse Station and Elevator #2 in the East Tower 6th Floor, failed to fully close and latch 1 of 2 doors. The door was observed to be dragging on the carpet and it was acknowledged by Scribe1 during the survey.

East Tower, Fifth Floor:
6. On 12/2/15, at 9:49 a.m., the cross corridor doors 5EB63, located by Module 4 in the East Tower 5th Floor, failed to fully close and latch 1 of 2 doors. The finding was acknowledged by Scribe1 during the survey.

East Tower, Second Floor:
7. On 12/2/15, at 10:43 a.m., the cross corridor doors 2A116.1, located by Elevator 4 in the East Tower 2nd Floor, failed to fully close and latch 1 of 2 doors. The finding was acknowledged by Scribe1 during the survey.

8. On 12/2/15, at 10:45 a.m., the cross corridor doors 2A100, located by Elevator 10 in the East Tower 2nd Floor, failed to fully close and latch 2 of 2 doors. The finding was acknowledged by Scribe1 during the survey.

West Tower, Second Floor:
9. On 12/2/15, at 1:25 p.m., the cross corridor doors 2WH42, located by Room W257 in the West Tower 2nd Floor, failed to fully close and latch 1 of 2 doors. The finding was acknowledged by Scribe1 during the survey.

La Vina Building, Second Floor:
10. On 12/3/15, at 1:38 p.m., the cross corridor doors 05227, located by Cath Lab 3 in the Lavina Building 2nd Floor, failed to fully close and latch 1 of 2 doors. The door was observed to have its rod latching mechanism not retracting and it was acknowledged by Scribe1 during the survey.


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Hahn Building, Ground Floor:
11. On 12/1/15, at 4:03 p.m., there was a cross-corridor door frame, outside the Perinatal Health Education/Breastfeeding Center, and there were fire alarm magnetic hold-open devices on either side of the door frame. The cross-corridor door was removed.

During an interview at 4:04 p.m., the Director of Facilities (DFS1) stated that the door was removed a few years ago because it was continuously getting hit by carts. He stated that the doors were removed without approval from the authority having jurisdiction (AHJ).

The blueprints showing the fire-rating of the removed door were requested but not provided.

Based on observation and interview, the facility failed to protect their hazardous area enclosures. This was evidenced by the failure to ensure the doors protecting hazardous areas latched upon self closure, by doors that were obstructed from closing, and by a penetration in one hazardous area enclosure. This could result in the increased risk of fire and or smoke to spread from one area to another. This affected one of eight floors in the East Tower and two of five floors in the Wingate Building, two of seven floors in the West Tower and one of four offsite suites in the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
18.3.2.1 Hazardous Areas. Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to the following:
(1) Boiler and fuel fired heater rooms
(2) Central/bulk laundries larger than 100 ft. (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft. (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
8.4.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.
8.4.1.2 In new construction, where protection is provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4.
Exception No. 1: This requirement shall not apply to mercantile occupancy general storage areas and stockrooms protected by automatic sprinklers in accordance with Section 9.7.
Exception No. 2: This requirement shall not apply to hazardous areas in industrial occupancies protected by automatic extinguishing systems in accordance with 40.3.2.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the hazardous areas were observed with the Plant Operations Manager (POM1), the Hospital Safety Officer (HPSO), the Plant Maintenance (PMM4), and the Director of Facilities (DFS1).

East Tower, Ground Floor:
1. On 12/1/15, at 9:59 a.m., the door to the trash collection room, located in the north east side of the emergency department, failed to latch upon self closure. During interview, POM1 stated the door was in the process of being repaired at the time of survey.

Wingate Building, Third Floor:
2. On 12/3/15, at 10:15 a.m., the dirty utility room door #3411 failed to latch upon self closure. This was confirmed by HPSO during the survey.

Wingate Building, Second Floor:
3. On 12/3/15, at 10:24 a.m., the dirty utility room door 2412.1 failed to latch upon self closure. The doors were open to the fullest extent and released. This was confirmed by HPSO during the survey.


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West Tower, Ground Floor:
4. On 11/30/15, at 4:05 p.m., the 60-minute fire-rated door into the pathology laboratory was held open by a rubber wedge and obstructed from closing.

West Tower, First Floor:
5. On 12/1/15, at 1:28 p.m., there was an approximately 6 inch by 3 inch penetration in the wall of the trash chute room, directly across from the chute.

Pavilion, Suite 345:
6. On 12/2/15, at 11:06 a.m., the door to the soiled linen room (Door 3124) was held open by a rubber wedge and obstructed from closing.

Based on record review and interview, the facility failed to maintain their battery-powered emergency lights. This was evidenced by missing and incomplete records of testing the battery-powered emergency lights. This could result in a delay in evacuation due to limited visibility, in the event of an emergency. This affected the Raymond Building and the Senior Care Network.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.1.1 Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the
following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator
that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and
vestibule emergency lighting power supply For the purposes of this requirement, exit access shall
include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

7.9.3 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. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with the Director of Facilities (DFS1) from 11/30/15 to 12/4/15, the emergency lights were observed and maintenance logs were requested.

Raymond Building:
1. On 12/2/15, at 3:10 p.m., records for the monthly 30-second and annual 90-minute testing of the battery-powered emergency lights were requested.

During an interview at 3:11 p.m., Raymond Building Maintenance Staff (Maint1) stated that the emergency lights and exit signs were not tested.

Senior Care Network (SCN):
2. On 12/3/15, at 9:40 a.m., records indicated that SCN Maintenance Staff (Maint2) was conducting monthly tests on the battery-powered emergency lights.

During an interview at 9:41 a.m., Maint2 stated that he checks the emergency lights by pushing the test buttons for a few seconds. He stated that he does not test them for 30 seconds monthly and 90 minutes annually.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by one exit sign that was not fully mounted, by one exit sign that was removed, and by two exit signs that were not illuminated. This could result in less visibility of the exit signs and a delay in evacuation. This affected one of five floors in the 1938 Building, the penthouse of the West Tower, and one of four offsite suites in the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
18.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

7.10.5.1 General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a facility tour with the Director of Facilities (DFS1), the Plant Operations Managers (POM1), the Plant Maintenance Mechanic (PMM2), and the Coordinator Orthopedic Joint Program (Scribe1) from 11/30/15 to 12/4/15, the exit signs were observed.

1938 Building, Second Floor:
1. On 12/1/15, at 1:26 p.m., the exit sign by the cross corridor doors 2247, located on the 2nd Floor in the 1938 Building, was not fully secured and hanging on by one screw. The finding was acknowledged by Scribe1 during the survey.


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West Tower, Seventh Floor Penthouse:
2. On 12/1/15, at 3:54 p.m., the base of an exit sign was observed on the wall outside Stairwell 10 (Door 7WHST10) but the actual exit sign was missing. The exit sign was observed on the floor near the stair landing.

Pavilion, Suite 100:
3. On 12/2/15, at 10:04 a.m., the LED exit sign by Room 1103 was not illuminated.

4. On 12/2/15, at 10:16 a.m., the LED exit sign outside the Equipment Room was not illuminated.

Based on document review and interview, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by quarterly fire drills held around the same time, by no activation of an audible fire alarm device during fire drills held after 6:00 a.m. and before 9:00 p.m., and by a staff who was not aware of her responsibilities and the use life safety devices in accordance with the facility's fire plan. This could result in staff to not properly respond to a fire and cause harm to patients. This affected the West Tower, the East Tower, and the Della Martin Center.

NFPA 101, Life Safety Code 2000 Edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.2* Fire 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2 Procedure in Case of Fire.
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During a tour of the facility and document review with the Plant Operations Managers (POM1 and POM2) and the Hospital Patient Safety Officer (HPSO) from 11/30/15 through 12/4/15, the quarterly fire drill reports were reviewed and the staff were interviewed to determine their knowledge of facility's fire emergency procedures.

West Tower:
1. On 12/3/15, between 3:30 p.m., and 4:30 p.m., the fire drills reports were provided. The fire drill reports for the West Tower PM shift (second shift), documented 4 of 10 drills were held between 7:40 p.m., and 7:45 p.m., all the fire drills were held before 9:00 p.m., and only two drills documented activation of a fire alarm device. The NOC shift (third Shift) fire drills documented 7 of 7 drills were held between 1:25 a.m., and 1:40 a.m.

East Tower:
2. On 12/3/15, between 3:30 and 4:30 p.m., the fire drill reports for East Tower documented the PM shift (second shift) were held between 7:40 p.m., and 7:45 p.m., there was no documentation for the activation of a fire alarm device during 5 of 5 drills. The NOC shift drills (third shift) documented 5 of 6 drills were held between 1:20 a.m. and 1:40 a.m.

Della Martin Center:
3. On 12/3/15, between 3:00 and 4:30 p.m., the fire drill reports for Della Martin Center documented 4 of 8 drills were held after 6 a.m., and before 9:00 p.m., there was no activation of a fire alarm device during any of the 4 fire drills. During an interview, the HPSO stated the fire drills are conducted by hospital security.


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East Tower, Ground Floor:
4. On 12/2/15, at 2:33 p.m., the environmental service staff working in the Emergency Department near the Patient Waiting Area was interviewed to determine her knowledge of the facility's fire emergency procedures and usage of life safety equipment. The staff stated that she had not received training and was not familiar with the facility's fire and disaster plan.

Based on observation, record review, and interview, the facility failed to ensure that their fire alarm system was in reliable operating condition. This was evidenced by the modification of the fire alarm system without approval from the authority having jurisdiction (AHJ). This was also evidenced by fire alarm notification appliances that could only be activated by a manual means. This could result in delayed notification and response, and possible harm to patients, in the event of a fire. This affected one of four patient care units at the Della Martin Center.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

4.1.1 Fire and Similar Emergency. The goal of this Code is to provide an environment for the occupants that is reasonably safe from fire and similar emergencies by the following means:
(1) Protection of occupants not intimate with the initial fire development
(2) Improvement of the survivability of occupants intimate with the initial fire development.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.1.3 System Design. Fire alarm system plans and specifications shall be developed in accordance with this code by persons who are experienced in the proper design, application, installation, and testing of fire alarm systems. The system designer shall be identified on the system design documents. Evidence of qualifications shall be provided when requested by the authority having jurisdiction.

1-5.5.2.1 All systems shall be installed in accordance with the specifications and standards approved by the authority having jurisdiction.

1-5.7.1.1 The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. All required annunciation means shall be readily accessible to responding personnel and shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.

1-6.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. At its request, complete information regarding the system or system alterations, including specifications, wiring diagrams, battery calculation, and floor plans shall be submitted for approval.

Findings:

During a facility tour with the Director of Facilities (DFS1) from 11/30/15 to 12/4/15, the fire alarm system at the DMC 400 Locked Unit was observed.

Della Martin Center (DMC), First Floor:
1. On 12/3/15, at 10:00 a.m., there were three pull stations in DMC 400 that had key inserts in the middle above the pull station handles. Per the Fire Alarm Training policy, keys can be inserted into the pull stations to unlock the exit doors. The policy stated that there were two stages to unlock the doors. The policy stated that the first stage (Phase 1) was to remove the pull station protective cover, pull the lever, and this should activate the strobes, bells, and notify PBX (operator). The second stage (Phase 2) was to insert the fire pull box key and rotate 1/4 turn clockwise to unlock the doors.

During an interview at 10:03 a.m., the DMC Interim Manager of Behavioral Services (IMBS) and the DMC Psych Services Supervisor (PSS) stated that this system was put in place approximately 1 year ago. The Director of Facilities (DFS1) stated that the facility did not obtain approval from the Office of Statewide Health Planning and Development (OSHPD) for these modifications to the fire alarm system.

An invoice from the fire alarm vendor indicated that the three pull stations were installed on 5/27/14.

On 12/4/15, at 1:20 p.m., a Fire Life Safety Officer (FLSO) and an Area Compliance Officer (ACO) from OSHPD were onsite at the facility. After observing the modified pull stations at DMC 400, the ACO confirmed that a permit/approval would have been required for installation of these pull stations.

2. On 12/3/15, at 10:04 a.m., the pull station outside Room 401 in DMC 400 was tested (Phase 1: pull station cover removed and pull station handle was pulled down). Alarm notification devices outside DMC 400 were activated but the three notification devices (horn/strobe combination) in DMC 400 failed. The alarms from outside DMC 400 could not be heard in the Day Room and towards the east end of the unit.

During an interview at 10:10 a.m., the DFS1 stated that a fire watch would be implemented in DMC 400 immediately.

3. On 12/3/15, at 10:13 a.m., the smoke detector in Room 401 was tested. Alarm notification devices outside DMC 400 were activated but the three notification devices in DMC 400 failed.
Facility staff were asked to demonstrate Phase 2 of their fire plan (insertion of the pull station key to unlock the exit doors) while the smoke detector was still in alarm. The three notification devices in DMC 400 only activated after turning of the key in the pull station.

During an interview at 10:16 a.m., the DFS1 stated that this was a programing error with the fire alarm system and fire alarm notification devices should have activated before Phase 2.

4. On 12/3/15, at 10:27 a.m., the Inspector's Test Valve (ITV) at DMC was tested. Alarm notification devices outside DMC 400 activated within 43 seconds but the three notification devices in DMC 400 failed to activate after two minutes of opening the ITV. The notification devices only activated after staff implemented Phase 2 of their fire plan (turning the key in the pull station).

On 12/4/15, at 9:00 a.m., the fire alarm system at DMC 400 was tested again after the vendor informed the facility that the programming issue was fixed. Activation of the pull station outside Room 401 (Phase 1) activated the notification devices in DMC 400. Activation of the smoke detector in 401 and the ITV failed to activate the notification devices in DMC 400 until Phase 2 (turning of the pull box key) was implemented by staff.

During an interview at 9:12 a.m., the DFS1 stated that they will continue to implement a fire watch at DMC 400 until the issue was fixed.

Based on observation and interview, the facility failed to maintain their fire alarm system. This was evidenced by visual alarms that fail to function, by strobe lights that were not synchronized, by one fire alarm panel that was out of service, one fire alarm subpanel that required updated device addresses, by one smoke detector that was dirty, and by one smoke detector that was obstructed. This was also evidenced by the failure of an Inspector's Test Valve to initiate an alarm throughout the third floor of the Pavilion, and by sealed-lead acid batteries that were due to be replaced. These deficiencies could result in a delay in notification and staff response, in the event of a fire or abnormal condition with the fire alarm system. This affected two of five Floors in Valentine Building, one of five floors in the Wingate Building, the West Tower, the smoke/fire dampers in the East Tower, three of four offsite suites in the Pavilion, and the Senior Care Network.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.
4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.7.1.1 The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. All required annunciation means shall be readily accessible to responding personnel and shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.
4-4.4.1.1 (4) More than two visible notification appliances in the same room or adjacent space within the field of view that flash on synchronization. This requirement shall not preclude synchronization of appliances that are not within the
same field of view.
7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.
Table 7-3.2 Testing Frequencies, requires annual testing of:
1. Control Equipment - Building Systems Connected to Supervising Station
a. Functions
b. Fuses
c. Interfaced Equipment
d. Lamps and LEDs
e. Primary (Main) Power Supply
f. Transponders
6. Batteries - Fire Alarm Systems
d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years.)
2. Discharge Test (30 minutes)
9. Control Unit Trouble Signals
14. Remote Annunciators
15. Initiating Devices
19. Alarm Notification Appliances
7-4.1 Fire alarm system equipment shall be maintained in accordance with the manufacturer's instructions. The frequency of maintenance shall depend on the type of equipment and the local ambient conditions.

Findings:

During a facility tour with the Director of Facilities (DFS1), the Plant Operations Managers (POM1), and the Coordinator Orthopedic Joint Program (Scribe1) from 11/30/15 to 12/4/15, the fire alarm system was observed.

Valentine Building, Fourth Floor:
1. On 12/3/15, at 2:08 p.m., the visual fire alarm device in the corridor outside of Room 4206, located in Valentine Building on the 4th Floor, failed to illuminate when a smoke detector was activated in the room. The device was red and labeled "fire."

Valentine Building, Third Floor:
2. On 12/3/15, at 2:16 p.m., the visual fire alarm device in the corridor outside of Room 3203, located in Valentine Building on the 3rd Floor, failed to illuminate when a smoke detector was activated in the room. The device was red and labeled "fire." The POM1 was interviewed and he stated that those devices in the Valentine Building are not currently working and that a project will be opened to make repairs.

Wingate Building, Second Floor:
3. On 12/3/15, at 2:16 p.m., the strobe light fire alarm device in the Cardiac Rehabilitation, located in the Wingate Building on the 2nd Floor, was not synchronized to flash at the same time with the strobe lights in the field of view and located in the corridor. The finding was acknowledged by Scribe1 during the survey.


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West Tower, Ground Floor:
4. On 11/30/15, at 4:00 p.m., Fire Alarm Control Panels (FACP) 47 and 48 were in the electrical room. The LED panel on FACP 48 was not lit and the panel did not exhibit the trouble signals shown in FACP 47.

On 12/3/15, at 1:15 p.m., FACP 48 was still inactive.
During an interview at 1:16 p.m., the Director of Facilities (DFS1) stated that the vendor needs to replace a module on this panel so it can be operational.

Hahn Building, Ground Floor:
5. On 11/30/15, at 5:15 p.m., there were fire alarm panels in the maintenance shop that showed the status of the fire smoke dampers connected to the fire alarm system. The panels indicated if the dampers were opened or closed. There were 42 dampers located in the East Tower that did not exhibit an "open" or "closed" status on the panel. Their status indicators were not lit.

During an interview at 5:16 p.m., the Plant Operations Manager (POM2) stated that he will have a vendor investigate and verify the status of the dampers that were not lit on the panel. He was unsure if those 42 dampers had issues with their relays or if there was an issue with the panel itself.

On 12/1/15, at 4:11 p.m., the damper panels in the maintenance shop were relabeled.

During an interview at 4:12 p.m., Technician 1 from the fire alarm vendor stated that the dampers that were not illuminated on the panel were removed or relocated during a 2010 Emergency Department remodel. He stated that technicians were still working on re-labeling the panels to make it accurate.

West Tower, First Floor:
6. On 12/1/15, at 1:27 p.m., the smoke detector in the trash chute room was covered in dirt, debris, and dust.

Pavilion:
7. On 12/2/15, at 10:48 a.m., the Inspector's Test Valve (ITV) on the third floor of Stairwell 2 was tested by a fire alarm vendor technician. The fire alarm notification devices on the first floor activated within 35 seconds but failed to activate on the third floor after the valve was opened for two minutes. No alarms could be heard on the third floor. The ITV was tested again at 11:12 a.m., and only the fire alarm notification devices on the first floor were activated.

Pavilion Building, Suite 345:
8. On 12/2/15, at 10:55 a.m., the smoke detector outside the IDF Room was entirely covered with a plastic cap.

Senior Care Network:
9. On 12/2/15, at 3:34 p.m., the two sealed-lead acid batteries in the fire alarm control panel were dated 3/30/10. The batteries were due to be replaced in 2014.

Based on observation, the facility failed to maintain their sprinkler system control valves. This was evidenced by supervised control valves that failed to initiate remote trouble signals at the fire alarm panel when closed. This affected the Pavilion and the Raymond Building and could result in a delay in response, in the event of closure of the valves.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

19.3.5.2 Where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.2 Supervision.
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-9 Supervisory Signal-Initiating Devices.
2-9.1 Control Valve Supervisory Signal-Initiating Device.
2-9.1.1 Two separate and distinct signals shall be initiated: one indicating movement of the valve from its normal position and the other indicating restoration of the valve to its normal position. The off-normal signal shall be initiated during the first two revolutions of the hand wheel or during one-fifth of the travel distance of the valve control apparatus from its normal position. The off-normal signal shall not be restored at any valve position except normal.

Findings:

During a facility tour with the Director of Facilities (DFS1) 11/30/15 to 12/4/15, the supervised sprinkler control valves were observed.

Pavilion:
1. On 12/2/15, at 9:40 a.m., two of two outside screw and yoke (OS&Y) valves were tested. Both were supervised by tamper switches designed to send a trouble signal to the fire alarm panel upon closure of the valves. Pavilion Facilities Staff 1 and 2 closed the OS&Y valves all the way and they failed to send supervisory trouble signals to the fire alarm panel.

Raymond Building:
2. On 12/2/15, at 2:36 p.m., the supervised outside screw and yoke (OS&Y) valve (west valve) was closed all the way by fire alarm vendor technician. Closure of the valve failed to send a supervisory trouble signal to the fire alarm panel.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinkler escutcheon rings that were missing, by sprinklers that were not flush with the ceiling and by sprinkler spray patterns that were obstructed. This had the potential for the sprinkler system failure to contain or extinguish a fire. This affected three of eight floors in the East Tower, three of five floors in the Hahn Building, one of eight floors in the West Tower, the Pavilion Building, and the Raymond Building.

NFPA 101, Life Safety Code (2000) Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 13, Installation of Sprinkler Systems 1999, edition
Chapter 12 System Inspection, Testing, and Maintenance
12-1 General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water- Base Fire Protection Systems, 1998 edition
Chapter 2 Sprinkler Systems
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 (e.g. upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the sprinkler system was observed throughout the facility with the Plant Operations Managers (POM1 and POM2), the Hospital Safety Officer (HPSO), the Plant Maintenance (PMM4), and the Director of Facilities (DFS1).

East Tower, Ground Floor:
1. On 12/1/15, at 9:15 a.m., there was tape hanging from a sprinkler deflector in the central sterile room. This was confirmed by HPSO during the survey.

East Tower, First Floor:
2. On 12/1/15, at 9:38 a.m., there were sprinklers in NICU pod A and C that were not flush with the ceiling. This was confirmed by HPSO during the survey.

East Tower, Second Floor:
3. On 12/1/15, at 10:51 a.m., the sprinkler escutcheon ring inside of housekeeping room 2D106 was missing. This was confirmed by HPSO during the survey.

4. On 12/1/15, at 11:04 a.m., the sprinkler escutcheon ring, located inside the Same Day Surgery treatment room 12, was missing. This was confirmed by HPSO during the survey.

Hahn Building, Third Floor:
5. On 12/3/15, at 8:47 a.m., the sprinkler escutcheon ring was missing inside the corridor alcove located next to room 3514. This was confirmed by HPSO during the survey.

6. At 12/3/15, at 8:59 a.m., the sprinkler deflector inside the alcove across from room 3517 was obstructed by cardboard boxes. This was confirmed by HPSO during the survey.

Hahn Building, First Floor:
7. On 12/3/15, at 9:09 a.m., the sprinkler escutcheon ring was missing inside the conference room 1514.2.

Hahn Building, Ground Floor:
8. On 12/3/15, at 9:31 a.m., the sprinkler deflector in ambulatory care unit #2 closet was obstructed by storage. The closet is between room 2-9 and 2-10. This was confirmed by HPSO during the survey.


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Hahn Building, Ground Floor:
9. On 12/3/15, at 9:37 a.m., the sprinkler head with escutcheon ring in the Employee Health Physician Room G521, located in the Hahn Building Ground Floor, was not flush with the ceiling. This exposed a penetration around the sprinkler that measured approximately 2-inches. This finding was acknowledged by PMM3 during the survey.

10. On 12/3/15, at 9:53 a.m., the sprinkler head with escutcheon ring by the cross corridor doors G595, located in the Hahn Building Ground Floor, was not flush with the ceiling. This finding was acknowledged by PMM3 during the survey.


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West Tower, First Floor:
11. On 12/1/15, at 10:22 a.m., the recessed sprinkler head in the kitchen, near the main hood, was missing its cover.

12. On 12/1/15, at 10:25 a.m., the recessed sprinkler head in the kitchen catering dry storage room was missing its cover.

13. On 12/1/15, at 10:56 a.m., the sprinkler head in the gift shop storage room, near the work station, was missing an escutcheon ring.

Pavilion Building:
14. On 12/2/15, at 9:39 a.m., two of two outside screw and yoke (OS&Y) control valves were leaking at the stem.

Raymond Building:
15. On 12/2/15, at 2:34 p.m., two of two OS&Y control valves were leaking at the stem.

16. On 12/2/15, at 3:00 p.m., quarterly, annual, and five-year sprinkler system testing and inspection records were requested but not provided.

Based on observation, the facility failed to maintain their fire extinguishers. This was evidenced by fire extinguishers that were obstructed and by fire extinguishers with pressure gauges that indicated they were not in operable range. This could result in a delay in extinguishing a fire. This affected one of seven floors in the West Tower and the Senior Care Network.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

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

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
4-3.2 Procedures. Periodic inspection of fire extinguishers
shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During a facility tour with the Director of Facilities (DFS1) from 11/30/15 to 12/4/15, the fire extinguishers were observed.

West Tower, First Floor:
1. On 12/1/15, at 10:56 a.m., the needle of the pressure gauge on the Class ABC fire extinguisher in the admitting room indicated that it needed to be recharged.

Senior Care Network:
2. On 12/2/15, at 3:40 p.m., access to the fire extinguisher in the Xerox Room was obstructed by a copy machine.

Based on observation, record review, and interview, the facility failed to maintain their heating, ventilating, and air-conditioning system (HVAC) system. This was evidenced by no documentation for the repairing of two failed fire dampers, by a fire panel that identified two smoke dampers in trouble, by air filters that were not free of excessive dust and dirt, by inoperable static pressure gauges, and by incomplete records of testing fire dampers. The dirty filters can cause the HVAC system to overheat and result in fire, and the failure to maintain dampers could result in the faster spread of smoke and fire through the HVAC system. This affected one of five Floors in La Vina Building, the East Tower, the Raymond Building, and the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
Exception: As modified in 19.5.2.2.
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
4.61.2 Any requirement that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.
2-1.3 Equipment shall be guarded for personnel protection and against the intake of foreign matter into the system.
3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct system.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During document review and the facility tour with the Plant Operations Manager (POM2), the Hospital Patient Safety Officer (HPSO), and the Director of Facilities (DFS1) from 11/30/15 through 12/4/15, the fire damper reports were reviewed and the HVAC system was observed.

La Vina Building, First Floor:
1. On 12/1/15, at 2:01 p.m., the damper inspection reports dated 3/22/13, from an outside vendor documented two fire dampers (Identification numbers 1-05 and 1-06) failed in the La Vina Building, first floor Rehab office. In the action required/comments noted Faulty Actuator/No Access. During interview, POM2 stated the dampers were not repaired because there was no access to the dampers.


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East Tower, Ground Floor:
2. On 12/2/15, at 9:02 a.m., the Fire Alarm Control Panel (FACP) in the Emergency Department, located in the East Tower on the Ground Floor, listed two devices in trouble (address 01-001-02130454 and 01-001-03090177). The fire alarm vendor technician pulled up the devices and identified them as smoke dampers that were labeled ED_MAIN_DMCG-241 and ED_MAIN_DMCG-257. The fire alarm vendor technician did not know why the damper devices were in trouble and stated that they would need to investigate.


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East Tower, Ground Floor:
3. On 12/1/15, at 1:02 p.m., the static pressure gauge for the final filters in air handler unit (AHU) 1A was reading at approximately 2 inches of water.

During an interview at 1:03 p.m., the Director of Facilities (DFS1) stated that the filters are supposed to be changed at a pressure of 1 inch of water.

At 1:08 p.m., AHU 1A was turned off and the pressure needle for the final filters went beyond 2 inches of water while the other gauges read 0 after air flow stopped.

During an interview at 1:09 p.m., the DFS1 stated that the gauge for the AHU 1A final filters was broken.

On 12/2/15, at 8:46 a.m., Plant Maintenance Mechanic (PMM5) stated that the facility does not maintain the gauges because they have a central automated system. The system did not give exact static pressure readings but instead monitored air flow. On 12/3/15, at 8:45 a.m., he stated that it was the facility's policy to change the filters when the static pressure was between 0.75 and 1.00.

On 12/3/15, at 8:30 a.m., the header on the Facility Management Filter Log stated "recommended change out is 1.0" of static pressure." The logs showed that Plant Maintenance Staff 7 was conducting monthly inspections on the air handler filters. The documentation showed that the static pressure was documented during the inspections. For AHU 2, the acronym "V.I." was documented in lieu of a static pressure since 3/27/15 for the final filters. For AHU 2B, the acronym "V.I." was documented in lieu of a static pressure since 3/24/15 for the final filters and in all the months of 2015 for the pre-filters.

During an interview at 8:39 a.m., Plant Maintenance Mechanic (PMM7) stated that when the static pressure gauges are not working, he conducts visual inspections of the filter and documents "V.I." on the logs. PMM7 stated that the gauges for AHU 2 and 2B were not working.

The facility failed to maintain the static pressure pressure gauges used by the facility as an indicator for changing the air filters.

4. On 12/1/15, at 1:10 p.m., the final filters for AHU 1A were observed to be dirty with an excess accumulation of dust.

5. On 12/2/15, at 8:36 a.m., the exterior air intakes for AHU 1 and 1A were covered with dust and debris.

During an interview at 8:37 a.m., the DFS1 stated that the intakes are not cleaned because they are difficult to reach.

6. On 12/2/15, at 8:58 a.m.,the pre-filters and final filters for AHU 1 were covered with an excess accumulation of dust and dirt.

East Tower, Third Floor:
7. On 12/2/15, at 9:01 a.m., the pre-filters and final filters for AHU 2A were covered with an excess accumulation of dust and dirt.

8. On 12/2/15, at 9:12 a.m., the pre-filters and final filters for AHU 2 were covered with and excess accumulation of dust and dirt.

9. On 12/2/15, at 9:16 a.m., the pre-filters and final filters for AHU 2B were covered with an excess accumulation of dust and dirt.

Raymond Building:
10. On 12/2/15, at 2:51 p.m., records of testing the fire dampers were requested.

During an interview at 2:52 p.m., Raymond Building Manager stated that the building was equipped with fire dampers but they were not tested.

Pavilion Building:
11. On 12/4/15, at 10:01 a.m., records indicated that the fire dampers at the Pavilion were most recently tested on 5/6/10. The dampers were due to be tested in May 2014.

Based on observation, the facility failed to ensure that their chutes be maintained with the appropriate protection. This was evidenced by chute discharge doors that did not maintain automatic closing function. This could result in the rapid spread of fire and smoke and had the potential of harming patients, visitors, and staff with burns and/or smoke inhalation in the event of a fire. This affected one of five Floors in La Vina Building.

NFPA 101, Life Safety Code, 2000 Edition
19.5.4.2 Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with Section 9.7. (See Section 9.5.)
9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, 1999 Edition
3-2.2.9 Chute Discharge Doors. Gravity chutes shall be constructed so that the base opening of the chute or shaft, or both, shall be protected by an approved automatic-closing or self-closing 1-hour fire door suitable for a Class B opening.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the laundry and trash chutes were observed with the Plant Operations Managers (POM2), the Plant Maintenance Mechanics(PMM2), and the Coordinator Orthopedic Joint Program (Scribe1).

La Vina Building, Ground Floor:
1. On 12/1/15, at 9:42 a.m., the trash chute in Room G112, located in the La Vina Building on the Ground Floor, had its discharge door that was obstructed by trash and the door was held open by an unapproved method. The discharge door was held open by metal wire instead of using an approved method that would allow the door to close automatically during a fire. This finding was acknowledged by POM2 and PMM2 during the survey.

2. On 12/1/15, at 9:46 a.m., the laundry chute in Room G111, located in the La Vina Building on the Ground Floor, had its discharge door that was held open by an unapproved method. The discharge door was held open by metal wire instead of using an approved method that would allow the door to close automatically during a fire. This finding was acknowledged by POM2 and PMM2 during the survey.

Based on observation and interview, the facility failed to ensure that means of egress are maintained free from any obstructions. This was evidenced by items blocking the egress paths. This could result in the delay in the evacuation of the facility and the increased risk of injury to the patients and staff. This affected one of eight floors in the East Tower, one of two floors of the Della Martin Center, and one of four outpatient suites in the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.1.10.1 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.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the means of egress were observed with the Plant Operations Manager (POM1), the Hospital Safety Officer (HPSO), the Plant Maintenance (PMM4), and the Director of Facilities (DFS1).

East Tower, Ground Floor:
1. On 11/30/15 at 3:38 p.m., four beds were observed obstructing both sides of the north east corridor located outside of the emergency department.

On 12/2/15, at 2:21 p.m., during fire alarm testing there were three beds observed in the north east corridor outside of the emergency department obstructing both sides of the corridor. During interview, HPSO acknowledged the beds were obstructing both sides of the egress corridor.


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Pavilion Building, Suite 345:
2. On 12/2/15, at 10:54 a.m., there were two soiled linen bags and a cart blocking the exit door outside the soiled utility room.

Della Martin Center (DMC), First Floor:
3. On 12/3/15, at 2:35 p.m., the paved and gated exit pathway, outside the east end exit door of DMC 300, was obstructed by patio furniture. The paved pathway was approximately 7 feet 9 inches wide and was obstructed by a round table and chairs spanning approximately 5 feet 3 inches in width. The width of the egress path was reduced to approximately 2 1/2 feet.

During an interview at 2:36 p.m., DMC Interim Manager of Behavioral Services (IMBS) and the DMC Psych Services Supervisor (PSS) stated that the area was used as an outside patio.

Based on observation, document review, and interview, the facility failed to maintain humidity in anesthetizing locations in accordance with NFPA 99. This was evidenced by facility policy and procedure indicating humidity level range is 30% to 60%, and by the facility building automation system (BAS) humidity range set at 20% - 60%. This affected the operating rooms on the first floor and the second floor in the East Tower.

NFPA 101, Life Safety Code (2000) Edition
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities (1999) Edition
5-4.1 Ventilation - Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During observation, document review, and interview on 11/30/15 through 12/4/15 with Plant Operations Manager (POM2), Plant Maintenance Supervisor (PMM6) and Hospital Patient Safety Officer (HPSO), the humidity reports were reviewed and the building automation system (BAS) was observed.

Central Plant:
1. On 12/2/15, at 3:38 p.m., the Building Automation System (BAS) was observed to have the alarm parameters for humidity set at 20 to 60%. During interview, PMM6 stated the BAS monitors humidity in all the operating rooms including labor and delivery.

On 12/3/15, at 11:00 a.m., during document review, HPSO provided Policy and Procedure No. 596, for the monitoring of the temperature and humidity in clinical areas. The policy states the humidity parameters are set at 30 to 60% and is monitored and controlled by BAS. During interview, HPSO stated the facility did not have a categorical waiver for humidity and stated the humidity parameters in the BAS have been changed and are now set at 35 to 60%.

Based on observation and interview, the facility failed to ensure that their anesthetizing locations were provided with functional battery-powered emergency lighting units. This was evidenced by the catheterization laboratories (Cath Lab) and Operating Rooms (ORs) with battery-powered emergency lighting units that failed to illuminate when tested. This could result in no illumination in the ORs during a power outage and during the generator start-up period, and could result in harm to patients during the period of no illumination. This affected the Cath Labs in the La Vina Building and the Labor and Delivery (L&D) ORs in the East Tower.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
7.9.3 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. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.2 All Patient Care Areas. 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, National Electrical Code, Section 700-12(e).

NFPA 70, National Electrical Code, 1999 Edition.
700-12. (e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment
The batteries shall be of suitable rating and capacity to supply and maintain at not less than 87.5 percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 1.5 hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 1.5 hours. Storage batteries, whether of the acid or alkali type,
shall be designed and constructed to meet the requirements of emergency service
Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the
normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the anesthetizing locations were observed with the Plant Operations Managers (POM1), the Plant Maintenance Mechanics (PMM2 and PMM3), and the Coordinator Orthopedic Joint Program (Scribe1).

La Vina Building, Second Floor:
1. On 12/1/15, at 3:10 p.m., Cath Lab 2, located in the La Vina Building on the 2nd Floor, failed to illuminate 4 of 6 battery-powered emergency lighting units when tested via its test button. This finding was acknowledged by PMM2 during the survey.

2. On 12/1/15, at 3:20 p.m., Cath Lab 3, located in the La Vina Building on the 2nd Floor, failed to illuminate 5 of 6 battery-powered emergency lighting units when tested via its test button. This finding was acknowledged by PMM2 during the survey.

East Tower, First Floor:
3. On 12/3/15, at 11:43 a.m., L&D OR 2 (Room 1B180), located in the East Tower on the 1st Floor, failed to illuminate its battery-powered emergency lighting unit when tested via its test button. This finding was acknowledged by PMM3 during the survey.

Based on observation and interview, the facility failed to maintain their emergency generators. This was evidenced by inoperable remote alarm annunciators. This could result in a delay in staff notification and response to troubles with the generator and the increased risk of injury to the patients. This affected eight of eight patient care buildings on the main campus.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
(a) Type I and Type II essential electrical system power (107C) or the engine water-jacket temperature at not less than sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (See NFPA 70, National Electrical Code, Section 700-12)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency power source is operating to supply power to load
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

Findings:

During tour of facility with staff from 11/30/15 to 12/4/15, the generator and generator components were observed.

West Tower, Ground Floor:
1. On 11/30/15, at 3:47 p.m., there was a remote annunciator panel in PBX for the hospital's four generators. There were no status indicators lit on the panel and it failed the lamp test.

During an interview at 3:48 p.m., the Director of Facilities (DFS1) stated that it seemed like there was no power going to the annunciator.

Central Plant:
2. On 11/30/15, at 4:54 p.m., there was a remote annunciator panel in Central Plant for the hospital's four generators. The module labeled "Emergency System Remote Annunciator" on the panel had two status indicators that were lit: "Horn Alarm Silenced" and "PLC Failure". Status indicators for the four generators were not lit and the annunciator panel failed a lamp test.

During an interview at 4:55 p.m., Plant Maintenance Mechanic (PMM4) stated that the panel has not been working for approximately one month.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by failing to ensure weatherproofing of an area containing circuit switches, by failing to properly secure conductor cables, by missing cover plates, by multi-outlet power strips and adapters used in methods not permitted, and by blocked electrical panels. This had the potential for increasing the risk of electrical fire and electrical shock that may result in the injury to patients, visitors, and staff. This affected two of five floors in the Hahn Building, two of eight floors in the East Tower, the Basement and one of five floors in the Valentine Building, one of five floors in the La Vina Building, three of eight floors in the West Tower, and the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (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.
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.
110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.
Table 210-21(b)(2). Maximum Cord- and Plug-Connected Load to Receptacle
Circuit Rating (Amperes): 20
Receptacle Rating (Amperes): 20
Maximum Load (Amperes): 16
210-23. Permissible Loads. In no case shall the load exceed the branch-circuit ampere rating. An individual circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) through (d) and as summarized in Section 210-24 and Table 210-24.
370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.
380-9. Provisions for Snap Switch Faceplates. (a) Position. Snap switches mounted in boxes shall have faceplates installed so as to completely cover the opening and seat against the finished surface.
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
380-4. Wet Locations. A switch or circuit breaker in a wet location or outside of a building shall be enclosed in a weatherproof enclosure or cabinet that shall comply with Section 373-2(a). Switches shall not be installed within wet locations in tub or shower spaces unless installed as part of
a listed tub or shower assembly.
For information on lockout/tagout procedures, see Standard for Electrical Safety Requirements for Employee Workplaces, NFPA 70E-1995.

Findings:

During the facility tour on 11/30/15 through 12/4/15, the electrical wiring and equipment was observed with the Plant Operations Managers (POM1 and POM2), the Hospital Safety Officer (HPSO), the Plant Maintenance Mechanics (PMM1, PMM2 and PMM4), and the Director of Facilities (DFS1).

East Tower, Ground Floor:
1. On 11/30/15, at 3:30 p.m., the refrigerator inside the social worker/care coordinator office GC135 was plugged into a power strip and not directly into the wall receptacle. This was confirmed by HPSO and POM1 during the survey.

2. On 11/30/15, at 3:26 p.m., the refrigerator in room GC140 was plugged into a power strip and not directly into the wall receptacle. This was confirmed by HPSO and POM1 during the survey.

3. On 12/1/15, at 9:09 a.m., there was a white extension cord used inside the radiology room GE137. The extension cord did not have overcurrent protection. This was confirmed by HPSO and POM1 during the survey.

East Tower, Fourth Floor:
4. On 12/01/15, at 11:30 a.m., a white three outlet wall adapter was observed in the corridor across from module 2 nurse station. The adapter was in use and had no overcurrent protection. This was confirmed by HPSO and POM1.

Hahn Building, Third Floor:
5. On 12/3/15, at 8:51 a.m., a power strip was observed to be plugged into another power strip under the desk in room 3520. This was confirmed by HPSO and POM1.


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Valentine Building, Basement Floor:
6. On 12/1/15, at 9:12 a.m., the electrical room containing high voltage switch gears, located in the Valentine Building on the Basement Floor, had a puddle of water in the corridor approximately 6-feet away from the door entrance. The water puddle measured approximately 3-feet in diameter. PMM1 stated that the water appeared to be coming from outside the building. PMM2 then stated that the building's seams between the wall and the floor needed some repair.

Valentine Building, Second Floor:
7. On 12/1/15, at 1:42 p.m., the IT Room, located in the Valentine Building on the 2nd Floor, had cables with exposed conductors coming out of the wall. POM1 stated that he believed that the electrical panel for the cables was located on the same wall adjacent to the cables. All the circuit switches to the panel (V2HEA) were in the off position. The panel was not locked and did not have the appropriate lockout/tagout procedures in place.

La Vina Building, Third Floor:
8. On 12/1/15, at 2:30 p.m., in the corridor by Room 3117, located in the La Vina Building on the 3rd Floor, there was white three outlet adapter connected to the dual wall outlet. The adapter had medical equipment plugged into it. This finding was confirmed by POM1 during the survey.

West Tower, Ground Floor:
9. On 12/2/15, at 2:04 p.m., in the corridor by Room GWH33, located in the West Tower on the Ground Floor, there was a dual wall outlet with scorched markings at the top of the outlet. This finding was confirmed by POM1 during the survey.

Hahn Building, Ground Floor:
10. On 12/3/15, at 9:32 p.m., in the Outpatient Clinic Area Room G525, located in the Hahn Building on the Ground Floor, there was no cover plate over a junction box.


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West Tower, Ground Floor:
11. On 11/30/15, at 4:25 p.m., there was a slide warmer and portable fume hood plugged into a six-plug power strip on the Cytology Bench in the laboratory.

12. On 11/30/15, at 4:26 p.m., there was an electrical box with no cover near the Cytology Bench in the laboratory.

West Tower, First Floor:
13. On 12/1/15, at 11:05 a.m., there was an extension cord plugged into a four-plug power strip near the work station in the gift shop storage room.

West Tower, Fifth Floor:
14. On 12/1/15, at 3:10 p.m., there was a four-plug power strip plugged into an eight-plug power strip in the Signal Room. The power strips were used for phone chargers.

Pavilion Building, Suite 100:
15. On 12/2/15, at 10:02 a.m., the light switch in Room 1104 was missing a cover plate.

16. On 12/2/15, at 10:08 a.m., access to Panel L136A was blocked by storage in the Equipment Room.

Based on observation and interview, the facility failed to have an appropriate life safety measure when devices for the fire alarm system were disabled. This was evidenced by failing to have a fire watch or other appropriate life safety measures when the smoke detectors were disabled for more than 4 hours in a 24-hour period. This could result in the delay in notifying occupants and responders during a fire, increasing the risk of injury to the patients and staff. This failure affected one of eight floors in the East Tower.

Findings:

During a facility tour with the Plant Operations Manage (POM1) from 11/30/15 to 12/4/15, the fire alarm system was observed.

East Tower, First Floor:
1. On 12/2/15, at 8:15 a.m., the Director of Facilities (DFS1) had informed the surveyor that four smoke detectors were disabled in an area that was undergoing a construction project and confirmed that no fire watch was conducted.

At 9:05 a.m., the Fire Alarm Control Panel (FACP) located in the Emergency Department listed four smoke detectors as disabled (address 01-001-2040008, 01-001-2040009, 01-001-2040010, and 01-001-2040011).

At 11:02 a.m., the smoke detector 2040010, located in the corridor by the soiled utility room in the Neonatal Intensive-Care Unit (NICU) on the 1st Floor East Tower, failed to alarm when attempting to activate it with canned smoke. The corridor containing the four smoke detectors were not separated from the egress path that was open to the NICU.

At 11:10 a.m., the Project Manager who identified himself as the Superintendent was interviewed. He stated that four smoke detectors (labeled 2040008, 2040009, 2040010, and 2040011) located in the corridor were disabled everyday from 7 a.m. to 2 p.m. while working on a construction project adjacent to the corridor. The Project Manager stated that there was no fire watch initiated during the times the four smoke detectors were disabled.