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Based on observation and interview, the facility failed to maintain fire-rated occupancy separations. This was evidenced by one fire-rated door into an offsite suite that failed to latch. This could result in the faster spread of smoke and fire. This affected one of four floors in the Pavilion 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.

Findings:

During a facility tour with the Director of Plant Services (DPS) and Journeyman1 (JM1) from 4/4/16 to 4/7/16, the fire-rated separations of the offsite suites were observed.

Pavilion, Third Floor:

1. On 4/6/16, at 3:17 p.m., the door into Suite 355 from the Pavilion hallway failed to latch upon activation of the fire alarm system. JM1 stated that the door's card reader would be required to be deactivated to allow for the door to latch properly. This was acknowledged by the DPS during the survey. This finding was also identified by a life safety surveyor on 12/2/15 at 11:16 a.m., during a full validation survey.


29665

21101

Based on observation, the facility failed to protect their hazardous areas. This was evidenced by the failure to ensure that doors protecting hazardous areas latched upon self-closure. This could result in the potential increase risk of fire and or smoke to spread from one area to another. This affected one of five floors in the Wingate Building.

NFPA 101, Life Safety Code, 2000 Edition
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 a facility tour with the Director of Plant Services (DPS) from 4/4/16 to 4/7/16, the hazardous areas were observed.

Wingate Building, Second Floor:

1. On 4/5/16, at 3:41 p.m., the door to the dirty utility room (# 2412.1), located in the Medication Therapy Management clinic, failed to latch upon opening the door to its full extent and releasing the door to test the function of the self-closure. This was acknowledged by the DPS during the survey. This finding was also identified by a life safety surveyor on 12/3/15 at 10:24 a.m., during a full validation survey.


29665

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 a fire alarm device not activated during fire drills held after 6:00 a.m. and before 9:00 p.m., and by fire drills not completed for each shift per quarter. This could result in staff to not properly respond to a fire and cause harm to patients. This affected 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.

Findings:

During document review with the Director of Plant Services (DPS) and the Badge Access Coordinator (BAC) from 4/4/16 to 4/7/16, the fire drill records were reviewed.

Della Martin Center:

1. On 4/6/16, at 11:46 a.m., a record for Della Martin Center documented a fire drill held at 6:15 p.m. on 2/3/16, with no activation of a fire alarm device. During an interview with the BAC, he acknowledged that the record noted that a fire alarm device was not activated during the fire drill. The failure to activate fire alarm device during fire drills held between 6 a.m. through 9 p.m. was also identified by a life safety surveyor on 12/3/15, during a full validation survey.

2. At 11:48 a.m., there was no record of a fire drill being completed for Della Martin Center during the first shift in the 1st quarter. During an interview with the BAC, he acknowledged that the fire drill was not completed for the first shift in the 1st quarter and he stated that the drill was not on the schedule.



21101

Based on observation, the facility failed to ensure that the fire alarm system was properly maintained. This was evidenced by 1 of 2 phone lines to the DACT (Digital Alarm Communicator Transmitter) that was displaying a trouble signal at the panel. This could result in the delay in notifying responders during a fire alarm system activation, potentially harming patients, visitors, and staff. This affected the Pavilion Building.

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

NFPA 72, National Fire Alarm Code, 1999 Edition
5-5.3.2.1.7 DACT Transmission Means.
5-5.3.2.1.7.1 A DACT shall be connected to two separate means of transmission at the protected premises. The DACT shall be capable of selecting the operable means of transmission in the event of failure of the other means. The primary means of transmission shall be a telephone line (number) connected to the public switched network.

Findings:

During a facility tour with the Director of Plant Services (DPS) and the Patient Safety Officer (PSO) from 4/4/16 to 4/7/16, the fire alarm system was tested and observed.

1. On 4/6/16, at 2:58 p.m., the secondary phone line to the DACT was displaying a trouble signal at the panel. This was acknowledged by the PSO during the survey.


29665

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 the hand wheels were turned two revolutions. This could result in a delay response to the tampering of the sprinkler system. This affected the Raymond Building.

NFPA 101, Life Safety Code, 2000 Edition
18.3.5.1 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.

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 Plant Services (DPS) from 4/4/16 to 4/7/16, the fire sprinkler control valves were observed.

Raymond Building:

1. On 4/6/16, at 9:08 a.m., the outside screw and yoke (OS&Y) valve located on the north side failed to send a trouble signal to the annunciator panel upon turning the hand wheel two revolutions. The trouble signal would only display when manually triggering the trip rod. This was acknowledged by the DPS during the survey. This finding was also identified by a life safety surveyor on 12/2/15 at 2:36 p.m., during a full validation survey.

2. At 9:12 a.m., the outside screw and yoke (OS&Y) valve located on the south side failed to send a trouble signal to the annunciator panel upon turning the hand wheel two revolutions. The trouble signal would only display when manually triggering the trip rod. This was acknowledged by the DPS during the survey. This finding was also identified by a life safety surveyor on 12/2/15 at 2:36 p.m., during a full validation survey.


29665

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 water-flow switches that required repairs, and by water leaking at a control valve. This had the potential for the sprinkler system failure to contain or extinguish a fire. This affected one of eight floors in the East Tower and the Raymond Building.

NFPA 101, Life Safety Code, 2000 Edition
18.3.5.1 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.
9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
3-2.7.2* Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water- Base Fire Protection Systems, 1998 Edition
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.
9-3.3.2 The valve inspection shall verify that the valves are in the following condition:
(e) Free from external leaks
9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

Findings:

During a facility tour with the Director of Plant Services (DPS) and the Building Engineer at Raymond (BER) from 4/4/16 to 4/7/16, the fire sprinkler control valves were observed.

East Tower, Second Floor:

1. On 4/5/16, at 11:03 a.m., the sprinkler escutcheon ring, located inside the Same Day Surgery Treatment Room 12 (# 2B127), was missing. This was acknowledged by the DPS during the survey. This finding was also identified by a life safety surveyor on 12/1/15 at 11:04 a.m., during a full validation survey.

Raymond Building:

2. On 4/6/16, at 9:02 a.m., the BER provided a sprinkler system inspection report, dated 3/30/16, that identified water flow switches on the 2nd and 3rd floors that required repairs. The BER stated that the repairs had not been completed and that they need to order parts to make the appropriate repairs.

3. At 9:20 a.m., the outside screw and yoke (OS&Y) valve located on the south side was observed to have water leaking from the stem. This was acknowledged by the DPS and BER during the survey. This finding was also identified by a life safety surveyor on 12/2/15 at 2:34 p.m., during a full validation survey.


21101




29665

Based on observation, the facility failed to maintain their kitchen hood fire suppression system. This was evidenced by the nozzles in the kitchen hood fire suppression system that did not have protective caps. This could increase the chance for fire in the kitchen and result in the failure of the kitchen hood fire suppression system that may be due to the accumulation of grease inside the nozzles. This affected one of eight floors in the West Tower.

NFPA 101, Life Safety Code, 2000 Edition
18.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and and Fire Protection of Commercial Cooking Equipment, 1998 Edition
7-2.2.1 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable.
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 1998 Edition
2-3.1.4 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping. The protection device shall blow off, open, or blow out upon agent discharge.

Findings:

During a facility tour with the Director of Plant Services (DPS) from 4/4/16 to 4/7/16, the kitchen hood fire-suppression system was observed.

West Tower, First Floor:

1. On 4/5/16, at 2:25 p.m., the kitchen hood fire suppression system (hood #3010), located by the kitchen serving area, was observed to have 3 of 5 nozzles without protective caps. This was acknowledged by the DPS during the survey.

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 a facility tour with the Director of Plant Services (DPS) from 4/4/16 to 4/7/16, the laundry and trash chutes were observed.

La Vina Building, Ground Floor:

1. On 4/4/16, at 3:46 p.m., the trash chute in Room G112 had its discharge door that was obstructed by handle from a dust/debris pan. This finding was acknowledged by the DPS during the survey. This finding was also identified by a life safety surveyor on 12/1/15 at 9:42 a.m., during a full validation survey.

Based on observation, the facility failed to ensure that their anesthetizing locations were provided with functional battery-powered emergency lighting units. This was evidenced by an Operating Room (OR) 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 Labor and Delivery (L&D) OR 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, 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.

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

Findings:

During a facility tour with the Director of Plant Services (DPS) from 4/4/16 to 4/7/16, the anesthetizing locations were observed.

East Tower, First Floor:

1. On 4/5/16, at 11:44 a.m., the L&D OR 2 (#1B180) failed to illuminate 1 of 2 battery-powered emergency lighting units when tested via its test button. This finding was acknowledged by the DPS during the survey. This finding was also identified by a life safety surveyor on 12/3/15 at 11:43 a.m., during a full validation survey.

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 West Tower.

Findings:

During a facility tour with the Director of Plant Services (DPS) and the Patient Safety Officer (PSO) from 4/4/16 to 4/7/16, the fire alarm system was observed.

West Tower, Ground Floor:

1. On 4/4/16, at 3:25 p.m., the Fire Alarm Control Panel (FACP) located in the Emergency Department listed three smoke detectors as disabled (address 47030040, 47030041, and 47040008) for more than 13 hours, since 1:40 a.m. The three disabled smoke detectors were located in Pathology's dressing room (door #GWH29), hall (door #GWH24), and waiting area (door #GWH23). The DPS stated that the smoke detectors were disabled to allow for a plumbing company to perform work above the ceiling and the devices should have been re-enabled after the work was completed. The DPS stated that no fire watch was completed during this time. The failure to complete a fire watch when the smoke detectors were disabled for more than 4 hours in a 24-hour period was also identified by a life safety surveyor on 12/2/15 at 9:05 a.m., during a full validation survey.

Based on observation, the facility failed to maintain their kitchen hood fire suppression system. This was evidenced by the nozzles in the kitchen hood fire suppression system that did not have protective caps. This could increase the chance for fire in the kitchen and result in the failure of the kitchen hood fire suppression system that may be due to the accumulation of grease inside the nozzles. This affected one of eight floors in the West Tower.

NFPA 101, Life Safety Code, 2000 Edition
18.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and and Fire Protection of Commercial Cooking Equipment, 1998 Edition
7-2.2.1 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable.
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 1998 Edition
2-3.1.4 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping. The protection device shall blow off, open, or blow out upon agent discharge.

Findings:

During a facility tour with the Director of Plant Services (DPS) from 4/4/16 to 4/7/16, the kitchen hood fire-suppression system was observed.

West Tower, First Floor:

1. On 4/5/16, at 2:25 p.m., the kitchen hood fire suppression system (hood #3010), located by the kitchen serving area, was observed to have 3 of 5 nozzles without protective caps. This was acknowledged by the DPS during the survey.