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Based on observation, the facility failed to maintain the two-hour fire-resistant separation walls between patient care areas and non-conforming buildings. This affected two of two outpatient clinics, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff on 5/24/11 and 5/25/11, the two-hour separation walls at the outpatient clinics were observed.

On 5/24/11 the Outpatient Rehabilitation building was surveyed.
At 2:45 p.m., the wall between the rehab center and the adjacent business office was observed from the director's office. There was an approximately 1/2 inch penetration around conduits on the right side of the wall. There was an approximately 2 inch penetration around a communications sleeve in the center of the wall. There was an approximately 1/4 inch penetration around a wooden beam running from the center to the right side of the wall. There was an approximately 1 inch unsealed pipe sleeve in the center of the wall, around blue, white, and grey wires.

On 5/25/11 the JFK Orthopedics building was surveyed.
At 9:00 a.m., the wall between the clinic and the adjacent business office was observed from the reception/waiting room area. There was an approximately 8 inch by 12 inch penetration in the center of the wall.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected 8 of 14 smoke compartments in the main hospital and two of two outpatient clinics. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff, from 5/23/11 to 5/25/11, the walls and ceilings were observed in the main hospital and at two off site buildings.

Main hospital on 5/23/11 -
At 2:14 p.m., there was an approximately 1 inch penetration around the emergency shower handle, in the chemistry laboratory ceiling.

At 2:41 p.m., there was an approximately 4 x 5 inch penetration around a conduit, in the ceiling tile near the front wall, in the telecommunications closet, across from RT.

At 2:59 p.m., there was an approximately 1 1/2 x 1 foot penetration in the hard deck ceiling of the Old ICU.
During an interview at 3:00 p.m., Maintenance Staff 2 stated that a construction project was in process. He stated there had been no work in the area for the last month.

At 3:02 p.m., there were four approximately 1/2 inch penetrations in the back wall of the case management closet near PCU West.

Main hospital on 5/24/11 -
At 8:41 a.m., there was an approximately 1 inch penetration, and an approximately 1/2 inch penetration, in the back wall of the environmental services closet, in the radiology department.

At 8:45 a.m., there was an approximately 2 x 2 inch penetration around an Internet cable, in the right wall of the front desk area in radiology.

Outpatient Rehabilitation on 5/24/11 -
At 2:37 p.m., there was an approximately 2 x 3 inch penetration in the right wall of the director's office.

At 2:40 p.m., the environmental services closet next to the staff lounge was observed. There was an approximately 5 inch penetration around old phone wires, and four approximately 1/4 inch penetrations around four wire conduits, in the ceiling.

JFK Orthopedics on 5/25/11 -
At 8:17 a.m., there were nine approximately 1/2 inch penetrations in the left wall of Office 120.




21026

On 5/23/11 - Main Hospital
At 1:50 p.m., there was an approximately 1/4 x 8 inch gap and an approximately 1/2 x 24 inch gap on the side of two ceiling tiles in the lobby area, above the left wall.
At 2:07 p.m., there were two approximately 1/4 - 1/2 inch penetrations in the wall next to the toilet, in the Emergency Department (ED) bathroom, across from Cubie 5.
At 2:08 p.m., there were two 1/2 - 3/4 inch penetrations in the wall below the TV, in Physical Therapy Room 7.
Pharmacy Area -
At 2:18 p.m., there was an approximately 1/4 - 1/2 inch penetration, next to the cover plate, in the right back corner of the pharmacy office. There was an approximately 1/8 - 1/4 inch penetration around two escutcheon rings in the ceiling above the solution area. Escutcheon rings were used to cover penetrations around the sprinkler pipes. There were two approximately 1/8 inch penetrations in the back wall of the Pharmacy Tech Office.
Cafeteria/Kitchen area -
At 2:33 p.m., there was an approximately 1/8 inch penetration around a conduit for the cafeteria hood suppression system, in the ceiling near the kitchen handwashing sink.
At 2:39 p.m., there was a 1/8 inch or less penetration around an electrical pipe sleeve and an approximately 1/8 - 1/4 inch penetration around a pipe sleeve and conduit for the main kitchen suppression system.
At 2:44 p.m., there were three approximately 1/8 inch penetrations in the wall above the prep sink.
At 2:48 p.m., there was a 1/8 inch or less penetration, around pipe sleeves, above the refrigerator in the dishwashing area.
At 2:50 a.m., there was an approximately 1/2 inch penetration in the wall above the clean dish counter. The penetration was above a pipe and the clock.

At 3:23 p.m., there was an approximately 1/2 inch square penetration in the ceiling in the Pediatric playroom.

On 5/24/11-
At 8:35 a.m., there was an approximately 1/4 - 1/2 inch penetration, around wires, in the ceiling of the materials management storage room. The penetration was above the ordering desk.
At 8:45 a.m., there were nine 1/8 inch or less penetrations, in the ceiling of the janitor's closet, in the materials management corridor. There was an approximately 1/8 inch penetration in the back wall.
ICU area -
At 9:20 a.m., there was an approximately 1/4 inch penetration in the wall above the ICU ice machine.
At 9:28 a.m., there was an approximately 1/4 inch penetration on the left side of the corridor wall, on the back side of the ED. The penetration was behind the handrail near the back entrance to the ED.

OR area -
At 4:01 p.m., there were seven approximately 1/8 inch penetrations in the wall of Cubie 1, in the Pre-op area. There were two approximately 1/8 inch penetrations in the wall of Cubie 2.
At 4:07 p.m., there was an approximately 1/8 inch penetration in the ceiling, around a pipe, on the left side of the sterilizer access room between OR Rooms 3 and 4. There was an approximately 1/4 inch around the middle pipe and an approximately 1/8 - 1/2 inch penetration around the pipe on the right side, above the left wall.
At 4:18 p.m., there was an approximately 1/2-1 inch penetration around a copper pipe, in the ceiling, above the sterilizer, in the access room between OR Rooms 2 and 1. There was an approximately 1/8 inch penetration around the pipe sleeve above the back wall. There was an approximately 1/8 - 1/4 inch penetration around the pipe sleeves on the left side of the ceiling.

Outpatient Rehabilitation Center -
At 2:38 p.m., there was an approximately 1 - 2 inch penetration around wires and cable, inside of four unsealed pipe sleeves, in the environmental services closet, near Exam Room 1.

5/25/11-
At 1:30 p.m., during alarm testing, there was an approximately 1/8 inch penetration around a conduit, in the ceiling in the materials management office area. The conduit was connected to the pull station near the exterior exit door. There was an approximately 1/2 - 3/4 inch penetration around wires in the same area.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected 6 of 14 smoke compartments and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with staff, from 5/23/11 to 5/25/11, the facility doors were observed.

Main Hospital on 5/23/11 -
At 1:55 p.m., the door to the gift shop storage room was equipped with a self-closing device. The door was held open with a rubber wedge.

At 3:26 p.m., the door to the PP clean linen closet was equipped with a self-closing device. The door closed but failed to latch.

At 3:29 p.m., the door to the shower room, next to the lactation consultant's office, in PP was equipped with a self-closing device. The door closed but failed to latch.

At 3:36 p.m., the door to the mechanical room in PCU West was equipped with a self-closing device. The door closed but failed to latch.

At 3:39 p.m., the door, to the office of the director of the adult telemetry unit, in PCU West, was equipped with a self-closing device. The door closed but failed to latch.

At 3:41 p.m., the door to social services in PCU west was equipped with a self-closing device. The door was obstructed from closing by a two-drawer dresser.

Main Hospital on 5/25/11 -
At 1:52 p.m., the door behind the lobby reception desk was equipped with a self-closing device. The door closed but failed to latch.

At 1:54 p.m., the double doors from the lobby to the ED corridor were held open by a magnetic hold-open device. The doors released from the magnet upon activation of the fire alarm. The right door closed but failed to latch.

At 2:06 p.m., the double doors on the East side of PP were held open by a magnetic hold-open device. The doors released from the magnet upon activation of the fire alarm. The left door closed but failed to latch.

At 2:10 p.m., the double doors on the West side of PP were held open by a magnetic hold-open device. The doors released from the magnet upon activation of the fire alarm. The right door closed but failed to latch.




21026

5/23/11 -
At 3:23 p.m., the door to the Pediatric playroom was equipped with a self-closing device. The door was obstructed by a foot stool used to hold the door open. During the survey on 5/24/11 and 5/25/11, the foot stool was observed in front of the door and obstructed the door from closing.

At 3:25 p.m., the door to Room 404 was obstructed by a linen cart.

5/24/11-
At 8:48 a.m., the self-closing door to the janitor's closet closed but failed to latch. The janitor's closet was located in the materials management corridor.
At 8:50 a.m., the self-closing door to the copy room closed but failed to latch, in the materials management corridor.

Based on observation and interview, the facility failed to ensure that no door in a smoke barrier is held open by a device that fails to close automatically after activation of any fire alarm. This was evidenced by one smoke barrier WON door that failed to close during fire alarm testing. This affected two of two smoke compartments in the ICU area.

Findings:

During the facility tour with facility staff, on 5/24/11, a WON door was observed at the ICU nurses station.
At 9:09 a.m., during an interview, Maintenance Staff 1 reported that the door only closed upon activation of the smoke detectors on either side of the door.

On 5/25/11 the fire alarm system was tested. At 2:20 p.m., the WON door failed to close after activation of a water flow for the sprinkler system.
At 2:23 p.m., the WON door failed to close after activation of a manual pull station. The smoke detectors adjacent to the door activated the WON door closure.

The door did not automatically close upon activation of any device of the fire alarm system.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls, as evidenced by penetrations around wires and pipe sleeves. This affected 8 of 14 smoke compartments and could result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During the facility tour with staff, on 5/24/11, the smoke barrier walls were observed.

Main Hospital on 5/24/11 -
At 9:27 a.m., the smoke barrier wall near RT was observed from the East side. There was an approximately 1 inch penetration on the right-hand side of the wall.

At 9:31 a.m., the smoke barrier wall near RT was observed from the West side. There was an approximately 3/4 inch penetration on the left-hand side of the wall.

At 9:40 a.m., the smoke barrier in the laboratory was observed. There was an approximately 1 inch penetration in the center of the wall, around a telephone wire.





21026

At 9:24 a.m., there was an approximately 1/2 inch penetration around four sides of the air conditioning duct, in the center of the smoke barrier wall in ICU.

At 9:30 a.m., there was an approximately 1/2 inch penetration around a water pipe in the left side corridor wall at the back door to the emergency department (ED). There was an approximately 1/2 inch penetration on the right side of the the duct near the top of the ceiling.

At 9:40 a.m., there was an approximately 1/4 inch penetration around an electrical pipe sleeve, an approximately 1/2 inch penetration around a water pipe, and an approximately 1/8 inch penetration around a pipe sleeve near the top/center area of the smoke barrier wall near Room 413.

At 10:04 a.m., there was an approximately 5 x 7 inch penetration, cutout around conduits and pipes, in the smoke barrier wall at the back entrance to the kitchen.

At 10:10 a.m., there was no protected wall in the smoke barrier at the NICU. The wall was exposed wood. There was an approximately 3 x 6 inch penetration on the far left side of the wall next to the beam. There was an approximately 1/4 inch penetration around cables inside of a pipe sleeve.

Based on observation, the facility failed to ensure that smoke barrier doors are capable to resist the passage of smoke. This was evidenced by one door that failed to latch after closing. This affected 2 of 14 smoke compartments, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with staff on 5/25/11, the smoke barrier doors were observed.

Main Hospital -

At 1:14 p.m., the smoke barrier double doors, leading to the nursing administration corridor, were released from the magnetic hold-open device upon activation of the fire alarm. The right door closed but failed to latch.

Based on observation the facility failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self closing doors. This was evidenced by hazardous areas with penetrations, by storage areas without self-closing doors, and by doors that failed to self close and latch. This affected 2 of 14 smoke compartments and could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour with staff, on 5/23/11 and 5/24/11, hazardous areas in the facility were observed. Hazardous areas are combustible storage rooms/spaces greater than 50 square feet, boiler and heater rooms, repair shops, and trash and soiled linen collection rooms.

On 5/23/11 - Main Hospital
At 2:21 p.m., the Telecom Room was greater than 50 square feet in size and contained boxes of wiring and equipment. There was no self-closing device on the door.

At 2:47 p.m., the kitchen dry storage room contained combustible cardboard boxes and paper packages of supplies. The room is greater than 50 square feet. There was no self-closer on the door. The door was obstructed from manual closing by a bread rack.

At 4:11 p.m., there was an approximately 1/4 - 1/2 inch penetration around a conduit connected to the smoke detector, in the Medical Air/vac Room. There was an approximately 1/4 inch penetration around a copper pipe in the ceiling.

At 4 :14 p.m., there was an approximately 2 inch penetration around a 1/2 inch copper pipe in the left wall of the boiler room access.

At 4:16 p.m., there were seven 1/2 - 1 inch penetrations in the back wall above electrical panel PM in the storeroom. There was an approximately 1 inch and 1 1/2 inch penetration around two separate pipe sleeves in the storeroom back wall.

On 5/24/11 - Materials Management area.
At 8:37 a.m., there was an approximately 18 x 18 inch ceiling area that was damaged and cracked, in the materials management supply room. The area was above the right wall.

At 8:39 a.m., the self-closing doors, to the materials management storage area, closed but failed to latch.

At 8:43 a.m., the double doors to the clean linen storage room closed but failed to latch.

Based on observation, the facility failed to ensure exits are accessible at all times, as evidenced by one exit that was blocked during the survey. This failure could result in the inability of patients to exit the facility in an emergency. This affected one of three exits at one of two offsite clinics.

Findings:

During the facility tour with facility staff on 5/25/11, the exits at the JFK Orthopedic Clinic were observed.
At 8:15 a.m., four computers on wheels and two chairs were placed in front of the exit door in Storage Room 108. The door, exiting to the corridor, was completely blocked. An exit sign is illuminated above the door.

Based on observation and interview, the facility failed to ensure emergency lighting is provided in accordance with NFPA 99 and NFPA 101. This was evidenced by no emergency lights in four of five operating rooms and by the failure of three emergency lights during testing. This affected all surgeries and two of two off site clinics. This could result in a possible patient injury if the power failed during a surgery or could delay evacuation in the clinic buildings.

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.
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code.
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.

NFPA 99, Health Care Facilities 1999 Edition
3-3.2.1.2 All Patient Care Areas.
(a) Wiring, Regular Voltage.
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).

Findings:

During the facility tour with staff on 5/24/11, emergency lights (bullfrog type) were observed in the facility and off site clinics.

At 4:12 p.m., the emergency light in OR 4 failed to illuminate when tested with the push button. During an interview at 4:15 p.m., the DSS was asked if there were emergency lights in OR 1, 2, 3 or 5. He reported there were no other emergency lights. One surgery was being completed during this time.

During an interview at 4:30 p.m., Maintenance Staff 1 reported there were two rechargeable flashlights available in two of the OR suites. He reported there were no emergency lights available in the other two surgery rooms. He stated they were trying to repair the bull frog type emergency light in OR 4.

At 4:45 p.m., the Plant Operations Director was notified regarding the lack of emergency lighting in the OR suites.

At 6 p.m., a vendor arrived on site to install emergency lighting in five of five OR suites.

On 5/25/11 - JFK Orthopedic Clinic
At 8:28 a.m., the emergency light outside of Room 106 failed to illuminate when tested with the push button. No records were provided for testing the emergency lights in the Orthopedic Clinic.


29665

On 5/24/11 - Rehabilitation Clinic

At 2:35 p.m., the emergency light in the rehabilitation clinic failed to activate when tested with the push button. During an interview at 2:36 p.m., Maintenance Staff 1 reported there was no record for testing the emergency lights in the rehab clinic building.

Based on observation, record review, and interview, the facility failed to maintain their complete fire alarm system. This was evidenced by alarm devices that failed, by two areas with no alarm annunciator, by expired fire alarm panel batteries, and by incomplete fire alarm system testing records for the Outpatient Rehabilitation clinic. This affected 14 of 14 smoke compartments in the main hospital, and two of two outpatient clinics. This could result in a failure of the alarm system or a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code 2000 Edition
19.3.4.3 Occupant Notification
Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

Maintaining 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.

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.

NFPA 72, National Fire Alarm Code, 1999 Edition.
Table 7-3.2 requires annual testing of building systems connected to the fire supervising station.

Table 7-3.2
6. Batteries d. Sealed-Lead Acid Type 1. Charger Test (Replace battery every 4 years.)

7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section _______."
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type, heat detectors
(12) Other tests as required by equipment manufactures
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)


Findings:

During the facility tour from 5/24/11 and 5/25/11, the fire alarm system was observed. The system was tested on 5/24/11 and 5/25/11.

On 5/24/11 - Main Hospital
At 3:21 p.m., the two sealed-lead acid batteries in the main fire alarm panel at PBX were dated 9/22/04.

At 1:30 p.m., the strobe light, in the main materials management storeroom, failed to activate during testing of the fire alarm system.

At 1:34 p.m., the combination audible/visible annunciator in the right wall of the pharmacy was observed. The strobe light failed to activate during fire alarm testing.

During record review for the Outpatient Rehabilitation Clinic, on 5/24/11, records for the annual fire alarm testing were requested.

At 2:00 p.m., a document for the annual testing of the fire alarm panel was provided in the form of an invoice. There was no complete list of devices and results for testing 17 heat detectors in the clinic.

On 5/25/11 - JFK Orthopedics

At 10:55 a.m., the fire alarm system was activated during a sprinkler system flow test. There was one combination audible/visual annunciator located in the reception/waiting room area of the clinic. The alarm could not be heard at Nurses Station 1.

During an interview at 10:57 a.m., nursing staff in station 1 confirmed the alarm was not audible.



21026

On 5/24/11 - Main Hospital
During fire alarm testing at 4:27 p.m., there was no audible alarms in the OR clean sterile area, after activation of a smoke detector. The surveyor was inside the area during alarm activation and failed to hear the alarm signal.

On 5/25/11, at 10:05 a.m., a smoke detector was activated outside of the OR area. No audible device was located inside the clean or dirty area.
At 10:06 a.m., during an interview, staff in the dirty side of the sterilizer room confirmed the alarm could not be heard over the equipment noise. A faint alarm signal was heard by the Plant Operations Director.

At 10:07 a.m., during an interview, the staff in the clean area reported he did not hear the alarm.

On 5/25/11 -
During fire alarm testing at 1:25 p.m., the chime in the chiller room failed to sound after activation of a manual pull station.
During an interview at 1:26 p.m., Maintenance Staff 1 reported that some old devices are no longer connected to the fire alarm system. He stated that they do not work.

During fire alarm testing, the smoke detectors located in various smoke barrier doors failed to activate when tested with smoke. The smoke barrier doors at the NICU staff entrance, lobby to main corridor, Post-partum corridor west, and Labor and Delivery west entrance failed when tested. Maintenance Staff 1 confirmed these devices were no longer in service.

At 2:08 p.m., the "old" strobe device failed to activate, in the Father's Waiting Room bathroom.
At 2:46 p.m., the "old" chime and strobe device failed to activate, in the women's bathroom, in the ED waiting area.

Maintenance Staff 1 confirmed these devices were no longer connected to the fire alarm system.

Based on observation and interview, the facility failed to ensure maintenance, inspection and testing of smoke detectors was conducted in accordance with the manufacturers' specifications and NFPA 72. This was evidenced by the failure of one smoke detector and by no documentation for testing and battery replacement for 1 of 2 smoke detectors located in the MRI building.


NFPA 72, National Fire Alarm Code, 1999 edition
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7.2.2. Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2 13. Initiating Devices (g) Smoke Detectors - 2. The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

Findings:

During the facility tour and interview with facility staff on 5/24/11, smoke detectors were observed in the MRI building.
At 9 a.m., Maintenance Staff 1 reported there were no records for testing the single station smoke detectors located in the MRI building. He reported there was no record for battery testing or replacement.

On 5/25/11, at 1:38 p.m., the single station smoke detector in the main MRI lobby failed to activate when tested with smoke.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by missing or displaced escutcheon rings, by sprinkler heads covered in paint or dust, by leaks at the main drain valve in two locations, by no complete supply of spare sprinklers and a wrench, and by incomplete documents for quarterly testing of the sprinkler system. This affected the 14 of 14 smoke compartments at the main hospital, and one of two outpatient clinics. This could result in a delay in extinguishing a fire.

Escutcheon rings (ER) are part of the sprinkler assembly that function to cover the penetration around the sprinkler pipe.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition.
1-6 Level of Protection.1-6.1 A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.
Exception: This requirement shall not apply where specific sections of this standard permit the omission of sprinklers.
3-2.9 Stock of Spare Sprinklers.
3-2.9.1 A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100 degrees F (38 degrees C).
3-2.9.2 A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.
3-2.9.3 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:
(1) For systems having less than 300 sprinklers, not fewer than six sprinklers
(2) For systems with 300 to 1000 sprinklers, not fewer than 12 sprinklers
(3) For systems with over 1000 sprinklers, not fewer than 24 sprinklers

5-1 Basic Requirements.5-1.1 The requirements for spacing, location, and position of sprinklers shall be based on the following principles: (1) Sprinklers installed throughout the premises.(2) Sprinklers located so as not to exceed maximum protection area per sprinkler.(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based 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 materials, 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.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
9-5.1 Inspection and Testing of Sprinkler Pressure Reducing Control Valves. Sprinkler pressure reducing control valves shall be inspected and tested as described in 9-5.1.1 and 9-5.1.2.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

Findings:

During a facility tour with staff from 5/23/11 to 5/24/11, the sprinkler system was observed.

On 5/23/11 - Main Hospital
At 2:23 p.m., there was an approximately 1/4 inch gap between the escutcheon ring (ER) and the ceiling in the medical staff office.

Kitchen/Cafeteria area
At 2:33 p.m., there was an approximately 1/4 inch gap between the ER and the ceiling, above the handwashing sink, on the cafeteria side of the kitchen.
At 2:41 p.m., there was an approximately 1/8 inch layer of dust and dirt completely covering the sprinkler head in the area above the tray line.
At 2:42 p.m., there was no sprinkler located in the walk in freezer/refrigerator.
At 2:57 p.m., there was an approximately 1/4 inch gap between the ER and the ceiling, above the ice machine area.

At 3:07 p.m., the escutcheon rings were missing in the Nurse Staffing Office and the dietary office.

At 3:15 p.m., the ER was hanging from the sprinkler head in the GI procedure area. There was an approximately 1/4 inch penetration exposed around the sprinkler pipe.
At 3:17 p.m., one ER was missing and one was hanging on the sprinkler head, in Room 1.

At 3:20 p.m., there was an approximately 1/4- 1/2 inch gap on one side of the ER in the pediatric playroom.

At 3:24 p.m., the ER was missing in the bathroom in Room 402.

At 3:26 p.m., the ER was hanging on the sprinkler head, in the bathroom in the pediatric lounge area.

At 3:45 p.m., the ER was missing in bathroom 715, in the office area.

At 4:05 p.m., there was a leak at the main drain on sprinkler riser #3.
During record review on 5/24/11, at 11:02 a.m., quarterly sprinkler testing records indicated the leak at the riser was identified by the vendor on 4/7/11.

On 5/24/11 - Materials Management
At 8:34 a.m., there was an approximately 1/4 inch gap between the ER and the ceiling, in the materials management general supply room.
At 8:35 a.m., there was an approximately 1/4 inch gap between the ER and the ceiling, in the area above the "needles cabinet."
At 8:40 a.m., there was an approximately 1/4 inch gap between the ER and the ceiling, exposing an approximately 1/4 inch penetration around the sprinkler pipe.

At 3:15 p.m., there were four spare sprinklers located in the spare sprinkler box at Risers 1 , 2, and 3. There was no wrench in the box.
During an interview at 3:15 p.m., Maintenance Staff 1 stated he did not know where the other sprinklers were located during the ongoing construction.

JFK Orthopedics on 5/25/11 -
At 10:55 a.m., the inspector's test valve was tested by the vendor. There was a leak at the pressure relief valve during the waterflow test.


29665

On 5/23/11 - Main Hospital
At 3:00 p.m., the sprinkler head on the left side of the storage closet in the Old ICU was observed. The sprinkler deflector was approximately 75 percent covered in white paint.

JFK Orthopedics on 5/25/11 -
At 10:40 a.m., there were no documents for quarterly testing of the sprinkler system for two of four quarters in 2010. The documents provided indicated that inspections of the sprinkler system were performed on 2/14/11, 11/24/10, and 2/15/10.

At 10:45 a.m., during an interview, the vendor reported they have not completed quarterly testing for the sprinkler system. He stated they have only conducted visual inspections of the sprinkler system.

Based on observation, the facility failed to ensure fire extinguishers are provided and maintained per NFPA 10. This was evidenced by fire extinguishers that were obstructed or missing. This affected 2 of 14 smoke compartments and could result in a delay in extinguishing a fire.

NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturers's instructions.

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 the facility tour with staff on 5/23 and 5/24/11, fire extinguishers were observed in the kitchen and OR area.

On 5/23/11 - Kitchen area
At 2:44 p.m., the fire extinguisher near the cooking area, was obstructed by a pan rack. The rack had to be moved before staff could reach the extinguisher.

At 2:48 p.m., a fire extinguisher sign indicated an extinguisher was located in the dishwashing area. There was no extinguisher visible in this area.

At 2:58 p.m., the fire extinguisher was obstructed by a tray cart in the kitchen back hallway, near the exit door.

Maintenance Staff 1 confirmed the extinguishers were obstructed.

On 5/24/11, at 4:15 p.m., the fire extinguisher was obstructed by a yellow trash can, outside of the EVS closet in the OR suite.

Based on observation and interview, the facility failed to maintain the means of egress free from obstructions, as evidenced by supplies and clean linen bins that were placed in one exit corridor. This failure could lead to an obstruction of the corridor and the exit path, during a fire or other emergency. This affected 1 of 14 smoke compartments.

Findings:

During the facility tour and interview with facility staff from 5/24/11 through 5/25/11, the egress corridors were observed.

On 5/24/11 at 8:30 a.m. and 9:50 a.m., four 132 Wt clean linen bins were stored against the left wall in the materials management corridor. 30-40 cardboard boxes were stacked in the corridor waiting to be put away in the supply room.

During an interview at 8:35 a.m., the supply manager reported the bins were located in this area until the linen was used from the clean linen room. When there was space the clean linen was put away. The supply manager reported the supplies had just come in and would be put away during the day.

On 5/25/11 at 9:45 and 11:30 a.m., there were five 132 Wt clean linen bins stored against the left wall in the materials management corridor.
There were 30-40 cardboard boxes of supplies stacked in the corridor outside of the supply room.

Based on observation and interview, the facility failed to maintain the medical gas storage areas in accordance with NFPA 99. This was evidenced by oxygen cylinders stored with combustibles and by unsecured cylinders. This affected 1 of 14 smoke compartments, and the outside medical gas storage area. This could result in the increased spread of fire, and the potential injury of patients, in the event of a fire.

NFPA 99 Health Care Facilities 1999 Edition

4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks of fastenings to protect cylinders from accidental damage or dislocation.
4-3.5.2.2 Storage of Cylinders and Containers. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings:

During the facility tour with staff from 5/23/11 to 5/25/11, the oxygen storage areas were observed at the main hospital.

Main Hospital on 5/23/11 -

At 2:29 p.m., there were 13 oxygen e-tanks stored in a rack in the RT storage area. The tanks were up against the front wall, approximately 6 inches directly below a light switch. There was no label distinguishing empty and full tanks.
During an interview at 2:31 p.m., a respiratory technician stated that empty and full cylinders were stored in the rack, and staff look at the gauge to distinguish them.

Main Hospital on 5/24/11 -

At 3:09 p.m., the outdoor medical gas storage area was observed. There were two unsecured nitrogen tanks, and two unsecured oxygen C-tanks on the floor of the storage area.

Based on observation, the facility failed to maintain their electrical wiring in accordance with NFPA 70. This was evidenced by the use of surge protectors and extension cords. This affected 4 of 14 smoke compartments in the main hospital and one of two outpatient clinics. This could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 5/23/11 to 5/25/11, the electrical wiring was observed.

Main Hospital on 5/23/11 -

At 2:00 p.m., there was a microwave plugged into a six-plug surge protector in the west wall of the admitting office.

At 2:17 p.m., there was a microwave, a coffee maker, and a water cooler, plugged into a six-plug surge protector in the laboratory staff break room. There was a refrigerator plugged into an extension cord in the break room.

At 2:46 p.m., there was a large copy machine and a microwave plugged into a six-plug surge protector in the PCU West case management office.

At 2:59 p.m., there were four electrical boxes with no cover plates, in the right wall of the Old ICU.

JFK Orthopedics on 5/25/11 -

At 8:23 a.m., the electrical box in the reception area had no cover plate.

At 8:30 a.m., the electrical box in the biohazard closet had no cover plate.



21026

On 5/23/11 - Main Hospital

At 2:14 p.m., there was no cover plate on an electrical outlet box in the pharmacy office.

At 2:25 p.m., there was an extension cord connecting a surge protector to a red outlet in the medical staff director's office.

At 2:55 p.m., the electrical panel/breaker box was obstructed by a tray cart in the kitchen back hallway.

At 3:35 p.m., there was a light fixture hanging from the ceiling in the clean linen room in Labor and Delivery West. An approximately 1/2 x 4 inch moon shaped penetration was exposed in the ceiling.

At 3:50 p.m., there was a surge protector connected to a surge protector in the Maternal Child Director's office. A refrigerator was connected to a surge protector in the manger's desk area.

On 5/24/11 - Materials Management
At 8:37 a.m., a cover plate was missing for the electrical box located above the stacks of 7-up cases.

At 9:14 a.m., an extension cord was connected to an extension cord that was plugged into a surge protector in the ICU director's office. A printer and refrigerator were powered by these cords. The surge protector was connected to a third extension cord that was plugged into the wall outlet.

Based on observation, the facility failed to ensure that alcohol based hand rub dispensers (ABHR) were not installed over ignition sources or within 4 feet of other dispensers. This was evidenced by three ABHR dispensers that were installed over light switches, electrical outlets or equipment. This affected 2 of 14 smoke compartments, and could result in the increased risk of a fire.

Findings:

During the facility tour with staff on 5/23/11, the ABHR dispensers were observed.

Main Hospital on 5/23/11 -
At 4:00 p.m., the area outside of delivery Rooms 708 and 709, in L&D East, were observed. The two ABHR dispensers outside of Rooms 708 and 709 were approximately three inches above light switches.


21026

At 1:55 p.m., there were two ABHR dispensers at the entrance to the emergency department (ED) waiting room. The dispenser on the left wall was located directly above the electrical outlet. The dispenser on the front wall, near the entrance door, was located approximately 18 inches from the dispenser on the right wall.

At 2:10 p.m., an ABHR dispenser was located directly above an UPS power system in ED Room 10. The power system is electrical.

Based on observation, the facility failed to maintain the two-hour fire-resistant separation walls between patient care areas and non-conforming buildings. This affected two of two outpatient clinics, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff on 5/24/11 and 5/25/11, the two-hour separation walls at the outpatient clinics were observed.

On 5/24/11 the Outpatient Rehabilitation building was surveyed.
At 2:45 p.m., the wall between the rehab center and the adjacent business office was observed from the director's office. There was an approximately 1/2 inch penetration around conduits on the right side of the wall. There was an approximately 2 inch penetration around a communications sleeve in the center of the wall. There was an approximately 1/4 inch penetration around a wooden beam running from the center to the right side of the wall. There was an approximately 1 inch unsealed pipe sleeve in the center of the wall, around blue, white, and grey wires.

On 5/25/11 the JFK Orthopedics building was surveyed.
At 9:00 a.m., the wall between the clinic and the adjacent business office was observed from the reception/waiting room area. There was an approximately 8 inch by 12 inch penetration in the center of the wall.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected 8 of 14 smoke compartments in the main hospital and two of two outpatient clinics. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff, from 5/23/11 to 5/25/11, the walls and ceilings were observed in the main hospital and at two off site buildings.

Main hospital on 5/23/11 -
At 2:14 p.m., there was an approximately 1 inch penetration around the emergency shower handle, in the chemistry laboratory ceiling.

At 2:41 p.m., there was an approximately 4 x 5 inch penetration around a conduit, in the ceiling tile near the front wall, in the telecommunications closet, across from RT.

At 2:59 p.m., there was an approximately 1 1/2 x 1 foot penetration in the hard deck ceiling of the Old ICU.
During an interview at 3:00 p.m., Maintenance Staff 2 stated that a construction project was in process. He stated there had been no work in the area for the last month.

At 3:02 p.m., there were four approximately 1/2 inch penetrations in the back wall of the case management closet near PCU West.

Main hospital on 5/24/11 -
At 8:41 a.m., there was an approximately 1 inch penetration, and an approximately 1/2 inch penetration, in the back wall of the environmental services closet, in the radiology department.

At 8:45 a.m., there was an approximately 2 x 2 inch penetration around an Internet cable, in the right wall of the front desk area in radiology.

Outpatient Rehabilitation on 5/24/11 -
At 2:37 p.m., there was an approximately 2 x 3 inch penetration in the right wall of the director's office.

At 2:40 p.m., the environmental services closet next to the staff lounge was observed. There was an approximately 5 inch penetration around old phone wires, and four approximately 1/4 inch penetrations around four wire conduits, in the ceiling.

JFK Orthopedics on 5/25/11 -
At 8:17 a.m., there were nine approximately 1/2 inch penetrations in the left wall of Office 120.




21026

On 5/23/11 - Main Hospital
At 1:50 p.m., there was an approximately 1/4 x 8 inch gap and an approximately 1/2 x 24 inch gap on the side of two ceiling tiles in the lobby area, above the left wall.
At 2:07 p.m., there were two approximately 1/4 - 1/2 inch penetrations in the wall next to the toilet, in the Emergency Department (ED) bathroom, across from Cubie 5.
At 2:08 p.m., there were two 1/2 - 3/4 inch penetrations in the wall below the TV, in Physical Therapy Room 7.
Pharmacy Area -
At 2:18 p.m., there was an approximately 1/4 - 1/2 inch penetration, next to the cover plate, in the right back corner of the pharmacy office. There was an approximately 1/8 - 1/4 inch penetration around two escutcheon rings in the ceiling above the solution area. Escutcheon rings were used to cover penetrations around the sprinkler pipes. There were two approximately 1/8 inch penetrations in the back wall of the Pharmacy Tech Office.
Cafeteria/Kitchen area -
At 2:33 p.m., there was an approximately 1/8 inch penetration around a conduit for the cafeteria hood suppression system, in the ceiling near the kitchen handwashing sink.
At 2:39 p.m., there was a 1/8 inch or less penetration around an electrical pipe sleeve and an approximately 1/8 - 1/4 inch penetration around a pipe sleeve and conduit for the main kitchen suppression system.
At 2:44 p.m., there were three approximately 1/8 inch penetrations in the wall above the prep sink.
At 2:48 p.m., there was a 1/8 inch or less penetration, around pipe sleeves, above the refrigerator in the dishwashing area.
At 2:50 a.m., there was an approximately 1/2 inch penetration in the wall above the clean dish counter. The penetration was above a pipe and the clock.

At 3:23 p.m., there was an approximately 1/2 inch square penetration in the ceiling in the Pediatric playroom.

On 5/24/11-
At 8:35 a.m., there was an approximately 1/4 - 1/2 inch penetration, around wires, in the ceiling of the materials management storage room. The penetration was above the ordering desk.
At 8:45 a.m., there were nine 1/8 inch or less penetrations, in the ceiling of the janitor's closet, in the materials management corridor. There was an approximately 1/8 inch penetration in the back wall.
ICU area -
At 9:20 a.m., there was an approximately 1/4 inch penetration in the wall above the ICU ice machine.
At 9:28 a.m., there was an approximately 1/4 inch penetration on the left side of the corridor wall, on the back side of the ED. The penetration was behind the handrail near the back entrance to the ED.

OR area -
At 4:01 p.m., there were seven approximately 1/8 inch penetrations in the wall of Cubie 1, in the Pre-op area. There were two approximately 1/8 inch penetrations in the wall of Cubie 2.
At 4:07 p.m., there was an approximately 1/8 inch penetration in the ceiling, around a pipe, on the left side of the sterilizer access room between OR Rooms 3 and 4. There was an approximately 1/4 inch around the middle pipe and an approximately 1/8 - 1/2 inch penetration around the pipe on the right side, above the left wall.
At 4:18 p.m., there was an approximately 1/2-1 inch penetration around a copper pipe, in the ceiling, above the sterilizer, in the access room between OR Rooms 2 and 1. There was an approximately 1/8 inch penetration around the pipe sleeve above the back wall. There was an approximately 1/8 - 1/4 inch penetration around the pipe sleeves on the left side of the ceiling.

Outpatient Rehabilitation Center -
At 2:38 p.m., there was an approximately 1 - 2 inch penetration around wires and cable, inside of four unsealed pipe sleeves, in the environmental services closet, near Exam Room 1.

5/25/11-
At 1:30 p.m., during alarm testing, there was an approximately 1/8 inch penetration around a conduit, in the ceiling in the materials management office area. The conduit was connected to the pull station near the exterior exit door. There was an approximately 1/2 - 3/4 inch penetration around wires in the same area.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected 6 of 14 smoke compartments and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with staff, from 5/23/11 to 5/25/11, the facility doors were observed.

Main Hospital on 5/23/11 -
At 1:55 p.m., the door to the gift shop storage room was equipped with a self-closing device. The door was held open with a rubber wedge.

At 3:26 p.m., the door to the PP clean linen closet was equipped with a self-closing device. The door closed but failed to latch.

At 3:29 p.m., the door to the shower room, next to the lactation consultant's office, in PP was equipped with a self-closing device. The door closed but failed to latch.

At 3:36 p.m., the door to the mechanical room in PCU West was equipped with a self-closing device. The door closed but failed to latch.

At 3:39 p.m., the door, to the office of the director of the adult telemetry unit, in PCU West, was equipped with a self-closing device. The door closed but failed to latch.

At 3:41 p.m., the door to social services in PCU west was equipped with a self-closing device. The door was obstructed from closing by a two-drawer dresser.

Main Hospital on 5/25/11 -
At 1:52 p.m., the door behind the lobby reception desk was equipped with a self-closing device. The door closed but failed to latch.

At 1:54 p.m., the double doors from the lobby to the ED corridor were held open by a magnetic hold-open device. The doors released from the magnet upon activation of the fire alarm. The right door closed but failed to latch.

At 2:06 p.m., the double doors on the East side of PP were held open by a magnetic hold-open device. The doors released from the magnet upon activation of the fire alarm. The left door closed but failed to latch.

At 2:10 p.m., the double doors on the West side of PP were held open by a magnetic hold-open device. The doors released from the magnet upon activation of the fire alarm. The right door closed but failed to latch.




21026

5/23/11 -
At 3:23 p.m., the door to the Pediatric playroom was equipped with a self-closing device. The door was obstructed by a foot stool used to hold the door open. During the survey on 5/24/11 and 5/25/11, the foot stool was observed in front of the door and obstructed the door from closing.

At 3:25 p.m., the door to Room 404 was obstructed by a linen cart.

5/24/11-
At 8:48 a.m., the self-closing door to the janitor's closet closed but failed to latch. The janitor's closet was located in the materials management corridor.
At 8:50 a.m., the self-closing door to the copy room closed but failed to latch, in the materials management corridor.

Based on observation and interview, the facility failed to ensure that no door in a smoke barrier is held open by a device that fails to close automatically after activation of any fire alarm. This was evidenced by one smoke barrier WON door that failed to close during fire alarm testing. This affected two of two smoke compartments in the ICU area.

Findings:

During the facility tour with facility staff, on 5/24/11, a WON door was observed at the ICU nurses station.
At 9:09 a.m., during an interview, Maintenance Staff 1 reported that the door only closed upon activation of the smoke detectors on either side of the door.

On 5/25/11 the fire alarm system was tested. At 2:20 p.m., the WON door failed to close after activation of a water flow for the sprinkler system.
At 2:23 p.m., the WON door failed to close after activation of a manual pull station. The smoke detectors adjacent to the door activated the WON door closure.

The door did not automatically close upon activation of any device of the fire alarm system.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls, as evidenced by penetrations around wires and pipe sleeves. This affected 8 of 14 smoke compartments and could result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During the facility tour with staff, on 5/24/11, the smoke barrier walls were observed.

Main Hospital on 5/24/11 -
At 9:27 a.m., the smoke barrier wall near RT was observed from the East side. There was an approximately 1 inch penetration on the right-hand side of the wall.

At 9:31 a.m., the smoke barrier wall near RT was observed from the West side. There was an approximately 3/4 inch penetration on the left-hand side of the wall.

At 9:40 a.m., the smoke barrier in the laboratory was observed. There was an approximately 1 inch penetration in the center of the wall, around a telephone wire.





21026

At 9:24 a.m., there was an approximately 1/2 inch penetration around four sides of the air conditioning duct, in the center of the smoke barrier wall in ICU.

At 9:30 a.m., there was an approximately 1/2 inch penetration around a water pipe in the left side corridor wall at the back door to the emergency department (ED). There was an approximately 1/2 inch penetration on the right side of the the duct near the top of the ceiling.

At 9:40 a.m., there was an approximately 1/4 inch penetration around an electrical pipe sleeve, an approximately 1/2 inch penetration around a water pipe, and an approximately 1/8 inch penetration around a pipe sleeve near the top/center area of the smoke barrier wall near Room 413.

At 10:04 a.m., there was an approximately 5 x 7 inch penetration, cutout around conduits and pipes, in the smoke barrier wall at the back entrance to the kitchen.

At 10:10 a.m., there was no protected wall in the smoke barrier at the NICU. The wall was exposed wood. There was an approximately 3 x 6 inch penetration on the far left side of the wall next to the beam. There was an approximately 1/4 inch penetration around cables inside of a pipe sleeve.

Based on observation, the facility failed to ensure that smoke barrier doors are capable to resist the passage of smoke. This was evidenced by one door that failed to latch after closing. This affected 2 of 14 smoke compartments, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with staff on 5/25/11, the smoke barrier doors were observed.

Main Hospital -

At 1:14 p.m., the smoke barrier double doors, leading to the nursing administration corridor, were released from the magnetic hold-open device upon activation of the fire alarm. The right door closed but failed to latch.

Based on observation the facility failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self closing doors. This was evidenced by hazardous areas with penetrations, by storage areas without self-closing doors, and by doors that failed to self close and latch. This affected 2 of 14 smoke compartments and could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour with staff, on 5/23/11 and 5/24/11, hazardous areas in the facility were observed. Hazardous areas are combustible storage rooms/spaces greater than 50 square feet, boiler and heater rooms, repair shops, and trash and soiled linen collection rooms.

On 5/23/11 - Main Hospital
At 2:21 p.m., the Telecom Room was greater than 50 square feet in size and contained boxes of wiring and equipment. There was no self-closing device on the door.

At 2:47 p.m., the kitchen dry storage room contained combustible cardboard boxes and paper packages of supplies. The room is greater than 50 square feet. There was no self-closer on the door. The door was obstructed from manual closing by a bread rack.

At 4:11 p.m., there was an approximately 1/4 - 1/2 inch penetration around a conduit connected to the smoke detector, in the Medical Air/vac Room. There was an approximately 1/4 inch penetration around a copper pipe in the ceiling.

At 4 :14 p.m., there was an approximately 2 inch penetration around a 1/2 inch copper pipe in the left wall of the boiler room access.

At 4:16 p.m., there were seven 1/2 - 1 inch penetrations in the back wall above electrical panel PM in the storeroom. There was an approximately 1 inch and 1 1/2 inch penetration around two separate pipe sleeves in the storeroom back wall.

On 5/24/11 - Materials Management area.
At 8:37 a.m., there was an approximately 18 x 18 inch ceiling area that was damaged and cracked, in the materials management supply room. The area was above the right wall.

At 8:39 a.m., the self-closing doors, to the materials management storage area, closed but failed to latch.

At 8:43 a.m., the double doors to the clean linen storage room closed but failed to latch.

Based on observation, the facility failed to ensure exits are accessible at all times, as evidenced by one exit that was blocked during the survey. This failure could result in the inability of patients to exit the facility in an emergency. This affected one of three exits at one of two offsite clinics.

Findings:

During the facility tour with facility staff on 5/25/11, the exits at the JFK Orthopedic Clinic were observed.
At 8:15 a.m., four computers on wheels and two chairs were placed in front of the exit door in Storage Room 108. The door, exiting to the corridor, was completely blocked. An exit sign is illuminated above the door.

Based on observation and interview, the facility failed to ensure emergency lighting is provided in accordance with NFPA 99 and NFPA 101. This was evidenced by no emergency lights in four of five operating rooms and by the failure of three emergency lights during testing. This affected all surgeries and two of two off site clinics. This could result in a possible patient injury if the power failed during a surgery or could delay evacuation in the clinic buildings.

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.
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code.
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.

NFPA 99, Health Care Facilities 1999 Edition
3-3.2.1.2 All Patient Care Areas.
(a) Wiring, Regular Voltage.
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).

Findings:

During the facility tour with staff on 5/24/11, emergency lights (bullfrog type) were observed in the facility and off site clinics.

At 4:12 p.m., the emergency light in OR 4 failed to illuminate when tested with the push button. During an interview at 4:15 p.m., the DSS was asked if there were emergency lights in OR 1, 2, 3 or 5. He reported there were no other emergency lights. One surgery was being completed during this time.

During an interview at 4:30 p.m., Maintenance Staff 1 reported there were two rechargeable flashlights available in two of the OR suites. He reported there were no emergency lights available in the other two surgery rooms. He stated they were trying to repair the bull frog type emergency light in OR 4.

At 4:45 p.m., the Plant Operations Director was notified regarding the lack of emergency lighting in the OR suites.

At 6 p.m., a vendor arrived on site to install emergency lighting in five of five OR suites.

On 5/25/11 - JFK Orthopedic Clinic
At 8:28 a.m., the emergency light outside of Room 106 failed to illuminate when tested with the push button. No records were provided for testing the emergency lights in the Orthopedic Clinic.


29665

On 5/24/11 - Rehabilitation Clinic

At 2:35 p.m., the emergency light in the rehabilitation clinic failed to activate when tested with the push button. During an interview at 2:36 p.m., Maintenance Staff 1 reported there was no record for testing the emergency lights in the rehab clinic building.

Based on observation, record review, and interview, the facility failed to maintain their complete fire alarm system. This was evidenced by alarm devices that failed, by two areas with no alarm annunciator, by expired fire alarm panel batteries, and by incomplete fire alarm system testing records for the Outpatient Rehabilitation clinic. This affected 14 of 14 smoke compartments in the main hospital, and two of two outpatient clinics. This could result in a failure of the alarm system or a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code 2000 Edition
19.3.4.3 Occupant Notification
Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

Maintaining 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.

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.

NFPA 72, National Fire Alarm Code, 1999 Edition.
Table 7-3.2 requires annual testing of building systems connected to the fire supervising station.

Table 7-3.2
6. Batteries d. Sealed-Lead Acid Type 1. Charger Test (Replace battery every 4 years.)

7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section _______."
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type, heat detectors
(12) Other tests as required by equipment manufactures
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)


Findings:

During the facility tour from 5/24/11 and 5/25/11, the fire alarm system was observed. The system was tested on 5/24/11 and 5/25/11.

On 5/24/11 - Main Hospital
At 3:21 p.m., the two sealed-lead acid batteries in the main fire alarm panel at PBX were dated 9/22/04.

At 1:30 p.m., the strobe light, in the main materials management storeroom, failed to activate during testing of the fire alarm system.

At 1:34 p.m., the combination audible/visible annunciator in the right wall of the pharmacy was observed. The strobe light failed to activate during fire alarm testing.

During record review for the Outpatient Rehabilitation Clinic, on 5/24/11, records for the annual fire alarm testing were requested.

At 2:00 p.m., a document for the annual testing of the fire alarm panel was provided in the form of an invoice. There was no complete list of devices and results for testing 17 heat detectors in the clinic.

On 5/25/11 - JFK Orthopedics

At 10:55 a.m., the fire alarm system was activated during a sprinkler system flow test. There was one combination audible/visual annunciator located in the reception/waiting room area of the clinic. The alarm could not be heard at Nurses Station 1.

During an interview at 10:57 a.m., nursing staff in station 1 confirmed the alarm was not audible.



21026

On 5/24/11 - Main Hospital
During fire alarm testing at 4:27 p.m., there was no audible alarms in the OR clean sterile area, after activation of a smoke detector. The surveyor was inside the area during alarm activation and failed to hear the alarm signal.

On 5/25/11, at 10:05 a.m., a smoke detector was activated outside of the OR area. No audible device was located inside the clean or dirty area.
At 10:06 a.m., during an interview, staff in the dirty side of the sterilizer room confirmed the alarm could not be heard over the equipment noise. A faint alarm signal was heard by the Plant Operations Director.

At 10:07 a.m., during an interview, the staff in the clean area reported he did not hear the alarm.

On 5/25/11 -
During fire alarm testing at 1:25 p.m., the chime in the chiller room failed to sound after activation of a manual pull station.
During an interview at 1:26 p.m., Maintenance Staff 1 reported that some old devices are no longer connected to the fire alarm system. He stated that they do not work.

During fire alarm testing, the smoke detectors located in various smoke barrier doors failed to activate when tested with smoke. The smoke barrier doors at the NICU staff entrance, lobby to main corridor, Post-partum corridor west, and Labor and Delivery west entrance failed when tested. Maintenance Staff 1 confirmed these devices were no longer in service.

At 2:08 p.m., the "old" strobe device failed to activate, in the Father's Waiting Room bathroom.
At 2:46 p.m., the "old" chime and strobe device failed to activate, in the women's bathroom, in the ED waiting area.

Maintenance Staff 1 confirmed these devices were no longer connected to the fire alarm system.

Based on observation and interview, the facility failed to ensure maintenance, inspection and testing of smoke detectors was conducted in accordance with the manufacturers' specifications and NFPA 72. This was evidenced by the failure of one smoke detector and by no documentation for testing and battery replacement for 1 of 2 smoke detectors located in the MRI building.


NFPA 72, National Fire Alarm Code, 1999 edition
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7.2.2. Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2 13. Initiating Devices (g) Smoke Detectors - 2. The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

Findings:

During the facility tour and interview with facility staff on 5/24/11, smoke detectors were observed in the MRI building.
At 9 a.m., Maintenance Staff 1 reported there were no records for testing the single station smoke detectors located in the MRI building. He reported there was no record for battery testing or replacement.

On 5/25/11, at 1:38 p.m., the single station smoke detector in the main MRI lobby failed to activate when tested with smoke.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by missing or displaced escutcheon rings, by sprinkler heads covered in paint or dust, by leaks at the main drain valve in two locations, by no complete supply of spare sprinklers and a wrench, and by incomplete documents for quarterly testing of the sprinkler system. This affected the 14 of 14 smoke compartments at the main hospital, and one of two outpatient clinics. This could result in a delay in extinguishing a fire.

Escutcheon rings (ER) are part of the sprinkler assembly that function to cover the penetration around the sprinkler pipe.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition.
1-6 Level of Protection.1-6.1 A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.
Exception: This requirement shall not apply where specific sections of this standard permit the omission of sprinklers.
3-2.9 Stock of Spare Sprinklers.
3-2.9.1 A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100 degrees F (38 degrees C).
3-2.9.2 A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.
3-2.9.3 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:
(1) For systems having less than 300 sprinklers, not fewer than six sprinklers
(2) For systems with 300 to 1000 sprinklers, not fewer than 12 sprinklers
(3) For systems with over 1000 sprinklers, not fewer than 24 sprinklers

5-1 Basic Requirements.5-1.1 The requirements for spacing, location, and position of sprinklers shall be based on the following principles: (1) Sprinklers installed throughout the premises.(2) Sprinklers located so as not to exceed maximum protection area per sprinkler.(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based 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 materials, 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.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
9-5.1 Inspection and Testing of Sprinkler Pressure Reducing Control Valves. Sprinkler pressure reducing control valves shall be inspected and tested as described in 9-5.1.1 and 9-5.1.2.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

Findings:

During a facility tour with staff from 5/23/11 to 5/24/11, the sprinkler system was observed.

On 5/23/11 - Main Hospital
At 2:23 p.m., there was an approximately 1/4 inch gap between the escutcheon ring (ER) and the ceiling in the medical staff office.

Kitchen/Cafeteria area
At 2:33 p.m., there was an approximately 1/4 inch gap between the ER and the ceiling, above the handwashing sink, on the cafeteria side of the kitchen.
At 2:41 p.m., there was an approximately 1/8 inch layer of dust and dirt completely covering the sprinkler head in the area above the tray line.
At 2:42 p.m., there was no sprinkler located in the walk in freezer/refrigerator.
At 2:57 p.m., there was an approximately 1/4 inch gap between the ER and the ceiling, above the ice machine area.

At 3:07 p.m., the escutcheon rings were missing in the Nurse Staffing Office and the dietary office.

At 3:15 p.m., the ER was hanging from the sprinkler head in the GI procedure area. There was an approximately 1/4 inch penetration exposed around the sprinkler pipe.
At 3:17 p.m., one ER was missing and one was hanging on the sprinkler head, in Room 1.

At 3:20 p.m., there was an approximately 1/4- 1/2 inch gap on one side of the ER in the pediatric playroom.

At 3:24 p.m., the ER was missing in the bathroom in Room 402.

At 3:26 p.m., the ER was hanging on the sprinkler head, in the bathroom in the pediatric lounge area.

At 3:45 p.m., the ER was missing in bathroom 715, in the office area.

At 4:05 p.m., there was a leak at the main drain on sprinkler riser #3.
During record review on 5/24/11, at 11:02 a.m., quarterly sprinkler testing records indicated the leak at the riser was identified by the vendor on 4/7/11.

On 5/24/11 - Materials Management
At 8:34 a.m., there was an approximately 1/4 inch gap between the ER and the ceiling, in the materials management general supply room.
At 8:35 a.m., there was an approximately 1/4 inch gap between the ER and the ceiling, in the area above the "needles cabinet."
At 8:40 a.m., there was an approximately 1/4 inch gap between the ER and the ceiling, exposing an approximately 1/4 inch penetration around the sprinkler pipe.

At 3:15 p.m., there were four spare sprinklers located in the spare sprinkler box at Risers 1 , 2, and 3. There was no wrench in the box.
During an interview at 3:15 p.m., Maintenance Staff 1 stated he did not know where the other sprinklers were located during the ongoing construction.

JFK Orthopedics on 5/25/11 -
At 10:55 a.m., the inspector's test valve was tested by the vendor. There was a leak at the pressure relief valve during the waterflow test.


29665

On 5/23/11 - Main Hospital
At 3:00 p.m., the sprinkler head on the left side of the storage closet in the Old ICU was observed. The sprinkler deflector was approximately 75 percent covered in white paint.

JFK Orthopedics on 5/25/11 -
At 10:40 a.m., there were no documents for quarterly testing of the sprinkler system for two of four quarters in 2010. The documents provided indicated that inspections of the sprinkler system were performed on 2/14/11, 11/24/10, and 2/15/10.

At 10:45 a.m., during an interview, the vendor reported they have not completed quarterly testing for the sprinkler system. He stated they have only conducted visual inspections of the sprinkler system.

Based on observation, the facility failed to ensure fire extinguishers are provided and maintained per NFPA 10. This was evidenced by fire extinguishers that were obstructed or missing. This affected 2 of 14 smoke compartments and could result in a delay in extinguishing a fire.

NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturers's instructions.

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 the facility tour with staff on 5/23 and 5/24/11, fire extinguishers were observed in the kitchen and OR area.

On 5/23/11 - Kitchen area
At 2:44 p.m., the fire extinguisher near the cooking area, was obstructed by a pan rack. The rack had to be moved before staff could reach the extinguisher.

At 2:48 p.m., a fire extinguisher sign indicated an extinguisher was located in the dishwashing area. There was no extinguisher visible in this area.

At 2:58 p.m., the fire extinguisher was obstructed by a tray cart in the kitchen back hallway, near the exit door.

Maintenance Staff 1 confirmed the extinguishers were obstructed.

On 5/24/11, at 4:15 p.m., the fire extinguisher was obstructed by a yellow trash can, outside of the EVS closet in the OR suite.

Based on observation and interview, the facility failed to maintain the means of egress free from obstructions, as evidenced by supplies and clean linen bins that were placed in one exit corridor. This failure could lead to an obstruction of the corridor and the exit path, during a fire or other emergency. This affected 1 of 14 smoke compartments.

Findings:

During the facility tour and interview with facility staff from 5/24/11 through 5/25/11, the egress corridors were observed.

On 5/24/11 at 8:30 a.m. and 9:50 a.m., four 132 Wt clean linen bins were stored against the left wall in the materials management corridor. 30-40 cardboard boxes were stacked in the corridor waiting to be put away in the supply room.

During an interview at 8:35 a.m., the supply manager reported the bins were located in this area until the linen was used from the clean linen room. When there was space the clean linen was put away. The supply manager reported the supplies had just come in and would be put away during the day.

On 5/25/11 at 9:45 and 11:30 a.m., there were five 132 Wt clean linen bins stored against the left wall in the materials management corridor.
There were 30-40 cardboard boxes of supplies stacked in the corridor outside of the supply room.

Based on observation and interview, the facility failed to maintain the medical gas storage areas in accordance with NFPA 99. This was evidenced by oxygen cylinders stored with combustibles and by unsecured cylinders. This affected 1 of 14 smoke compartments, and the outside medical gas storage area. This could result in the increased spread of fire, and the potential injury of patients, in the event of a fire.

NFPA 99 Health Care Facilities 1999 Edition

4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks of fastenings to protect cylinders from accidental damage or dislocation.
4-3.5.2.2 Storage of Cylinders and Containers. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings:

During the facility tour with staff from 5/23/11 to 5/25/11, the oxygen storage areas were observed at the main hospital.

Main Hospital on 5/23/11 -

At 2:29 p.m., there were 13 oxygen e-tanks stored in a rack in the RT storage area. The tanks were up against the front wall, approximately 6 inches directly below a light switch. There was no label distinguishing empty and full tanks.
During an interview at 2:31 p.m., a respiratory technician stated that empty and full cylinders were stored in the rack, and staff look at the gauge to distinguish them.

Main Hospital on 5/24/11 -

At 3:09 p.m., the outdoor medical gas storage area was observed. There were two unsecured nitrogen tanks, and two unsecured oxygen C-tanks on the floor of the storage area.

Based on observation, the facility failed to maintain their electrical wiring in accordance with NFPA 70. This was evidenced by the use of surge protectors and extension cords. This affected 4 of 14 smoke compartments in the main hospital and one of two outpatient clinics. This could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 5/23/11 to 5/25/11, the electrical wiring was observed.

Main Hospital on 5/23/11 -

At 2:00 p.m., there was a microwave plugged into a six-plug surge protector in the west wall of the admitting office.

At 2:17 p.m., there was a microwave, a coffee maker, and a water cooler, plugged into a six-plug surge protector in the laboratory staff break room. There was a refrigerator plugged into an extension cord in the break room.

At 2:46 p.m., there was a large copy machine and a microwave plugged into a six-plug surge protector in the PCU West case management office.

At 2:59 p.m., there were four electrical boxes with no cover plates, in the right wall of the Old ICU.

JFK Orthopedics on 5/25/11 -

At 8:23 a.m., the electrical box in the reception area had no cover plate.

At 8:30 a.m., the electrical box in the biohazard closet had no cover plate.



21026

On 5/23/11 - Main Hospital

At 2:14 p.m., there was no cover plate on an electrical outlet box in the pharmacy office.

At 2:25 p.m., there was an extension cord connecting a surge protector to a red outlet in the medical staff director's office.

At 2:55 p.m., the electrical panel/breaker box was obstructed by a tray cart in the kitchen back hallway.

At 3:35 p.m., there was a light fixture hanging from the ceiling in the clean linen room in Labor and Delivery West. An approximately 1/2 x 4 inch moon shaped penetration was exposed in the ceiling.

At 3:50 p.m., there was a surge protector connected to a surge protector in the Maternal Child Director's office. A refrigerator was connected to a surge protector in the manger's desk area.

On 5/24/11 - Materials Management
At 8:37 a.m., a cover plate was missing for the electrical box located above the stacks of 7-up cases.

At 9:14 a.m., an extension cord was connected to an extension cord that was plugged into a surge protector in the ICU director's office. A printer and refrigerator were powered by these cords. The surge protector was connected to a third extension cord that was plugged into the wall outlet.