HospitalInspections.org

Based on observation, the facility failed to maintain the occupancy separations as evidenced by unsealed penetrations in the common walls. This affected three of three offsite suites in POB 1, and affected one of three floors of POB2, and had the potential to allow the spread of smoke and fire which could lead to injury to the patients.

Findings:

During the facility tour with Engineering Staff 1 from 6/11/12 to 6/14/12, the facility occupancy separation walls were observed.

1. At 1:10 p.m., on 6/13/12, there was an unsealed penetration in the common wall between Suite 102 and Suite 107. Engineering Staff 1 confirmed there was an unsealed penetration in the wall.
2. At 1:47 p.m., on 6/13/12, two air conditioning ducts were observed to penetrate the occupancy separation wall above the break room in Suite 308. Engineering Staff 1 was unable to confirm the presence of dampers where the ducts penetrated the wall.
3. At 1:52 p.m., on 6/13/12, two air conditioning ducts were observed to penetrate the occupancy separation wall between Suite 308 and Suite 307. Engineering Staff 1 was unable to confirm the presence of dampers where the ducts penetrated the wall.
4. At 2:08 p.m., on 6/13/12, there were three 5 inch by 5 inch inch unsealed penetrations in the common wall between Suite 215 and Suite 206. Engineering Staff 1 confirmed there were unsealed penetrations in the wall.
5. At 11:15 a.m., on 6/13/12, there were unsealed penetrations in the common wall between the Cardiac Rehab Suite and Suite 307 in the POB 2. There was an approximately 4 inch penetration, with red wires running through the penetration, and an unsealed ? inch gap around two conduits that penetrated the wall. Engineering Staff 1 confirmed there were unsealed penetrations in the wall.

Based on observation and interview, the facility failed to maintain the integrity of their building construction as evidenced by penetrations in the ceiling. This affected the basement of the C Building, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with engineering staff from 6/11/12 to 6/14/12, the walls and ceilings were observed.

At 10:54 a.m., on 6/12/12, Electrical Closet C030 located in the C Building basement was observed. There was an approximately 3 foot by 6 inch penetration, and two approximately 1 foot by 6 inch penetrations around electrical conduits, in the ceiling. The penetrations were sealed with non-fire rated insulation material.

During an interview at 10:55 a.m., Engineering Staff 4 stated that the penetrations were sealed with fiber glass insulation.

Based on observation, the facility failed to maintain the corridor walls as evidenced by unsealed corridor wall penetrations, and by the smoke barrier frame rating labels that were painted over. This affected one of five floors of POB 1, and affected two of three floors of POB 2, and had the potential to transmit smoke and door failure causing harm to the patients.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.
3-4.3.2 Components. Fire door hardware shall include hinge brackets, hinges, latches, latch keepers, and operating handle mechanisms; hardware for inactive door or pairs of doors includes top and bottom bolts and keepers.

Findings:

During the facility tour with Engineering Staff 1 from 6/11/12 to 6/14/12, the facility corridor walls and ceilings were observed.

1. At 12:55 p.m., on 6/13/12, there were three unsealed penetrations through the east corridor side of the wall in Suite 102 in POB 1. Engineering Staff 1 confirmed there were unsealed penetrations in the corridor wall.
2. At 12:58 p.m., on 6/13/12, three of three door rating labels in the east corridor doors of Suite 102 in POB 1 were painted over, and the door fire ratings could not be identified. Engineering Staff 1 confirmed the door rating labels were painted over.
3. At 1:00 p.m., on 6/13/12, there was an unsealed penetration around a conduit, through the west corridor side of the wall in Suite 102 in POB 1. Engineering Staff 1 confirmed there was an unsealed penetration in the corridor wall.
4. At 1:34 p.m., on 6/13/12, there were four unsealed penetrations through the corridor wall adjacent to the elevator and Suite 109 in POB 1. Engineering Staff 1 confirmed there were unsealed penetrations in the corridor wall.
5. At 10:15 a.m., on 6/13/12, in the lobby separation wall to Suite 101, at the elevator wall in POB 2, there were three 3 inch conduits that penetrated the wall. There was an approximately four inch unsealed gap around the conduits. Engineering Staff 1 confirmed there were unsealed penetrations in the wall.
6. At 10:18 a.m., on 6/13/12, there was a self-closing door above the drop ceiling in the Suite 101 Conference Room in POB 2. The door was to an enclosure housing an air conditioning unit and had fallen out of place. Engineering Staff 1 confirmed the door was not in place.
7. At 11:00 a.m., on 6/13/12, in the wall separating the Cardiac Rehab Suite and the corridor in POB 2, there were nine approximately 2 inch by 2 inch unsealed penetrations through the wall with a conduit running through the unsealed penetration. Engineering Staff 1 confirmed there were unsealed penetrations in the corridor wall.
8. At 11:05 a.m., on 6/13/12, there was an unsealed penetration in the wall separating the 3rd floor electrical room from the corridor in POB-2. There was an approximately 1 inch gap around a conduit that went through the penetration. Engineering Staff 1 confirmed there was an unsealed penetration.

Based on observation, interview, and document review, the facility failed to maintain the corridor doors as evidenced by corridor doors that failed to fully close and latch without assistance, and by the failure to provide documentation for the inspection and maintenance of the rolling fire windows. This affected five of six floors and the basement, of the main hospital building, and had the potential for the failure to contain smoke and fire and causing harm to the patients.

NFPA 101, Life Safety Code, 2000 Edition
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
15-2.1.1 Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately.
15-2.1.3 Chains or cables employed on suspended doors shall be inspected frequently for excessive wear and stretching.
15-2.2.1 Guides and bearings shall be kept well lubricated to facilitate operation.
15-2.2.2 Chains or cables on biparting, counterbalanced doors shall be checked frequently and adjustments shall be made to ensure proper latching and to keep the doors in proper relation to the opening.
15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.
15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During a facility tour with engineering staff from 6/11/12 to 6/14/12, the corridor doors were observed.

1. At 4:30 p.m., on 6/11/12, the door to Room B677, located on the sixth floor of Building B, was equipped with a self-closing device. The door closed but failed to latch.
2. At 9:45 a.m., on 6/12/12, the door to the storage room, near the B Building elevators in the basement, was equipped with a self-closing device. The door closed but failed to latch.
3. At 10:51 a.m., on 6/12/12, the door to Janitor Closet C026, located in the C Building basement, was equipped with a self-closing device. The door closed but failed to latch.
4. At 10:59 a.m., on 6/13/12, the door to the soiled utility room, located in the surgery department on the second floor of Building C, was equipped with a self-closing device. The door closed but failed to latch.
5. At 9:00 a.m., on 6/11/12, the self-closing corridor door to B474 failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.
6. At 9:37 a.m., on 6/11/12, the self-closing corridor door to the Janitor Room C420.4 failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.
7. At 1:02 p.m., on 6/11/12, the self-closing corridor door to the clean linen room in the B300 Pediatrics Corridor failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.
8. At 3:02 p.m., on 6/11/12, the inspection, maintenance, and testing records for the roll down fire window in the Emergency Room were requested. The fire alarm vendor stated the windows were only tested with the fire alarm system. Engineering Staff 4 stated the window was inspected, but that the report was unavailable.
9. At 8:38 a.m., on 6/13/12, the self-closing corridor door to the Linen Room adjacent to Room 201 in Building D failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.
10. At 8:40 a.m., on 6/13/12, the self-closing corridor door to the Lounge adjacent to Room 201 in Building D failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.

Based on observation, the facility failed to maintain their vertical openings. This was evidenced by a stairwell doors that failed to fully close and latch without assistance. This affected the basement of the main hospital, and one of five floors in POB 1, and had the potential to allow the spread of smoke and fire due to a non-functional door which could lead to injury to the residents.

NFPA 101, Life Safety Code, 2000 Edition
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following:
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirements of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provision of 7.2.1.

Findings:

During the facility tour with engineering staff from 6/11/12 to 6/14/12, the facility stairwells were observed.

1. At 8:30 a.m., on 6/13/12, the stairwell door in D Building Basement adjacent to the elevator failed to latch. The screw holding the cross bar in place on the door was loose. Engineering Staff 1 confirmed the door failed to latch.
2. At 3:20 p.m., on 6/13/12, the stairwell door adjacent to Room 211 in POB 1 failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.

Based on observation, the facility failed to maintain the access to the exits as evidenced by the failure to mark access to exits where the exits were not readily apparent. This affected one of three floors in POB 2, and had the potential to delay egress from the building during an emergency.

Findings:

During the facility tour with Staff 1 from June 11, 2012, to June 14, 2012, the facility exit access was observed.

At 10:35 a.m. on 6/13/12, the west hall of the Breast Imaging Center in POB 2 was not marked with signs that indicated the way to the exits. Engineering Staff 1 confirmed there were not exit signs in the corridor.

Based on observation, the facility failed to maintain the smoke barriers as evidenced by an unsealed penetration in a smoke barrier wall. This affected the one of six floors in the main hospital, and had the potential to fail to contain smoke during a fire which could cause harm to the patients.

Findings:

During the facility tour with engineering staff from 6/11/12 to 6/14/12, the facility smoke barriers were observed.

At 4:22 p.m., on 6/11/12, there was an approximately 4 inch by 4 inch unsealed penetration in the smoke barrier wall adjacent to B575. Engineering Staff 1 confirmed there was an unsealed penetration in the smoke barrier wall.

Based on observation, the facility failed to maintain their doors in smoke barriers. This was evidenced by smoke barrier door frame labels that were painted over, and by smoke barrier doors that failed to latch. This affected four of six floors in the main hospital, and had the potential to allow the spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.
8.3.3 Fire Barrier Used as Smoke Barrier. A fire barrier shall be permitted to be used as a smoke barrier, provided that it meets the requirements of 8.3.4 through 8.3.6.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Findings:

During the facility tour with engineering staff from 6/11/12 to 6/14/12, the doors in smoke barriers were observed.

1. At 4:15 p.m., on 6/11/12, two of two doors in the smoke barrier adjacent to Room B575 were equipped with surface vertical rod hardware for latching at the top of the door. The door adjacent to B575 had been modified by the removal of the lower bar and latching mechanism at the bottom of the door. The bottom of the door failed to latch. Engineering Staff 1 confirmed the bottom of the door failed to latch, and that the bottom bar and latching mechanism were not in place.

2. At 8:40 a.m., on 6/12/12, the fire rating label on the door to the fourth floor B Building elevator was painted over. The rating of the door could not be determined. Engineering Staff 1 confirmed the door rating label was painted over.

3. At 1:02 p.m., on 6/12/12, two of two doors in the smoke barrier adjacent to Room B375 were equipped with surface vertical rod hardware for latching at the bottom of the door. Both doors had been modified by the removal of the lower bar and latching mechanism at the bottom of the door. The bottom of the doors failed to latch. Engineering Staff 1 confirmed the bottom of the doors failed to latch, and that the bottom bar and latching mechanism were not in place.

4. At 8:36 a.m., on 6/13/12, two of two doors in the smoke barrier adjacent to Room 207 in Building D failed to latch when tested. The doors were equipped with surface vertical rod hardware for latching at the top and bottom of the door. Engineering Staff 1 confirmed the doors failed to latch.

Based on observation, record review, and interview, the facility failed to maintain their emergency lighting. This was evidenced by no battery-powered emergency lighting in anesthetizing locations, and by no documentation for testing emergency lights at one offsite location. This affected one of six floors in the main hospital and one of five floors in POB 1. This could result in no lighting during procedures where anesthetics are used and the failure of emergency lighting at the offsite clinic.

NFPA 101, Life Safety Code, 2000 Edition
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 1 1/2 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.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

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).

Findings:

During a facility tour with engineering staff from 6/11/12 to 6/14/12, the emergency lighting was observed.

1. At 11:30 a.m. on 6/13/12, Operating Rooms 10 and 11, located on the second floor of Building B, were observed. There were no battery-powered emergency lighting units in the rooms.
During an interview at 11:41 a.m., Engineering Staff 2 inspected the rooms and confirmed that they were not equipped with battery-powered emergency lighting. Engineering Staff 2 installed battery-powered emergency lighting units in Operating Rooms 10 and 11 at 3:21 p.m.

2. At 1:27 p.m., on 6/13/12, Engineering Staff 4 was asked to provide documentation for monthly and annual testing of exit signs and battery-powered egress lights in Suite 109 of POB 1. Engineering Staff 4 stated they thought the units were tested, but was unable to provide documentation for testing of the exit signs and battery-powered egress lights.

Based on observation, the facility failed to maintain the fire alarm system in accordance with NFPA 72. This was evidenced by obstructed access to a manual fire alarm box. This affected one of three floors in POB 2, and could result in a delay in activation of the fire alarm system in the event of a fire.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

NFPA 101, Life Safety Code, 2000 Edition
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

Findings:

During the facility tour with Engineering Staff from 6/11/12 to 6/14/12, the manual fire alarm boxes were observed.

At 10:16 a.m., on 6/13/12, access to the manual fire alarm box in the lobby of the Cancer Treatment Center in POB 2 was obstructed by a chair. Engineering Staff 1 confirmed the chair obstructed access to the manual fire alarm box and moved the chair.

Based on observation, document review, and interview, the facility failed to maintain their smoke alarms. This was evidenced by two smoke alarms that were covered with tape, and by the failure to provide current documentation for the inspection, testing, sensitivity testing, and maintenance of the smoke alarms. This affected the main hospital and POB 2, and could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
8-3.5 Unless otherwise recommended by the manufacturer, smoke alarms installed in accordance with Chapters 18, 19, or 21 of NFPA 101, Life Safety Code, shall be replaced when they fail to respond to tests conducted in accordance with 8-3.4 but shall not remain in service longer than 10 years from the date of installation.

Findings:

During a facility tour with engineering staff from 6/11/12 to 6/14/12, the smoke alarms were observed, and maintenance records were requested.

1. At 2:22 p.m., on 6/12/12, there was blue masking tape covering the smoke detector in the back of the emergency department waiting room.
During an interview at 2:23 p.m., Emergency Department Staff 1 stated that the waiting room was renovated approximately one to two weeks ago.
2. At 8:40 a.m., on 6/13/12, there was blue masking tape covering the smoke detector in Janitor Closet C244, located on the second floor of Building C.
3. At 2:28 p.m., on 6/12/12, the self-closing corridor door to Medical Records was equipped with an automatic closing device designed to release and close the door when the smoke alarm, built into the closing device, was activated. The facility provided documentation for the fire alarm system tests dated 4/12/12. The report failed to document the inspection, testing, sensitivity testing, and maintenance of the smoke alarm in the Medical Records door automatic closing device. Engineering Staff 5 stated that the system was not inspected by the vendor, and Engineering Staff 4 stated the system was not inspected by the facility.
4. At 9 a.m. on 6/13/12, the self-closing corridor doors to Room D 219 and Room D 221 were equipped with automatic closing devices designed to release and close the door upon activation of smoke alarms in the rooms. The facility provided documentation for the fire alarm system tests dated 4/12/12. The report failed to document the inspection, testing, sensitivity testing, and maintenance of the doors to D219 and D221. Engineering Staff 5 stated the system was not inspected by the vendor, and Engineering Staff 4 stated the system was not inspected by the facility.
5. At 9:45 a.m., on 6/14/12, the facility failed to provide documentation for the sensitivity testing of the smoke alarms in POB 2. Engineering Staff 4 confirmed there was no documentation for the sensitivity testing of the smoke alarms.

Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by the failure to provide documentation for 2 of 4 required quarterly sprinkler inspections, by obstructed sprinkler spray patterns, by a sprinkler head that was not free of foreign materials, by the failure to provide documentation for the inspection, testing, and maintenance of the dry pipe sprinkler system, by a dry pipe sprinkler system tamper alarm that was not connected to the fire alarm system, and by a non-sprinklered canopy. This affected the main hospital, POB 1, and POB 2, and had the potential for sprinkler system to fail to function as designed in the event of a fire.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
5-13.8 Sprinklers shall be installed under exterior roof or canopies exceeding 4 ft (1.2 m) in width.
Exception: Sprinklers are permitted to be omitted where the canopy or roof is noncombustible or limited combustible construction.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
2-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.
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, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
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.
2-4.2 Dry Pipe Systems. Dry pipe systems shall be kept dry at all times.
Exception: During nonfreezing weather, a dry pipe system shall be permitted to be left wet if the only other option is to remove the system from service while waiting for parts or during repair activities.
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
9-4.4 Dry Pipe Valves/Quick-Opening Devices.
9-4.4.1.2 Gauges shall be inspected weekly.
(a) The gauge on the supply side of the dry pipe valve shall indicate that the normal supply water pressure is being maintained.
(b) The gauge on the system side of the dry pipe valve shall indicate that the proper ratio of air or nitrogen pressure to water supply pressure is being maintained in accordance with the manufacturer ' s instructions.
(c) The gauge on the quick-opening device, if provided, shall indicate the same pressure as the gauge on the system side of the dry pipe valve.
Exception: Systems equipped with low air or nitrogen pressure alarms shall be inspected monthly.
9-4.4.1.3 The dry pipe valve shall be externally inspected monthly to verify the following:
(a) The valve is free of physical damage.
(b) All trim valves are in the appropriate open or closed position.
(c) There is no leakage from the intermediate chamber.
9-4.4.1.4 The interior of the dry pipe valve shall be inspected annually when the trip test is conducted.
9-4.4.2 Testing.
9-4.4.2.1 The priming water level shall be tested quarterly.
9-4.4.2.2 Each dry pipe valve shall be trip tested annually during warm weather.
Exception: Dry pipe valves protecting freezers shall be trip tested in a manner that does not introduce moisture into the piping in the freezers.
9-4.4.2.2.1 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.
9-4.4.2.2.2 During those years when full flow testing in accordance with 9-4.4.2.2.1 is not required, each dry pipe valve shall be trip tested with the control valve partially open.
9-4.4.2.3 Grease or other sealing materials shall not be applied to the seating surfaces of dry pipe valves.
9-4.4.2.4 Quick-opening devices, if provided, shall be tested quarterly.
9-4.4.2.6 Low air pressure alarms, if provided, shall be tested quarterly in accordance with the manufacturer ' s instructions.
9-4.4.2.7 Low temperature alarms, if installed in valve enclosures, shall be tested annually at the beginning of the heating season.
9-4.4.2.8 Automatic air pressure maintenance devices, if provided, shall be tested annually during the dry pipe valve trip test in accordance with the manufacturer ' s instructions.
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 the document review and facility tour with engineering staff between 6/11/12, to 6/14/12, the automatic sprinkler system was observed, and the sprinkler inspection and test reports were reviewed.

1. At 2:58 p.m., on 6/11/12, the facility failed to provide documentation for the 3rd quarter (July-September, 2011) and the first quarter (January-March, 2012) sprinkler system inspections and tests for the main hospital, POB 1, and POB 2. There was no evidence that the sprinkler system components were inspected to assure they were free of physical damage, testing of the sprinkler system alarms, inspections of the valves and fire department connections. Engineering Staff 1 confirmed there were no other documents available for review.
2. At 1:28 p.m., on 6/13/12, the sprinkler head deflector in the corridor adjacent to Suites 102 and 107 in POB 1 had foreign debris that appeared to be paint on the deflector. Engineering Staff 1 confirmed there was foreign debris on the deflector.
3. At 3:30 p.m., on 6/13/12, there was a sprinkler riser observed in Suite 109 in POB 1. The tamper alarm on the water control valve was not connected to the fire alarm system. Engineering Staff 1 confirmed the alarm was not connected to the fire alarm system. The vendor representative identified the sprinkler riser as a riser for a dry pipe sprinkler system.
4. At 9:45 a.m., on 6/14/12, the vendor inspection, test, and maintenance reports for the fire sprinkler system for POB 1 dated 6/21/11, 10/6/11, and 4/13/12 failed to indicate the weekly, monthly, quarterly, and annual inspection, testing, and maintenance of the dry pipe sprinkler system as required in NFPA 25, 2-4.2, and 9-4.4. Engineering Staff 1 confirmed the documents failed to indicate the dry pipe sprinkler system had been inspected, tested, and maintained.
10. At 9:50 a.m., on 6/13/12, there was an approximately 20 foot by 30 foot fabric canopy attached to the roof at the main entrance of POB 2 that was not sprinklered. Engineering Staff 1 confirmed the canopy was not sprinklered, and did not know if the facility had documentation indicating the flame resistance of the canopy fabric.

Based on observation, interview, and document review, the facility failed to maintain their heating, ventilating, and air conditioning systems. This was evidenced by the failure to identify duct service openings adjacent to dampers, and by the failure to inspect, test, and maintain the fire dampers. This affected three of six floors in the main hospital, and three of three floors of POB 2, and had the potential for damper failure in the event of a fire.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During the document review and facility tour with engineering staff from 6/11/12, to 6/14/12, the facility dampers were observed, and damper maintenance records were reviewed.

1. At 9:20 a.m., on 6/12/12, three of three duct access panels adjacent to the dampers in Mechanical Room C475 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
2. At 9:21 a.m., on 6/12/12, three of three duct access panels adjacent to the dampers in the fourth floor Mechanical Room 7 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
3. At 9:32 a.m., on 6/12/12, three of three duct access panels adjacent to the dampers in Mechanical Room C454 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
4. At 9:34 a.m., on 6/12/12, two of two duct access panels at the smoke barrier adjacent to Room C454 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
5. At 9:35 a.m., on 6/12/12, the duct access panel at the smoke barrier adjacent to the Critical Care Telemetry Office was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
6. At 9:36 a.m., on 6/12/12, two of two duct access panels in Electrical Room C443 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
7. At 9:40 a.m., on 6/12/12, the duct access panel in Soiled Linen Room C430.3 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
8. At 9:41 a.m., on 6/12/12, the duct access panel in Ante Room C430.1 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
9. At 9:45 a.m., on 6/12/12, the duct access panel in the corridor adjacent to Room C468 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
10. At 9:45 a.m., on 6/12/12, the duct access panel in Room C400.3 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
11. At 9:47 a.m., on 6/12/12, two of two duct access panels in the smoke barrier, on the north side of the ICU, were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
12. At 10:18 a.m., on 6/12/12, on the corridor side of Room C410.4, the damper access panel was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
13. At 10:20 a.m., on 6/12/12, two of two duct access panels in Room C410.1 were not identified indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
14. At 10:21 a.m., on 6/12/12, the duct access panel in the smoke barrier adjacent to Room C464 was not identified indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
15. At 10:29 a.m., on 6/12/12, the duct access panel in Room C461 was not identified indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
16. At 10:45 a.m., on 6/12/12, ceiling dampers were observed in the fourth floor Building B Nourishment Room. The dampers were not identified on the damper location map provided by the facility. Staff 4 confirmed the dampers at the location and stated that the area was recently remodeled and the map had not been updated.
17. At 11:19 a.m., on 6/12/12, two of two duct access panels in the two-hour separation barrier, on the third floor, were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
18. At 11:20 a.m., on 6/12/12, two of two duct access panels in Medication Room 3006.1 were not identified indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
19. At 11:26 a.m., on June 12, 2012, the duct access panel observed in the third floor mechanical room was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
20. At 12:40 p.m., on 6/12/12, three of three duct access panels adjacent to the dampers in Mechanical Room 3003.1 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
21. At 1:21 p.m,. on 6/12/12, the duct access panel in the corridor adjacent to Room D302 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
22. At 1:21 p.m., on 6/12/12, the duct access panel in the corridor adjacent to Room D308 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
23. At 2:58 p.m., on 6/12/12, one of two duct access panels in Mechanical Room C119 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
24. At 10:03 a.m., on 6/13/12, four of four duct access, panels adjacent to the dampers in the first floor fire panel room in POB 2, were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
25. At 10:10 a.m., on 6/13/12, four air ducts were observed to penetrate the wall between the corridor and Suite 109 in POB 2. Engineering Staff 1 stated he did not know if the ducts had dampers to prevent the passage of smoke between the corridor and the Suite.
26. At 10:14 a.m., on 6/13/12, the duct access panel adjacent to the damper in the wall separating Suite 109 and the lobby, where the wall met the elevator wall, was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
28. At 10:27 a.m., on 6/13/12, an air duct was observed above the drop ceiling in the Suite 109 break room. The air duct penetrated the wall separating the suite from the corridor. There was no air duct connected to the duct housing at the wall. Engineering Staff 1 confirmed there was no duct attached to the duct housing on the wall.
29. At 10:44 a.m., on 6/13/12, there was a duct access panel adjacent to the damper in the wall that separated the corridor from the Breast Imaging Center Work Station in POB 2. The access panel was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
30. At 11:00 a.m., on 6/13/12, two air ducts were observed to penetrate the wall between the corridor and the Cardiac Rehab Suite in POB 2. Engineering Staff 1 stated he did not know if the ducts had dampers to prevent the passage of smoke between the corridor and the Suite.
31. At 11:04 a.m., on 6/13/12, two of two duct access panels adjacent to the dampers in the third floor electrical room in POB 2 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
32. At 11:10 a.m., on 6/13/12, two of two duct access panels adjacent to the dampers in wall above the Cardiac Rehab Changing Area in POB 2 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
33. At 12:45 p.m., on 6/13/12, the facility was requested to provide documentation for the inspection, testing, and maintenance of the dampers in POB 2. Engineering Staff 4 stated there were no records for inspection, testing, and maintenance of the dampers in POB 2.

Based on record review, a letter from CMS dated June 1, 2012, stated that the facility was granted an extension by CMS for their waiver to reduce the lower-limit requirement for relative humidity in anesthetizing locations from 35%, to 20%.

Based on observation, document review, and interview, the facility failed to maintain the generator in accordance with NFPA 99 and NFPA 110. This was evidenced by maintenance-free batteries used for the Level 1 generators. This affected the main hospital, and had the potential for generator failure.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
3-5.4.5 Type of Battery. The battery shall be of the nickelcadmium or lead-acid type. Lead-acid batteries shall be furnished as charged when wet. Drain-dry batteries or drycharged lead-acid batteries shall be permitted. Vented nickelcadmium batteries shall be filled and charged when furnished and shall have listed flip-top, flame arrestor vent caps. The manufacturer shall provide installation, operation, and maintenance instructions, and, when shipped dry, electrolyte mixing instructions. Batteries shall not be installed until the battery charger is in service.
All batteries used in this service shall have been designed for this duty and shall have demonstrable characteristics of performance and reliability acceptable to the authority having jurisdiction. Batteries shall be prepared for use according to the battery manufacturer ' s instructions.
Starting batteries for Level 1 installations shall not be of the maintenance-free variety.
6-3.6 Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

Findings:

During the document review and facility tour with Engineering Staff 1 on January 12, 2012, the facility generator was observed, and inspection documents were reviewed.

1. At 1:43 p.m., on 6/12/12, the generator inspection logs were reviewed. The facility failed to provide documentation for the weekly inspection of the electrolyte levels in the batteries. Engineering Staff 2 stated the levels were not checked as the batteries were maintenance free.

2. At 8:50 a.m., on 6/14/14, the batteries were observed to be maintenance free batteries, and were not in compliance with NFPA 110, 3-5.4.5.

Based on observation and interview, the facility failed to maintain their electrical wiring in accordance with NFPA 70, and NFPA 99. This was evidenced by appliances plugged into multi-plug adaptors, by multi-plug adaptors plugged into other multi-plug adaptors, by missing and damaged electrical box faceplates, by breakers in the " on " position and not labeled as to the purpose or use, and by damaged electrical receptacles. This affected three floors in the main hospital, and two of five floors of POB 1, and could result in an increased risk of an electrical fire.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.
NFPA 70, National Electric Code, 1999 Edition.
110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.
370-28(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.
384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.
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 engineering staff from 6/11/12 to 6/14/12, the electrical wiring was observed.

1. At 4:00 p.m., on 6/11/12, the electrical receptacle in the fifth floor corridor adjacent to the elevator was damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacle was damaged around the ground port.
2. At 9:14 a.m., on 6/12/12, the electrical receptacle in the corridor adjacent to Door N-4 in the ICU was damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacle was damaged around the ground port.
3. At 1:25 p.m., on 6/12/12, on Electrical Panel 3EDG, breakers 31, 32, 33, 35-39, 46, 49, and 55 were in the " on " position, and not labeled as to the area served by the breakers. Engineering Staff 1 confirmed the breakers were not labeled.
4. At 9:20 a.m., on 6/12/12, the faceplate of the receptacle outlet outside the Cath Lab Dark Room, located in the B Building basement, was not flush to the wall, and the wires of the electrical box were exposed.
5. At 12:59 p.m., on 6/12/12, there was a microwave plugged into a six-plug surge protector that was plugged into another six-plug surge protector, in the first floor gift shop storage room.
6. At 1:12 p.m., on 6/12/12, there was an approximately 3 inch by 2 inch electrical box with no faceplate in the back storage room of financial services, located on the first floor of the B Building.
7. At 2:56 p.m., on 6/12/12, there was a refrigerator plugged into a six-plug surge protector in the kitchen, near the dry storage room on the first floor.
8. At 10:48 a.m., on 6/13/12, there was an open junction box above the drop ceiling in the corridor between Medical Records and the activity room. Adjacent to the open junction box there was a fuse box with the door open on the corridor side of the Medical Records wall. Engineering Staff 1 confirmed the junction box was missing the cover plate and the fuse box door was open.
9. At 12:55 p.m., on 6/13/12, there was an open junction box above the drop ceiling in the corridor adjacent to Suite 102. Engineering Staff 1 confirmed the junction box was missing the cover plate.
10. At 12:55 p.m., on 6/13/12, the electrical receptacle in the corridor adjacent to Suite 102 was damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacle was damaged.
11. At 2:12 p.m., on 6/13/12, two of two electrical receptacles in the corridor of Suite 214, adjacent to the lunch room, were damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacles were damaged.
12. At 2:13 p.m., on 6/13/12, the electrical receptacle in the director ' s restroom of Suite 214 was damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacle was damaged around the ground port.
13. At 2:14 p.m., on 6/13/12, the electrical receptacle in the kitchen adjacent to the corridor door in Suite 214 was damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacle was damaged.

Based on observation, the facility failed to maintain the occupancy separations as evidenced by unsealed penetrations in the common walls. This affected three of three offsite suites in POB 1, and affected one of three floors of POB2, and had the potential to allow the spread of smoke and fire which could lead to injury to the patients.

Findings:

During the facility tour with Engineering Staff 1 from 6/11/12 to 6/14/12, the facility occupancy separation walls were observed.

1. At 1:10 p.m., on 6/13/12, there was an unsealed penetration in the common wall between Suite 102 and Suite 107. Engineering Staff 1 confirmed there was an unsealed penetration in the wall.
2. At 1:47 p.m., on 6/13/12, two air conditioning ducts were observed to penetrate the occupancy separation wall above the break room in Suite 308. Engineering Staff 1 was unable to confirm the presence of dampers where the ducts penetrated the wall.
3. At 1:52 p.m., on 6/13/12, two air conditioning ducts were observed to penetrate the occupancy separation wall between Suite 308 and Suite 307. Engineering Staff 1 was unable to confirm the presence of dampers where the ducts penetrated the wall.
4. At 2:08 p.m., on 6/13/12, there were three 5 inch by 5 inch inch unsealed penetrations in the common wall between Suite 215 and Suite 206. Engineering Staff 1 confirmed there were unsealed penetrations in the wall.
5. At 11:15 a.m., on 6/13/12, there were unsealed penetrations in the common wall between the Cardiac Rehab Suite and Suite 307 in the POB 2. There was an approximately 4 inch penetration, with red wires running through the penetration, and an unsealed ? inch gap around two conduits that penetrated the wall. Engineering Staff 1 confirmed there were unsealed penetrations in the wall.

Based on observation and interview, the facility failed to maintain the integrity of their building construction as evidenced by penetrations in the ceiling. This affected the basement of the C Building, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with engineering staff from 6/11/12 to 6/14/12, the walls and ceilings were observed.

At 10:54 a.m., on 6/12/12, Electrical Closet C030 located in the C Building basement was observed. There was an approximately 3 foot by 6 inch penetration, and two approximately 1 foot by 6 inch penetrations around electrical conduits, in the ceiling. The penetrations were sealed with non-fire rated insulation material.

During an interview at 10:55 a.m., Engineering Staff 4 stated that the penetrations were sealed with fiber glass insulation.

Based on observation, the facility failed to maintain the corridor walls as evidenced by unsealed corridor wall penetrations, and by the smoke barrier frame rating labels that were painted over. This affected one of five floors of POB 1, and affected two of three floors of POB 2, and had the potential to transmit smoke and door failure causing harm to the patients.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.
3-4.3.2 Components. Fire door hardware shall include hinge brackets, hinges, latches, latch keepers, and operating handle mechanisms; hardware for inactive door or pairs of doors includes top and bottom bolts and keepers.

Findings:

During the facility tour with Engineering Staff 1 from 6/11/12 to 6/14/12, the facility corridor walls and ceilings were observed.

1. At 12:55 p.m., on 6/13/12, there were three unsealed penetrations through the east corridor side of the wall in Suite 102 in POB 1. Engineering Staff 1 confirmed there were unsealed penetrations in the corridor wall.
2. At 12:58 p.m., on 6/13/12, three of three door rating labels in the east corridor doors of Suite 102 in POB 1 were painted over, and the door fire ratings could not be identified. Engineering Staff 1 confirmed the door rating labels were painted over.
3. At 1:00 p.m., on 6/13/12, there was an unsealed penetration around a conduit, through the west corridor side of the wall in Suite 102 in POB 1. Engineering Staff 1 confirmed there was an unsealed penetration in the corridor wall.
4. At 1:34 p.m., on 6/13/12, there were four unsealed penetrations through the corridor wall adjacent to the elevator and Suite 109 in POB 1. Engineering Staff 1 confirmed there were unsealed penetrations in the corridor wall.
5. At 10:15 a.m., on 6/13/12, in the lobby separation wall to Suite 101, at the elevator wall in POB 2, there were three 3 inch conduits that penetrated the wall. There was an approximately four inch unsealed gap around the conduits. Engineering Staff 1 confirmed there were unsealed penetrations in the wall.
6. At 10:18 a.m., on 6/13/12, there was a self-closing door above the drop ceiling in the Suite 101 Conference Room in POB 2. The door was to an enclosure housing an air conditioning unit and had fallen out of place. Engineering Staff 1 confirmed the door was not in place.
7. At 11:00 a.m., on 6/13/12, in the wall separating the Cardiac Rehab Suite and the corridor in POB 2, there were nine approximately 2 inch by 2 inch unsealed penetrations through the wall with a conduit running through the unsealed penetration. Engineering Staff 1 confirmed there were unsealed penetrations in the corridor wall.
8. At 11:05 a.m., on 6/13/12, there was an unsealed penetration in the wall separating the 3rd floor electrical room from the corridor in POB-2. There was an approximately 1 inch gap around a conduit that went through the penetration. Engineering Staff 1 confirmed there was an unsealed penetration.

Based on observation, interview, and document review, the facility failed to maintain the corridor doors as evidenced by corridor doors that failed to fully close and latch without assistance, and by the failure to provide documentation for the inspection and maintenance of the rolling fire windows. This affected five of six floors and the basement, of the main hospital building, and had the potential for the failure to contain smoke and fire and causing harm to the patients.

NFPA 101, Life Safety Code, 2000 Edition
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
15-2.1.1 Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately.
15-2.1.3 Chains or cables employed on suspended doors shall be inspected frequently for excessive wear and stretching.
15-2.2.1 Guides and bearings shall be kept well lubricated to facilitate operation.
15-2.2.2 Chains or cables on biparting, counterbalanced doors shall be checked frequently and adjustments shall be made to ensure proper latching and to keep the doors in proper relation to the opening.
15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.
15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During a facility tour with engineering staff from 6/11/12 to 6/14/12, the corridor doors were observed.

1. At 4:30 p.m., on 6/11/12, the door to Room B677, located on the sixth floor of Building B, was equipped with a self-closing device. The door closed but failed to latch.
2. At 9:45 a.m., on 6/12/12, the door to the storage room, near the B Building elevators in the basement, was equipped with a self-closing device. The door closed but failed to latch.
3. At 10:51 a.m., on 6/12/12, the door to Janitor Closet C026, located in the C Building basement, was equipped with a self-closing device. The door closed but failed to latch.
4. At 10:59 a.m., on 6/13/12, the door to the soiled utility room, located in the surgery department on the second floor of Building C, was equipped with a self-closing device. The door closed but failed to latch.
5. At 9:00 a.m., on 6/11/12, the self-closing corridor door to B474 failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.
6. At 9:37 a.m., on 6/11/12, the self-closing corridor door to the Janitor Room C420.4 failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.
7. At 1:02 p.m., on 6/11/12, the self-closing corridor door to the clean linen room in the B300 Pediatrics Corridor failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.
8. At 3:02 p.m., on 6/11/12, the inspection, maintenance, and testing records for the roll down fire window in the Emergency Room were requested. The fire alarm vendor stated the windows were only tested with the fire alarm system. Engineering Staff 4 stated the window was inspected, but that the report was unavailable.
9. At 8:38 a.m., on 6/13/12, the self-closing corridor door to the Linen Room adjacent to Room 201 in Building D failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.
10. At 8:40 a.m., on 6/13/12, the self-closing corridor door to the Lounge adjacent to Room 201 in Building D failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.

Based on observation, the facility failed to maintain their vertical openings. This was evidenced by a stairwell doors that failed to fully close and latch without assistance. This affected the basement of the main hospital, and one of five floors in POB 1, and had the potential to allow the spread of smoke and fire due to a non-functional door which could lead to injury to the residents.

NFPA 101, Life Safety Code, 2000 Edition
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following:
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirements of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provision of 7.2.1.

Findings:

During the facility tour with engineering staff from 6/11/12 to 6/14/12, the facility stairwells were observed.

1. At 8:30 a.m., on 6/13/12, the stairwell door in D Building Basement adjacent to the elevator failed to latch. The screw holding the cross bar in place on the door was loose. Engineering Staff 1 confirmed the door failed to latch.
2. At 3:20 p.m., on 6/13/12, the stairwell door adjacent to Room 211 in POB 1 failed to fully close and latch without assistance. Engineering Staff 1 confirmed the door failed to fully close and latch without assistance.

Based on observation, the facility failed to maintain the access to the exits as evidenced by the failure to mark access to exits where the exits were not readily apparent. This affected one of three floors in POB 2, and had the potential to delay egress from the building during an emergency.

Findings:

During the facility tour with Staff 1 from June 11, 2012, to June 14, 2012, the facility exit access was observed.

At 10:35 a.m. on 6/13/12, the west hall of the Breast Imaging Center in POB 2 was not marked with signs that indicated the way to the exits. Engineering Staff 1 confirmed there were not exit signs in the corridor.

Based on observation, the facility failed to maintain the smoke barriers as evidenced by an unsealed penetration in a smoke barrier wall. This affected the one of six floors in the main hospital, and had the potential to fail to contain smoke during a fire which could cause harm to the patients.

Findings:

During the facility tour with engineering staff from 6/11/12 to 6/14/12, the facility smoke barriers were observed.

At 4:22 p.m., on 6/11/12, there was an approximately 4 inch by 4 inch unsealed penetration in the smoke barrier wall adjacent to B575. Engineering Staff 1 confirmed there was an unsealed penetration in the smoke barrier wall.

Based on observation, the facility failed to maintain their doors in smoke barriers. This was evidenced by smoke barrier door frame labels that were painted over, and by smoke barrier doors that failed to latch. This affected four of six floors in the main hospital, and had the potential to allow the spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.
8.3.3 Fire Barrier Used as Smoke Barrier. A fire barrier shall be permitted to be used as a smoke barrier, provided that it meets the requirements of 8.3.4 through 8.3.6.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Findings:

During the facility tour with engineering staff from 6/11/12 to 6/14/12, the doors in smoke barriers were observed.

1. At 4:15 p.m., on 6/11/12, two of two doors in the smoke barrier adjacent to Room B575 were equipped with surface vertical rod hardware for latching at the top of the door. The door adjacent to B575 had been modified by the removal of the lower bar and latching mechanism at the bottom of the door. The bottom of the door failed to latch. Engineering Staff 1 confirmed the bottom of the door failed to latch, and that the bottom bar and latching mechanism were not in place.

2. At 8:40 a.m., on 6/12/12, the fire rating label on the door to the fourth floor B Building elevator was painted over. The rating of the door could not be determined. Engineering Staff 1 confirmed the door rating label was painted over.

3. At 1:02 p.m., on 6/12/12, two of two doors in the smoke barrier adjacent to Room B375 were equipped with surface vertical rod hardware for latching at the bottom of the door. Both doors had been modified by the removal of the lower bar and latching mechanism at the bottom of the door. The bottom of the doors failed to latch. Engineering Staff 1 confirmed the bottom of the doors failed to latch, and that the bottom bar and latching mechanism were not in place.

4. At 8:36 a.m., on 6/13/12, two of two doors in the smoke barrier adjacent to Room 207 in Building D failed to latch when tested. The doors were equipped with surface vertical rod hardware for latching at the top and bottom of the door. Engineering Staff 1 confirmed the doors failed to latch.

Based on observation, record review, and interview, the facility failed to maintain their emergency lighting. This was evidenced by no battery-powered emergency lighting in anesthetizing locations, and by no documentation for testing emergency lights at one offsite location. This affected one of six floors in the main hospital and one of five floors in POB 1. This could result in no lighting during procedures where anesthetics are used and the failure of emergency lighting at the offsite clinic.

NFPA 101, Life Safety Code, 2000 Edition
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 1 1/2 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.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

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).

Findings:

During a facility tour with engineering staff from 6/11/12 to 6/14/12, the emergency lighting was observed.

1. At 11:30 a.m. on 6/13/12, Operating Rooms 10 and 11, located on the second floor of Building B, were observed. There were no battery-powered emergency lighting units in the rooms.
During an interview at 11:41 a.m., Engineering Staff 2 inspected the rooms and confirmed that they were not equipped with battery-powered emergency lighting. Engineering Staff 2 installed battery-powered emergency lighting units in Operating Rooms 10 and 11 at 3:21 p.m.

2. At 1:27 p.m., on 6/13/12, Engineering Staff 4 was asked to provide documentation for monthly and annual testing of exit signs and battery-powered egress lights in Suite 109 of POB 1. Engineering Staff 4 stated they thought the units were tested, but was unable to provide documentation for testing of the exit signs and battery-powered egress lights.

Based on observation, the facility failed to maintain the fire alarm system in accordance with NFPA 72. This was evidenced by obstructed access to a manual fire alarm box. This affected one of three floors in POB 2, and could result in a delay in activation of the fire alarm system in the event of a fire.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

NFPA 101, Life Safety Code, 2000 Edition
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

Findings:

During the facility tour with Engineering Staff from 6/11/12 to 6/14/12, the manual fire alarm boxes were observed.

At 10:16 a.m., on 6/13/12, access to the manual fire alarm box in the lobby of the Cancer Treatment Center in POB 2 was obstructed by a chair. Engineering Staff 1 confirmed the chair obstructed access to the manual fire alarm box and moved the chair.

Based on observation, document review, and interview, the facility failed to maintain their smoke alarms. This was evidenced by two smoke alarms that were covered with tape, and by the failure to provide current documentation for the inspection, testing, sensitivity testing, and maintenance of the smoke alarms. This affected the main hospital and POB 2, and could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
8-3.5 Unless otherwise recommended by the manufacturer, smoke alarms installed in accordance with Chapters 18, 19, or 21 of NFPA 101, Life Safety Code, shall be replaced when they fail to respond to tests conducted in accordance with 8-3.4 but shall not remain in service longer than 10 years from the date of installation.

Findings:

During a facility tour with engineering staff from 6/11/12 to 6/14/12, the smoke alarms were observed, and maintenance records were requested.

1. At 2:22 p.m., on 6/12/12, there was blue masking tape covering the smoke detector in the back of the emergency department waiting room.
During an interview at 2:23 p.m., Emergency Department Staff 1 stated that the waiting room was renovated approximately one to two weeks ago.
2. At 8:40 a.m., on 6/13/12, there was blue masking tape covering the smoke detector in Janitor Closet C244, located on the second floor of Building C.
3. At 2:28 p.m., on 6/12/12, the self-closing corridor door to Medical Records was equipped with an automatic closing device designed to release and close the door when the smoke alarm, built into the closing device, was activated. The facility provided documentation for the fire alarm system tests dated 4/12/12. The report failed to document the inspection, testing, sensitivity testing, and maintenance of the smoke alarm in the Medical Records door automatic closing device. Engineering Staff 5 stated that the system was not inspected by the vendor, and Engineering Staff 4 stated the system was not inspected by the facility.
4. At 9 a.m. on 6/13/12, the self-closing corridor doors to Room D 219 and Room D 221 were equipped with automatic closing devices designed to release and close the door upon activation of smoke alarms in the rooms. The facility provided documentation for the fire alarm system tests dated 4/12/12. The report failed to document the inspection, testing, sensitivity testing, and maintenance of the doors to D219 and D221. Engineering Staff 5 stated the system was not inspected by the vendor, and Engineering Staff 4 stated the system was not inspected by the facility.
5. At 9:45 a.m., on 6/14/12, the facility failed to provide documentation for the sensitivity testing of the smoke alarms in POB 2. Engineering Staff 4 confirmed there was no documentation for the sensitivity testing of the smoke alarms.

Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by the failure to provide documentation for 2 of 4 required quarterly sprinkler inspections, by obstructed sprinkler spray patterns, by a sprinkler head that was not free of foreign materials, by the failure to provide documentation for the inspection, testing, and maintenance of the dry pipe sprinkler system, by a dry pipe sprinkler system tamper alarm that was not connected to the fire alarm system, and by a non-sprinklered canopy. This affected the main hospital, POB 1, and POB 2, and had the potential for sprinkler system to fail to function as designed in the event of a fire.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
5-13.8 Sprinklers shall be installed under exterior roof or canopies exceeding 4 ft (1.2 m) in width.
Exception: Sprinklers are permitted to be omitted where the canopy or roof is noncombustible or limited combustible construction.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
2-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.
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, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
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.
2-4.2 Dry Pipe Systems. Dry pipe systems shall be kept dry at all times.
Exception: During nonfreezing weather, a dry pipe system shall be permitted to be left wet if the only other option is to remove the system from service while waiting for parts or during repair activities.
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
9-4.4 Dry Pipe Valves/Quick-Opening Devices.
9-4.4.1.2 Gauges shall be inspected weekly.
(a) The gauge on the supply side of the dry pipe valve shall indicate that the normal supply water pressure is being maintained.
(b) The gauge on the system side of the dry pipe valve shall indicate that the proper ratio of air or nitrogen pressure to water supply pressure is being maintained in accordance with the manufacturer ' s instructions.
(c) The gauge on the quick-opening device, if provided, shall indicate the same pressure as the gauge on the system side of the dry pipe valve.
Exception: Systems equipped with low air or nitrogen pressure alarms shall be inspected monthly.
9-4.4.1.3 The dry pipe valve shall be externally inspected monthly to verify the following:
(a) The valve is free of physical damage.
(b) All trim valves are in the appropriate open or closed position.
(c) There is no leakage from the intermediate chamber.
9-4.4.1.4 The interior of the dry pipe valve shall be inspected annually when the trip test is conducted.
9-4.4.2 Testing.
9-4.4.2.1 The priming water level shall be tested quarterly.
9-4.4.2.2 Each dry pipe valve shall be trip tested annually during warm weather.
Exception: Dry pipe valves protecting freezers shall be trip tested in a manner that does not introduce moisture into the piping in the freezers.
9-4.4.2.2.1 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.
9-4.4.2.2.2 During those years when full flow testing in accordance with 9-4.4.2.2.1 is not required, each dry pipe valve shall be trip tested with the control valve partially open.
9-4.4.2.3 Grease or other sealing materials shall not be applied to the seating surfaces of dry pipe valves.
9-4.4.2.4 Quick-opening devices, if provided, shall be tested quarterly.
9-4.4.2.6 Low air pressure alarms, if provided, shall be tested quarterly in accordance with the manufacturer ' s instructions.
9-4.4.2.7 Low temperature alarms, if installed in valve enclosures, shall be tested annually at the beginning of the heating season.
9-4.4.2.8 Automatic air pressure maintenance devices, if provided, shall be tested annually during the dry pipe valve trip test in accordance with the manufacturer ' s instructions.
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 the document review and facility tour with engineering staff between 6/11/12, to 6/14/12, the automatic sprinkler system was observed, and the sprinkler inspection and test reports were reviewed.

1. At 2:58 p.m., on 6/11/12, the facility failed to provide documentation for the 3rd quarter (July-September, 2011) and the first quarter (January-March, 2012) sprinkler system inspections and tests for the main hospital, POB 1, and POB 2. There was no evidence that the sprinkler system components were inspected to assure they were free of physical damage, testing of the sprinkler system alarms, inspections of the valves and fire department connections. Engineering Staff 1 confirmed there were no other documents available for review.
2. At 1:28 p.m., on 6/13/12, the sprinkler head deflector in the corridor adjacent to Suites 102 and 107 in POB 1 had foreign debris that appeared to be paint on the deflector. Engineering Staff 1 confirmed there was foreign debris on the deflector.
3. At 3:30 p.m., on 6/13/12, there was a sprinkler riser observed in Suite 109 in POB 1. The tamper alarm on the water control valve was not connected to the fire alarm system. Engineering Staff 1 confirmed the alarm was not connected to the fire alarm system. The vendor representative identified the sprinkler riser as a riser for a dry pipe sprinkler system.
4. At 9:45 a.m., on 6/14/12, the vendor inspection, test, and maintenance reports for the fire sprinkler system for POB 1 dated 6/21/11, 10/6/11, and 4/13/12 failed to indicate the weekly, monthly, quarterly, and annual inspection, testing, and maintenance of the dry pipe sprinkler system as required in NFPA 25, 2-4.2, and 9-4.4. Engineering Staff 1 confirmed the documents failed to indicate the dry pipe sprinkler system had been inspected, tested, and maintained.
10. At 9:50 a.m., on 6/13/12, there was an approximately 20 foot by 30 foot fabric canopy attached to the roof at the main entrance of POB 2 that was not sprinklered. Engineering Staff 1 confirmed the canopy was not sprinklered, and did not know if the facility had documentation indicating the flame resistance of the canopy fabric.

Based on observation, interview, and document review, the facility failed to maintain their heating, ventilating, and air conditioning systems. This was evidenced by the failure to identify duct service openings adjacent to dampers, and by the failure to inspect, test, and maintain the fire dampers. This affected three of six floors in the main hospital, and three of three floors of POB 2, and had the potential for damper failure in the event of a fire.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During the document review and facility tour with engineering staff from 6/11/12, to 6/14/12, the facility dampers were observed, and damper maintenance records were reviewed.

1. At 9:20 a.m., on 6/12/12, three of three duct access panels adjacent to the dampers in Mechanical Room C475 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
2. At 9:21 a.m., on 6/12/12, three of three duct access panels adjacent to the dampers in the fourth floor Mechanical Room 7 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
3. At 9:32 a.m., on 6/12/12, three of three duct access panels adjacent to the dampers in Mechanical Room C454 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
4. At 9:34 a.m., on 6/12/12, two of two duct access panels at the smoke barrier adjacent to Room C454 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
5. At 9:35 a.m., on 6/12/12, the duct access panel at the smoke barrier adjacent to the Critical Care Telemetry Office was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
6. At 9:36 a.m., on 6/12/12, two of two duct access panels in Electrical Room C443 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
7. At 9:40 a.m., on 6/12/12, the duct access panel in Soiled Linen Room C430.3 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
8. At 9:41 a.m., on 6/12/12, the duct access panel in Ante Room C430.1 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
9. At 9:45 a.m., on 6/12/12, the duct access panel in the corridor adjacent to Room C468 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
10. At 9:45 a.m., on 6/12/12, the duct access panel in Room C400.3 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
11. At 9:47 a.m., on 6/12/12, two of two duct access panels in the smoke barrier, on the north side of the ICU, were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
12. At 10:18 a.m., on 6/12/12, on the corridor side of Room C410.4, the damper access panel was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
13. At 10:20 a.m., on 6/12/12, two of two duct access panels in Room C410.1 were not identified indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
14. At 10:21 a.m., on 6/12/12, the duct access panel in the smoke barrier adjacent to Room C464 was not identified indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
15. At 10:29 a.m., on 6/12/12, the duct access panel in Room C461 was not identified indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
16. At 10:45 a.m., on 6/12/12, ceiling dampers were observed in the fourth floor Building B Nourishment Room. The dampers were not identified on the damper location map provided by the facility. Staff 4 confirmed the dampers at the location and stated that the area was recently remodeled and the map had not been updated.
17. At 11:19 a.m., on 6/12/12, two of two duct access panels in the two-hour separation barrier, on the third floor, were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
18. At 11:20 a.m., on 6/12/12, two of two duct access panels in Medication Room 3006.1 were not identified indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
19. At 11:26 a.m., on June 12, 2012, the duct access panel observed in the third floor mechanical room was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
20. At 12:40 p.m., on 6/12/12, three of three duct access panels adjacent to the dampers in Mechanical Room 3003.1 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
21. At 1:21 p.m,. on 6/12/12, the duct access panel in the corridor adjacent to Room D302 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
22. At 1:21 p.m., on 6/12/12, the duct access panel in the corridor adjacent to Room D308 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
23. At 2:58 p.m., on 6/12/12, one of two duct access panels in Mechanical Room C119 was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
24. At 10:03 a.m., on 6/13/12, four of four duct access, panels adjacent to the dampers in the first floor fire panel room in POB 2, were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
25. At 10:10 a.m., on 6/13/12, four air ducts were observed to penetrate the wall between the corridor and Suite 109 in POB 2. Engineering Staff 1 stated he did not know if the ducts had dampers to prevent the passage of smoke between the corridor and the Suite.
26. At 10:14 a.m., on 6/13/12, the duct access panel adjacent to the damper in the wall separating Suite 109 and the lobby, where the wall met the elevator wall, was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
28. At 10:27 a.m., on 6/13/12, an air duct was observed above the drop ceiling in the Suite 109 break room. The air duct penetrated the wall separating the suite from the corridor. There was no air duct connected to the duct housing at the wall. Engineering Staff 1 confirmed there was no duct attached to the duct housing on the wall.
29. At 10:44 a.m., on 6/13/12, there was a duct access panel adjacent to the damper in the wall that separated the corridor from the Breast Imaging Center Work Station in POB 2. The access panel was not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panel to note the presence of the damper.
30. At 11:00 a.m., on 6/13/12, two air ducts were observed to penetrate the wall between the corridor and the Cardiac Rehab Suite in POB 2. Engineering Staff 1 stated he did not know if the ducts had dampers to prevent the passage of smoke between the corridor and the Suite.
31. At 11:04 a.m., on 6/13/12, two of two duct access panels adjacent to the dampers in the third floor electrical room in POB 2 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
32. At 11:10 a.m., on 6/13/12, two of two duct access panels adjacent to the dampers in wall above the Cardiac Rehab Changing Area in POB 2 were not labeled indicating a damper within the duct. Engineering Staff 1 confirmed there was no lettering on the access panels to note the presence of the dampers.
33. At 12:45 p.m., on 6/13/12, the facility was requested to provide documentation for the inspection, testing, and maintenance of the dampers in POB 2. Engineering Staff 4 stated there were no records for inspection, testing, and maintenance of the dampers in POB 2.

Based on record review, a letter from CMS dated June 1, 2012, stated that the facility was granted an extension by CMS for their waiver to reduce the lower-limit requirement for relative humidity in anesthetizing locations from 35%, to 20%.

Based on observation, document review, and interview, the facility failed to maintain the generator in accordance with NFPA 99 and NFPA 110. This was evidenced by maintenance-free batteries used for the Level 1 generators. This affected the main hospital, and had the potential for generator failure.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
3-5.4.5 Type of Battery. The battery shall be of the nickelcadmium or lead-acid type. Lead-acid batteries shall be furnished as charged when wet. Drain-dry batteries or drycharged lead-acid batteries shall be permitted. Vented nickelcadmium batteries shall be filled and charged when furnished and shall have listed flip-top, flame arrestor vent caps. The manufacturer shall provide installation, operation, and maintenance instructions, and, when shipped dry, electrolyte mixing instructions. Batteries shall not be installed until the battery charger is in service.
All batteries used in this service shall have been designed for this duty and shall have demonstrable characteristics of performance and reliability acceptable to the authority having jurisdiction. Batteries shall be prepared for use according to the battery manufacturer ' s instructions.
Starting batteries for Level 1 installations shall not be of the maintenance-free variety.
6-3.6 Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

Findings:

During the document review and facility tour with Engineering Staff 1 on January 12, 2012, the facility generator was observed, and inspection documents were reviewed.

1. At 1:43 p.m., on 6/12/12, the generator inspection logs were reviewed. The facility failed to provide documentation for the weekly inspection of the electrolyte levels in the batteries. Engineering Staff 2 stated the levels were not checked as the batteries were maintenance free.

2. At 8:50 a.m., on 6/14/14, the batteries were observed to be maintenance free batteries, and were not in compliance with NFPA 110, 3-5.4.5.

Based on observation and interview, the facility failed to maintain their electrical wiring in accordance with NFPA 70, and NFPA 99. This was evidenced by appliances plugged into multi-plug adaptors, by multi-plug adaptors plugged into other multi-plug adaptors, by missing and damaged electrical box faceplates, by breakers in the " on " position and not labeled as to the purpose or use, and by damaged electrical receptacles. This affected three floors in the main hospital, and two of five floors of POB 1, and could result in an increased risk of an electrical fire.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.
NFPA 70, National Electric Code, 1999 Edition.
110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.
370-28(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.
384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.
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 engineering staff from 6/11/12 to 6/14/12, the electrical wiring was observed.

1. At 4:00 p.m., on 6/11/12, the electrical receptacle in the fifth floor corridor adjacent to the elevator was damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacle was damaged around the ground port.
2. At 9:14 a.m., on 6/12/12, the electrical receptacle in the corridor adjacent to Door N-4 in the ICU was damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacle was damaged around the ground port.
3. At 1:25 p.m., on 6/12/12, on Electrical Panel 3EDG, breakers 31, 32, 33, 35-39, 46, 49, and 55 were in the " on " position, and not labeled as to the area served by the breakers. Engineering Staff 1 confirmed the breakers were not labeled.
4. At 9:20 a.m., on 6/12/12, the faceplate of the receptacle outlet outside the Cath Lab Dark Room, located in the B Building basement, was not flush to the wall, and the wires of the electrical box were exposed.
5. At 12:59 p.m., on 6/12/12, there was a microwave plugged into a six-plug surge protector that was plugged into another six-plug surge protector, in the first floor gift shop storage room.
6. At 1:12 p.m., on 6/12/12, there was an approximately 3 inch by 2 inch electrical box with no faceplate in the back storage room of financial services, located on the first floor of the B Building.
7. At 2:56 p.m., on 6/12/12, there was a refrigerator plugged into a six-plug surge protector in the kitchen, near the dry storage room on the first floor.
8. At 10:48 a.m., on 6/13/12, there was an open junction box above the drop ceiling in the corridor between Medical Records and the activity room. Adjacent to the open junction box there was a fuse box with the door open on the corridor side of the Medical Records wall. Engineering Staff 1 confirmed the junction box was missing the cover plate and the fuse box door was open.
9. At 12:55 p.m., on 6/13/12, there was an open junction box above the drop ceiling in the corridor adjacent to Suite 102. Engineering Staff 1 confirmed the junction box was missing the cover plate.
10. At 12:55 p.m., on 6/13/12, the electrical receptacle in the corridor adjacent to Suite 102 was damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacle was damaged.
11. At 2:12 p.m., on 6/13/12, two of two electrical receptacles in the corridor of Suite 214, adjacent to the lunch room, were damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacles were damaged.
12. At 2:13 p.m., on 6/13/12, the electrical receptacle in the director ' s restroom of Suite 214 was damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacle was damaged around the ground port.
13. At 2:14 p.m., on 6/13/12, the electrical receptacle in the kitchen adjacent to the corridor door in Suite 214 was damaged around the ground port. Engineering Staff 1 confirmed the electrical receptacle was damaged.