HospitalInspections.org

Based on observation of the physical environment and interview with the facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors able to latch and resist the passage of smoke as required, thereby creating a hazardous condition.

The findings include:

1) During this survey between 0900 and 1030 hours on February 25, 2014 it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that the corridor doors to patient rooms in Weinberg Building W5L wing are two leaf doors. These doors are equipped with a flush bolt latch on one leaf that engages a striker on the overhead door frame and a second leaf with a passage type door knob latch. These doors are required to have the small leaf closed and latched when not in use. The doors in these wings when both leaves are closed have a greater than 1/8" gap between the door leaves (approximately 1/4"), therefore rendering the doors non-smoke resistive. The facility shall perform an audit of all doors to insure that all doors required to be smoke resistive function as such and that two leaf doors are equipped with an astragal, rabbet, or bevel as required to eliminate the gap between the door leaves.

These conditions could prevent the proper closing of the doors to resist the passage of smoke in the event of a fire and has the potential to promote harm to occupants of the facility.

See also CMS Memo S&C-07-18 (Question #3) dated 4/10/2007.

Based on observation of the physical environment and interview with the facility staff, it was determined that the facility staff failed to provide as safe an environment as possible by not ensuring that all smoke barrier doors throughout the facility close properly.

The findings include:

1) During this survey on February 24, 2014 between 0900 hours and 1500 hours it was observed and confirmed through interview with the Vice President of Facilities that the corridor smoke barrier doors in the North Building basement level Pathology area by room NB1222 have a large gap between the leaves of the doors when closed, thereby rendering the doors not smoke resistive.

The failure of these smoke barrier doors to function as required has the potential to cause harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining hazardous areas as required.

The findings include:

1) During this survey on February 24, 2014 at approximately 1325 hours it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that the South Building SGD18 Trash Room door to the corridor (1 of 2 doors) to the corridor was held open by a non-approved device. The door was propped open by a hand cleaner dispenser stand and was not smoke resistive when closed.

All doors to and from hazardous areas must be self-closing and/or automatic closing in the event of an emergency, smoke resistive when closed, and must not be held open unless by an approved device that is released by the fire alarm systems. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interviews with the facility staff it was determined that the exit stairways are not maintained as required by the Code, thereby creating an unsafe condition.

The findings include:

1) During this survey between 0900 and 1500 hours on February 25, 2015 it was observed and confirmed through interview with the Vice President of Facilities that the exit stairway at the Mechanical Area level of the Shock Trauma Building there was a step ladder stored within the stairway enclosure next to the egress door.

The storage of items within these stairways can impede access to or egress from floors in the event of a fire, thereby promoting harm to occupants of the building.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not fulfilling all fire alarm system maintenance requirements of NFPA 70 and NFPA 72.

The findings include:

1) During this survey between 0900 hours and 1500 hours on February 25, 2014 it was determined through observation of the physical environment and confirmed through interview with the Vice President of Facilities that all components of the fire alarm system are not maintained as required by NFPA 72. The heat detector for the fire alarm system located in the Trauma Building Penthouse Elevator Machine Room was observed to have a significant lint buildup.

Failure to properly maintain all components of the building fire alarm system has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility failed to provide a safe and hazard free environment by not having a sprinkler system installed in accordance with NFPA 13 to provide complete coverage for all portions of the building.

The findings include:

1) During this survey on February 24, 2014 between 0900 and 1500 hours it was observed and confirmed through interview with the Vice President of Facilities that in the Sub-Basement of the North Building in the Paint Room the suspended ceiling tiles had been removed resulting in the improper placement of the upright sprinkler heads in this area.

2) During this survey on February 24, 2014 at approximately 1430 hours it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that in the South Building Medical Cylinder Storage Room storing "H" cylinders the suspended ceiling tiles had been removed resulting in the improper placement of the sprinkler heads in this area.

Failure to provide complete automatic sprinkler coverage in accordance with NFPA 13 for all parts of the building has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility failed to provide a safe and hazard free environment by not having an automatic sprinkler system maintained in accordance with NFPA 25 as required.

The findings include:

1) During this survey on February 24 & 25, 2014 it was observed and confirmed with the Vice President of Facilities between 0900 hours and 1500 hours each day that automatic sprinkler heads in the facility were in need of required maintenance. The following locations were observed to be non-compliant:
a) South Building room SBE01- one (1) recessed sprinkler head was exposed/protruding and its cover plate was missing.
b) North Building 3rd floor Hemodialysis- three (3) pendant sprinkler heads observed to be corroded (greenish discoloration visible) and two (2) sprinkler heads were heavily loaded with foreign material (lint).
c) Gudelsky Building basement level Linen Chute Room- one (1) pendant sprinkler head observed to have plastic bag debris attached to the sprinkler head assembly.
d) Shock Trauma Building Penthouse level Elevator Machine Room- one (1) sprinkler head observed to be loaded with foreign material (lint).
e) Shock Trauma Building at the Heliport Bunker- a large step ladder was observed to be chained to the automatic sprinkler system piping /riser.
f) In various areas of the facility several sprinkler escutcheon plates were observed to be missing.

Failure to maintain automatic sprinkler systems through a proper testing and maintenance program for all parts of the building has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to insure that all of the portable fire extinguishers in the facility are maintained as required by NFPA 10.

The findings include:

1) Throughout this survey on February 24 to 27, 2014 it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance and other facility staff that the required portable fire extinguishers in the facility were not maintained as required

Locations and details of non-compliant portable fire extinguishers included:

a) In the South building in the "C" wings the portable fire extinguishers were observed to be mounted higher than permitted by NFPA 10. The top of the extinguishers were measured to be 72" from the floor.

b) In the 29 S. Greene Street building at the 4th floor Transplant Office there was a portable fire extinguisher observed to be sitting on the floor. This extinguisher was not mounted on the wall as required, was last serviced in 2010 by BFPE, and has no documented required monthly checks.

c) In the Shock Trauma Heliport Bunker there was observed to be one small (2.5 lb.) portable fire extinguisher observed to be sitting on the floor.This extinguisher was not mounted on the wall as required and not displaying an annual inspection tag as required.

All portable fire extinguishers in the facility are required to be properly maintained at all times. The failure to maintain portable extinguishers as required by the Code has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not meeting all requirements of NFPA 96 regarding fire protection for the cooking facilities.

The findings include:

1) During this survey at approximately 1445 hours on February 24, 2014 through observation of the physical environment and interview with the Director of Facilities Operations and Maintenance it was determined that the NFPA 96 required manual activation pull stations for the hood extinguishing systems were not identified as required. The facility shall provide signs to mark and identify the hood(s) protected by each extinguishing system pull station.

Failure to maintain the required NFPA 96 fire protection equipment has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and staff interviews, it was determined that the facility staff failed to provide as safe an environment as possible by allowing non-compliant electric portable space heater use in the facility.

The findings include:

1) Throughout this survey on February 24 to 27, 2014 it was observed and confirmed through an interview with the Director of Facilities Operations and Maintenance and other facility staff that there were portable electric space heaters with non-compliant heating elements, portable electric space heaters plugged into extension cords, and portable electric space heaters located too close to combustibles.

Locations of non-compliant space heater use included:
a) South Building Room S12C09- Oil filled portable electric space heater sitting against a wooden desk panel, plugged into a 15 amp rated strip outlet extension cord.
b) South Building Room S10B10- A ceramic element portable electric space heater was observed to be sitting less than 12" from the employee's clothing.
c) South Building Room S10B02- A "glowing coil" portable electric space heater was observed sitting on the floor.
d) South Building Room S9D12- A "glowing coil" portable electric space heater was observed plugged into a 15 amp rated strip extension cord at the secretary's desk..
e) Weinberg Building Room W5L158- A "glowing coil" portable electric space heater was observed in this room.
f) 29 S. Greene St. 4th floor Transplant Office- A "glowing coil" portable electric space heater was observed plugged into a 15 amp rated strip outlet and sitting less than 2" from cardboard boxes and the employees feet.

The space heaters observed were immediately removed by staff.

The facility staff shall perform an audit of the entire facility to insure compliance with this Code requirement.

The use of portable electric space heaters in a non-complaint manner has the potential to promote harm to occupants of the facility.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining soiled linen and trash receptacles in approved hazardous areas as required.

1) On February 24, 2014 at approximately 1300 hours it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that there were two (2) wheeled recycling carts each approximately 115 gallon capacity stored in the corridor of the South Building in the S8B Wing. All trash and soiled lined receptacles in the facility that contain trash and linens shall comply with 19.7.5.5.

A Categorical Waiver is available for clean recycling material receptacles if compliance with the 2012 Life Safety Code is met.

All soiled linen or trash collection receptacles over 32 gallons capacity must be maintained in accordance with all requirements of NFPA 101. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

K-130- Miscellaneous- Flammable Gas Storage

NFPA 1, 2000 edition, Uniform Fire Code
NFPA 99, 1999 edition, Health Care Facilities

Based on observation of the physical environment and interview with facility staff it was determined that facility staff failed to provide a safe and hazard free environment by allowing flammable materials to be stored within the facility.

The findings include:

1) During this survey on February 24, 2014 between 0900 hours and 1500 hours it was observed and confirmed through interview with the Vice President of Facilities that a vendor supplied acetylene tank and torch set was located in the North Building Penthouse (14th floor). This is a repeat deficiency from the December 2011 hospital survey when an acetylene tank was observed in the basement mechanical area of the South Building.

Allowing flammable or combustible gas storage within the health care facility is hazardous and can result in fire. This has the potential to promote harm to occupants of the building.

K-130- Miscellaneous- Danger to Life from Fire

NFPA 101, 2000 Edition, 1.2.1*

Danger to Life from Fire. The Code addresses those construction, protection, and occupancy features necessary to minimize danger to life from fire, including smoke, fumes, or panic.

Based on observation of the physical environment, review of facility documents, and interviews with the staff it was determined that the facility staff failed to provide as safe and hazard free of an environment as possible by failing to have properly identified corridors and means of egress components.

The findings include:

1) During this survey on February 25, 2014 at approximately 1400 hours it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that the corridors and floors as designated in the facility do not adhere to a consistent identification and numbering scheme.

The levels of the IPBH Building identified on the printed facility stacking diagram, corridor room ID's, and stairway ID signs as the "Ground Floor (G)" and "Basement (B)" are identified by the elevator control panel indicators as "T" and "M". These levels shall be identified throughout the building and on the printed floor plan, evacuation plan, and fire alarm zones using a single, consistent term.

The floor numbering and identification scheme developed by the facility shall be structured in a consistent, comprehensive, and user friendly pattern to not cause confusion to facility occupants or firefighting forces. The facility shall insure that all other systems dependent upon proper floor numbering are also synchronized to the floor numbering scheme to be implemented (e.g. fire alarm zones).

Failure to consistently identify the levels within the facility has the potential to promote harm to occupants of the building in the event of an emergency.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining flammable and combustible liquids in an approved manner as required.

1) On February 25, 2014 at approximately 1130 hours it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that in the Shock Trauma Extension basement level Laboratory there was a flammable liquids storage cabinet with a capacity of approximately twenty (20) one gallon plastic containers of an alcohol based product. This cabinet was only labelled with a 3" X 9" placard "Solvent". This cabinet should be labelled with an NFPA 704 marking system placard to more specifically identify the product(s) stored within to responding emergency forces.

All flammable and combustible liquids shall be stored and used in accordance with applicable requirements. The failure to do so has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interview with facility staff it was determined that the facility failed to provide a safe and hazard free environment by having non-compliant electrical applications.

The findings include:

1) Throughout this survey on February 24 to 27, 2014 it was observed and confirmed through an interview with the Director of Facilities Operations and Maintenance and other facility staff that there were non-compliant electrical applications in place.

Locations of non-compliant electrical applications included:
a) South Building room S12C09- Observed two (2) 15 amp rated strip outlet extension cords "daisy chained" and powering five (5) IT devices and a portable electric space heater.
b) South Building room S10A11- Observed a microwave oven, refrigerator, and coffee maker all plugged into a 15 amp rated strip outlet extension cord which was plugged into a 120 VAC wall outlet receptacle.
c) South Building room S10B09- Observed a toaster oven, microwave oven, refrigerator, and radio all plugged into 15 amp rated strip outlet extension cord which was plugged into a 120 VAC wall outlet receptacle.
d) South Building room S10B10- Observed a ceramic element portable electric space heater and refrigerator plugged into 15 amp rated strip outlet extension cord which was plugged into a 120 VAC wall outlet receptacle.
e) 29 S. Greene St.4th floor Transplant Office- Observed two (2) 15 amp rated strip outlet extension cords "daisy chained" and powering eight (8) IT devices and a portable electric space heater.
f) 29 S. Greene St.2nd floor Director of Transplant Office- Observed a microwave oven, two (2) refrigerators, and coffee maker all plugged into a 15 amp rated strip outlet extension cord which was plugged into a 120 VAC wall outlet receptacle.

The facility staff shall perform an audit of the entire facility to insure compliance with this Code requirement.

The use of these items in this manner will create hazards and can result in fire or electrical shock which can promote harm to occupants of the building.

Based on observation of the physical environment and interview with the facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors able to latch and resist the passage of smoke as required, thereby creating a hazardous condition.

The findings include:

1) During this survey between 0900 and 1030 hours on February 25, 2014 it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that the corridor doors to patient rooms in Weinberg Building W5L wing are two leaf doors. These doors are equipped with a flush bolt latch on one leaf that engages a striker on the overhead door frame and a second leaf with a passage type door knob latch. These doors are required to have the small leaf closed and latched when not in use. The doors in these wings when both leaves are closed have a greater than 1/8" gap between the door leaves (approximately 1/4"), therefore rendering the doors non-smoke resistive. The facility shall perform an audit of all doors to insure that all doors required to be smoke resistive function as such and that two leaf doors are equipped with an astragal, rabbet, or bevel as required to eliminate the gap between the door leaves.

These conditions could prevent the proper closing of the doors to resist the passage of smoke in the event of a fire and has the potential to promote harm to occupants of the facility.

See also CMS Memo S&C-07-18 (Question #3) dated 4/10/2007.

Based on observation of the physical environment and interview with the facility staff, it was determined that the facility staff failed to provide as safe an environment as possible by not ensuring that all smoke barrier doors throughout the facility close properly.

The findings include:

1) During this survey on February 24, 2014 between 0900 hours and 1500 hours it was observed and confirmed through interview with the Vice President of Facilities that the corridor smoke barrier doors in the North Building basement level Pathology area by room NB1222 have a large gap between the leaves of the doors when closed, thereby rendering the doors not smoke resistive.

The failure of these smoke barrier doors to function as required has the potential to cause harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining hazardous areas as required.

The findings include:

1) During this survey on February 24, 2014 at approximately 1325 hours it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that the South Building SGD18 Trash Room door to the corridor (1 of 2 doors) to the corridor was held open by a non-approved device. The door was propped open by a hand cleaner dispenser stand and was not smoke resistive when closed.

All doors to and from hazardous areas must be self-closing and/or automatic closing in the event of an emergency, smoke resistive when closed, and must not be held open unless by an approved device that is released by the fire alarm systems. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interviews with the facility staff it was determined that the exit stairways are not maintained as required by the Code, thereby creating an unsafe condition.

The findings include:

1) During this survey between 0900 and 1500 hours on February 25, 2015 it was observed and confirmed through interview with the Vice President of Facilities that the exit stairway at the Mechanical Area level of the Shock Trauma Building there was a step ladder stored within the stairway enclosure next to the egress door.

The storage of items within these stairways can impede access to or egress from floors in the event of a fire, thereby promoting harm to occupants of the building.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not fulfilling all fire alarm system maintenance requirements of NFPA 70 and NFPA 72.

The findings include:

1) During this survey between 0900 hours and 1500 hours on February 25, 2014 it was determined through observation of the physical environment and confirmed through interview with the Vice President of Facilities that all components of the fire alarm system are not maintained as required by NFPA 72. The heat detector for the fire alarm system located in the Trauma Building Penthouse Elevator Machine Room was observed to have a significant lint buildup.

Failure to properly maintain all components of the building fire alarm system has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility failed to provide a safe and hazard free environment by not having a sprinkler system installed in accordance with NFPA 13 to provide complete coverage for all portions of the building.

The findings include:

1) During this survey on February 24, 2014 between 0900 and 1500 hours it was observed and confirmed through interview with the Vice President of Facilities that in the Sub-Basement of the North Building in the Paint Room the suspended ceiling tiles had been removed resulting in the improper placement of the upright sprinkler heads in this area.

2) During this survey on February 24, 2014 at approximately 1430 hours it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that in the South Building Medical Cylinder Storage Room storing "H" cylinders the suspended ceiling tiles had been removed resulting in the improper placement of the sprinkler heads in this area.

Failure to provide complete automatic sprinkler coverage in accordance with NFPA 13 for all parts of the building has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility failed to provide a safe and hazard free environment by not having an automatic sprinkler system maintained in accordance with NFPA 25 as required.

The findings include:

1) During this survey on February 24 & 25, 2014 it was observed and confirmed with the Vice President of Facilities between 0900 hours and 1500 hours each day that automatic sprinkler heads in the facility were in need of required maintenance. The following locations were observed to be non-compliant:
a) South Building room SBE01- one (1) recessed sprinkler head was exposed/protruding and its cover plate was missing.
b) North Building 3rd floor Hemodialysis- three (3) pendant sprinkler heads observed to be corroded (greenish discoloration visible) and two (2) sprinkler heads were heavily loaded with foreign material (lint).
c) Gudelsky Building basement level Linen Chute Room- one (1) pendant sprinkler head observed to have plastic bag debris attached to the sprinkler head assembly.
d) Shock Trauma Building Penthouse level Elevator Machine Room- one (1) sprinkler head observed to be loaded with foreign material (lint).
e) Shock Trauma Building at the Heliport Bunker- a large step ladder was observed to be chained to the automatic sprinkler system piping /riser.
f) In various areas of the facility several sprinkler escutcheon plates were observed to be missing.

Failure to maintain automatic sprinkler systems through a proper testing and maintenance program for all parts of the building has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to insure that all of the portable fire extinguishers in the facility are maintained as required by NFPA 10.

The findings include:

1) Throughout this survey on February 24 to 27, 2014 it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance and other facility staff that the required portable fire extinguishers in the facility were not maintained as required

Locations and details of non-compliant portable fire extinguishers included:

a) In the South building in the "C" wings the portable fire extinguishers were observed to be mounted higher than permitted by NFPA 10. The top of the extinguishers were measured to be 72" from the floor.

b) In the 29 S. Greene Street building at the 4th floor Transplant Office there was a portable fire extinguisher observed to be sitting on the floor. This extinguisher was not mounted on the wall as required, was last serviced in 2010 by BFPE, and has no documented required monthly checks.

c) In the Shock Trauma Heliport Bunker there was observed to be one small (2.5 lb.) portable fire extinguisher observed to be sitting on the floor.This extinguisher was not mounted on the wall as required and not displaying an annual inspection tag as required.

All portable fire extinguishers in the facility are required to be properly maintained at all times. The failure to maintain portable extinguishers as required by the Code has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not meeting all requirements of NFPA 96 regarding fire protection for the cooking facilities.

The findings include:

1) During this survey at approximately 1445 hours on February 24, 2014 through observation of the physical environment and interview with the Director of Facilities Operations and Maintenance it was determined that the NFPA 96 required manual activation pull stations for the hood extinguishing systems were not identified as required. The facility shall provide signs to mark and identify the hood(s) protected by each extinguishing system pull station.

Failure to maintain the required NFPA 96 fire protection equipment has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and staff interviews, it was determined that the facility staff failed to provide as safe an environment as possible by allowing non-compliant electric portable space heater use in the facility.

The findings include:

1) Throughout this survey on February 24 to 27, 2014 it was observed and confirmed through an interview with the Director of Facilities Operations and Maintenance and other facility staff that there were portable electric space heaters with non-compliant heating elements, portable electric space heaters plugged into extension cords, and portable electric space heaters located too close to combustibles.

Locations of non-compliant space heater use included:
a) South Building Room S12C09- Oil filled portable electric space heater sitting against a wooden desk panel, plugged into a 15 amp rated strip outlet extension cord.
b) South Building Room S10B10- A ceramic element portable electric space heater was observed to be sitting less than 12" from the employee's clothing.
c) South Building Room S10B02- A "glowing coil" portable electric space heater was observed sitting on the floor.
d) South Building Room S9D12- A "glowing coil" portable electric space heater was observed plugged into a 15 amp rated strip extension cord at the secretary's desk..
e) Weinberg Building Room W5L158- A "glowing coil" portable electric space heater was observed in this room.
f) 29 S. Greene St. 4th floor Transplant Office- A "glowing coil" portable electric space heater was observed plugged into a 15 amp rated strip outlet and sitting less than 2" from cardboard boxes and the employees feet.

The space heaters observed were immediately removed by staff.

The facility staff shall perform an audit of the entire facility to insure compliance with this Code requirement.

The use of portable electric space heaters in a non-complaint manner has the potential to promote harm to occupants of the facility.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining soiled linen and trash receptacles in approved hazardous areas as required.

1) On February 24, 2014 at approximately 1300 hours it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that there were two (2) wheeled recycling carts each approximately 115 gallon capacity stored in the corridor of the South Building in the S8B Wing. All trash and soiled lined receptacles in the facility that contain trash and linens shall comply with 19.7.5.5.

A Categorical Waiver is available for clean recycling material receptacles if compliance with the 2012 Life Safety Code is met.

All soiled linen or trash collection receptacles over 32 gallons capacity must be maintained in accordance with all requirements of NFPA 101. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

K-130- Miscellaneous- Flammable Gas Storage

NFPA 1, 2000 edition, Uniform Fire Code
NFPA 99, 1999 edition, Health Care Facilities

Based on observation of the physical environment and interview with facility staff it was determined that facility staff failed to provide a safe and hazard free environment by allowing flammable materials to be stored within the facility.

The findings include:

1) During this survey on February 24, 2014 between 0900 hours and 1500 hours it was observed and confirmed through interview with the Vice President of Facilities that a vendor supplied acetylene tank and torch set was located in the North Building Penthouse (14th floor). This is a repeat deficiency from the December 2011 hospital survey when an acetylene tank was observed in the basement mechanical area of the South Building.

Allowing flammable or combustible gas storage within the health care facility is hazardous and can result in fire. This has the potential to promote harm to occupants of the building.

K-130- Miscellaneous- Danger to Life from Fire

NFPA 101, 2000 Edition, 1.2.1*

Danger to Life from Fire. The Code addresses those construction, protection, and occupancy features necessary to minimize danger to life from fire, including smoke, fumes, or panic.

Based on observation of the physical environment, review of facility documents, and interviews with the staff it was determined that the facility staff failed to provide as safe and hazard free of an environment as possible by failing to have properly identified corridors and means of egress components.

The findings include:

1) During this survey on February 25, 2014 at approximately 1400 hours it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that the corridors and floors as designated in the facility do not adhere to a consistent identification and numbering scheme.

The levels of the IPBH Building identified on the printed facility stacking diagram, corridor room ID's, and stairway ID signs as the "Ground Floor (G)" and "Basement (B)" are identified by the elevator control panel indicators as "T" and "M". These levels shall be identified throughout the building and on the printed floor plan, evacuation plan, and fire alarm zones using a single, consistent term.

The floor numbering and identification scheme developed by the facility shall be structured in a consistent, comprehensive, and user friendly pattern to not cause confusion to facility occupants or firefighting forces. The facility shall insure that all other systems dependent upon proper floor numbering are also synchronized to the floor numbering scheme to be implemented (e.g. fire alarm zones).

Failure to consistently identify the levels within the facility has the potential to promote harm to occupants of the building in the event of an emergency.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining flammable and combustible liquids in an approved manner as required.

1) On February 25, 2014 at approximately 1130 hours it was observed and confirmed through interview with the Director of Facilities Operations and Maintenance that in the Shock Trauma Extension basement level Laboratory there was a flammable liquids storage cabinet with a capacity of approximately twenty (20) one gallon plastic containers of an alcohol based product. This cabinet was only labelled with a 3" X 9" placard "Solvent". This cabinet should be labelled with an NFPA 704 marking system placard to more specifically identify the product(s) stored within to responding emergency forces.

All flammable and combustible liquids shall be stored and used in accordance with applicable requirements. The failure to do so has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interview with facility staff it was determined that the facility failed to provide a safe and hazard free environment by having non-compliant electrical applications.

The findings include:

1) Throughout this survey on February 24 to 27, 2014 it was observed and confirmed through an interview with the Director of Facilities Operations and Maintenance and other facility staff that there were non-compliant electrical applications in place.

Locations of non-compliant electrical applications included:
a) South Building room S12C09- Observed two (2) 15 amp rated strip outlet extension cords "daisy chained" and powering five (5) IT devices and a portable electric space heater.
b) South Building room S10A11- Observed a microwave oven, refrigerator, and coffee maker all plugged into a 15 amp rated strip outlet extension cord which was plugged into a 120 VAC wall outlet receptacle.
c) South Building room S10B09- Observed a toaster oven, microwave oven, refrigerator, and radio all plugged into 15 amp rated strip outlet extension cord which was plugged into a 120 VAC wall outlet receptacle.
d) South Building room S10B10- Observed a ceramic element portable electric space heater and refrigerator plugged into 15 amp rated strip outlet extension cord which was plugged into a 120 VAC wall outlet receptacle.
e) 29 S. Greene St.4th floor Transplant Office- Observed two (2) 15 amp rated strip outlet extension cords "daisy chained" and powering eight (8) IT devices and a portable electric space heater.
f) 29 S. Greene St.2nd floor Director of Transplant Office- Observed a microwave oven, two (2) refrigerators, and coffee maker all plugged into a 15 amp rated strip outlet extension cord which was plugged into a 120 VAC wall outlet receptacle.

The facility staff shall perform an audit of the entire facility to insure compliance with this Code requirement.

The use of these items in this manner will create hazards and can result in fire or electrical shock which can promote harm to occupants of the building.