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Based on observation it was determined the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed a penetration in the corridor wall located in the projection room measuring approximately 10 inches by six inches.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Walls must remain smoke tight.

Based on observation and interview it was determined the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke... Section 19.3.6.4 "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Findings Include:

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed the following doors that have been removed, were not smoke tight or had "Transfer grills" installed:

1. Door 8603, Visitors Lounge, door tested three of three times, will not positively latch.
2. Door 8522 B, will not positively latch.
3. Door 8628, door closing device disconnected.
4. Door 8616, will not positively latch.
5. Door 7637, Birth Register, door closing device removed.
6. Door 2805, door removed from GI office area.
7. Door 2502 H, Product Manager office, has a transfer grill.
8. Door 2502 B, has a transfer grill.
9. Door 2614 A, will not close and positively latch, impeded by door hanger.
10. Door 2428, tested three of three times, will not positively latch.
11. Lab in back of Acute care, door has transfer grill.
12. Door 1530, tested three of three times, will not positively latch.
13. Door 1564, to MRI break room tested three of three times, will not positively latch.
14. Door 15651 to corridor, tested three of three times, will not positively latch.
15. Door 0807, rated 30 minutes, not smoke tight.
16. Double doors on magnet hold open device in the Pharmacy by Exit, will not close and positively latch.
17. Door 0603, janitors closet, tested three of three times, will not positively latch.
18.West double doors at Diamond Four have been removed smoke barrier meets at the deck, door opening hardware still in place.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

The facility failed to protect patients from heat and smoke which could cause harm.

Based on observation it was determined the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ½ hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed the unsealed penetration in the smoke barrier, located by the 1683 Hall. The penetration is a cable tray approximately eight inches by four inches.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation it was determined the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed the following hazardous area doors:

1. Kitchen closet door vented with grill, room contains chemicals.
2. Kitchen janitors closet contains chemicals, flammables and combustibles. The door has no door closing device.
3. Room/door 2502 T contains a flammable locker and combustibles, the door has no closing device.
4. Dish wash area, both double doors held open with racks. (2702 C).
5. Door/Room, 2603 F, door will not positively latch, tested three of three times.
6. Stage door H to the stage studio removed.
7. Studio work area door latch taped and chalked open. Room has a gallon of thinner open to the room.
8. Rated 1-1/2 hr door by 1681, one of two door closing devices disconnected.
9. Room 0617, No door closing device, room contains heavy fire load.
10. Room 0603, door tested three of three times, will not positively latch.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation it was determined the facility did not keep the required signs posted at the exit doors equipped with special operating features.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.1, Section 18.2.1 " Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.2.1.6.1 (d) " On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in high and not less than 1/8 in. in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS.

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed the exit door serving the Basement Pharmacy Exit to the stairwell was labeled "NO EXIT", and equipped with a magnetic lock that releases upon activation of the fire Alarm. The door does not have a posted sign or signs on or adjacent to the special locking exit door.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failure to keep the signs posted could delay the exiting of patients during a fire or emergency.

Based on observation and staff interview it was determined the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000,Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed the storage of, eight pieces of medical equipment within the exit corridor. The storage was blocking the exit access located in one of two exits. The exit access when measured was reduced from eight feet to five feet six inches. Staff member stated the equipment had been stored from 7:00 AM until 12:35 PM.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on observation staff interview and record review the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

Findings include:

Three employees were interviewed, length of employment range from one year to two and a half years. Employees stated they have had no fire drills in there work areas. One employee stated they never participate in fire drills.


During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on record review and interview it was determined the facility failed to complete sensitivity testing on the facilities smoke detectors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.1.1.1.1 " The requirements of this chapter apply to the following: (1) New buildings or portions thereof used as health care occupancies. (2) Additions made to, or used as, a health care occupancy. " or Chapter 19, Section 19.1.1.1.1, "The requirements of this chapter apply to existing buildings or portions thereof currently occupied as health care. Existing health care facilities shall comply with the provisions of this chapter" Chapter 18, Section 18.3.4.1 or Chapter 19, Section 19.3.4.1 "General" "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.", Chapter 9, Section 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. NFPA 101, Chapter 4, Section 4.6.12.3, " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 72 National Fire Alarm Code, Chapter 7 Inspection Testing, and Maintenance/Paragraph 7-3.2 "Testing shall be performed in accordance with the schedules in this chapter or more frequently where required by authority having jurisdiction. Section 7-3.2.1 "Detectors sensitivity shall be checked within 1 year after installation and every alternate year thereafter. Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced."

Findings include:

On December 17, of 2014, the surveyor, accompanied by the Facilities Specialists requested the documentation of the non-addressable Floors 7 & 8 sensitivity testing.
The facility has no documentation.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failure to test and maintain the fire alarm systems smoke detectors could result in harm to the patients.

Based on observation, and documentation it was determined the facility failed to maintain the sprinkler heads from lint, obstructions, and standpipe systems for annual testing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7."."Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 5, Section 5-8.5.1.1, "Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard."

9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

NFPA 25 1998 Edition Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. Chapter 3 Standpipe and Systems.

NFPA 25 Section 3-2 Inspection. Section 3-2.1 Components of standpipe and hose systems shall be visually inspected quarterly or as specified in Table 3-1 and 3-2.3.

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities and Facilities Specialists reviewed the documentation and observed the following sprinkler system deficiencies:

1. The facilities documentation did not include the visual quarterly standpipe inspection.
2. Room/Door 8511, one of four sprinklers covered with lint.
3. Kitchen, main cook area, seventeen escutcheon plates not smoke tight
4. Cooks freezer 2502,one of two escutcheon plates missing.
5. 2502 M refrigerator, two of two escutcheon plates missing, and one of two sprinklers corroded.
6. Dish wash area, one of five escutcheon plates missing.
7. Breakfast prep area, one of five escutcheon plates missing.
8. Auditorium stage area, five of six escutcheon plates not smoke tight, gaps greater than 1/4 inch.
9. OR 11 (#2) and OR 12 (#?), Hanauport mounts impede the sprinklers.
10. Room/Door 1532, four of four sprinklers impeded
11. Room/Door, 0621, Pharmacy refrigerator, two sprinklers impeded by lights, and one escutcheon plate not smoke tight.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failure to maintain the sprinklers heads could result in a malfunction during a fire. Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Lint on the head could slow that response or disable the sprinkler head. Failure to test and maintain the standpipe systems in case of a fire could cause harm to the patients.
Installing obstructions next to the sprinkler head may prevent it from providing adequate coverage of the hazard. This may cause harm to the patients.

Based on observation the facility did not assure that the fire extinguisher was readily available for use in an emergency.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6, "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1." Section 9.7.4.1, "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed in accordance with NFPA 10 Standard for the Installation of Portable Fire Extinguishers. NFPA 10, Chapter 1, General Requirements, Section 1-6.3 "Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of a fire."

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities, Facilities Specialists, and staff observed the fire extinguisher located in the left side of the flammable bulk waste storage container blocked by containers of flammable waste and not readily available for use in an emergency.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to make a fire extinguisher readily available in case of a fire will cause injury.

Based on observation, it was determined the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19-3.2.6,"Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge."

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities and Facilities Specialists, inspected the kitchen exhaust system hood, the patient cook line has ten of ten filters with an excessive amount of grease buildup.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a delay in the fire suppression system to activate which could cause more damage to the kitchen and could cause harm to the residents.

Based on observation, staff interview and documentation it was determined the facility failed to provide the flame spread rating of the holiday directions covering the doors.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.7.5.4, "Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant."

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities and Facilities Specialists reviewed the documentation and observed the following combustible decorations:

1. Room/Door, 7643, completely wrapped with combustible paper decorations.
2. Imaging, break room, two of two doors wrapped with combustible paper decorations.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to maintain decorations in exit corridors could contribute to fire spread and cause harm to the patients.

Based on observation it was determined the facility failed to secure medical gas cylinders.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities and Facilities Specialists observed the following unsecured medical gas cylinders located in the following rooms/areas:

1. Diamond four west bed area, across from door DC 4155, four unsecured E-O2 bottles.
2. Heart storage room, three O2 bottles unsecured.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.

Based on observation and documentation it was determined the facility failed to maintain the " Emergency Shower".

NFPA 99, Health Care Facilities, Chapter 10, Section 10-6 "Emergency Shower." "Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching of flushing of the eyes and body shall be provided within the work area for immediate emergency use...."

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities, Facilities Specialists, and staff observed the bulk hazardous waste storage container. The "Emergency Shower" was blocked and not accessible, nor was documentation available of testing of the shower.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to provide an emergency shower with in the worked place will cause harm to Staff if a spill should occur.

Based on observation it was determined the facility failed to store flammable liquids in an approved flammable/combustible liquid cabinet.

NFPA 101 Life Safety Code, 2000 Chapter 19, Section 19.3.2 "Protection from Hazards,"
18.3.2.2 "Laboratories," and Table 19.3.2.1 "Physical plant maintenance shops," and "Storage Rooms"
or Chapter 19, Section, 19.3.2.1 "Hazardous Areas" "(4) Repair shops," "(7) Storage rooms,"
and (8) " Laboratories."

Chapter 19.3.2.2* Laboratories. Laboratories employing quantities of flammable, combustible or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99 Health Care Facilities, 1999 Chapter 10, Section 10-7-2* Storage and Use, Established laboratory practice shall limit working supplies of flammable or combustible liquid. The total volume of Class l, 11, and 111A, liquids outside of an approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class 1, 11, and 111A liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal...

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities, Facilities Specialists, and staff observed the following:

1. Auto clave room, a one gallon can with acetone stored on a shelf used to transfer flammable liquid.
2. Ten gallons of flammable waste stored under a counter in the lab, with no spill protection and not stored in a flammable cabinet.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to store flammable and combustible liquids properly may create a spill hazard, and will contribute to a fire, which will cause harm to patients and staff.

Based on observation it was determined the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances. The facility failed to provide a guard on the light bulbs; and the facility failed to allow access to the electrical equipment/panel.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions. ( NO STORAGE ALLOWED IN THE WORKING SPACE)

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities and Facilities Specialists observed the following electrical deficiencies:

1. Room/Door, 8590, electrical closet, light no guard.
2. Room/Door, 7301, Dr. office, three light fixtures no guards.
3. Room/Door, 2823, wellness Center, two lights no guards.
4. Wellness preventative break room, microwave plugged into a breaker bar.
5. By room 2702D, above the ceiling, the FD J-box is open, exposed energized electrical wires.
6. Room/Door 2603, closet with an unprotected light, no guard.
7. Lab in back of Acute care, light, no guard.
8. Lab, electrical panel 1415E blocked.
9. Basement, BME bed shop, extension cord used for 18 hrs to test equipment.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.
Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.
Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.

Based on observation it was determined the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed a penetration in the corridor wall located in the projection room measuring approximately 10 inches by six inches.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Walls must remain smoke tight.

Based on observation and interview it was determined the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke... Section 19.3.6.4 "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Findings Include:

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed the following doors that have been removed, were not smoke tight or had "Transfer grills" installed:

1. Door 8603, Visitors Lounge, door tested three of three times, will not positively latch.
2. Door 8522 B, will not positively latch.
3. Door 8628, door closing device disconnected.
4. Door 8616, will not positively latch.
5. Door 7637, Birth Register, door closing device removed.
6. Door 2805, door removed from GI office area.
7. Door 2502 H, Product Manager office, has a transfer grill.
8. Door 2502 B, has a transfer grill.
9. Door 2614 A, will not close and positively latch, impeded by door hanger.
10. Door 2428, tested three of three times, will not positively latch.
11. Lab in back of Acute care, door has transfer grill.
12. Door 1530, tested three of three times, will not positively latch.
13. Door 1564, to MRI break room tested three of three times, will not positively latch.
14. Door 15651 to corridor, tested three of three times, will not positively latch.
15. Door 0807, rated 30 minutes, not smoke tight.
16. Double doors on magnet hold open device in the Pharmacy by Exit, will not close and positively latch.
17. Door 0603, janitors closet, tested three of three times, will not positively latch.
18.West double doors at Diamond Four have been removed smoke barrier meets at the deck, door opening hardware still in place.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

The facility failed to protect patients from heat and smoke which could cause harm.

Based on observation it was determined the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ½ hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed the unsealed penetration in the smoke barrier, located by the 1683 Hall. The penetration is a cable tray approximately eight inches by four inches.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation it was determined the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed the following hazardous area doors:

1. Kitchen closet door vented with grill, room contains chemicals.
2. Kitchen janitors closet contains chemicals, flammables and combustibles. The door has no door closing device.
3. Room/door 2502 T contains a flammable locker and combustibles, the door has no closing device.
4. Dish wash area, both double doors held open with racks. (2702 C).
5. Door/Room, 2603 F, door will not positively latch, tested three of three times.
6. Stage door H to the stage studio removed.
7. Studio work area door latch taped and chalked open. Room has a gallon of thinner open to the room.
8. Rated 1-1/2 hr door by 1681, one of two door closing devices disconnected.
9. Room 0617, No door closing device, room contains heavy fire load.
10. Room 0603, door tested three of three times, will not positively latch.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation it was determined the facility did not keep the required signs posted at the exit doors equipped with special operating features.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.1, Section 18.2.1 " Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.2.1.6.1 (d) " On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in high and not less than 1/8 in. in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS.

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed the exit door serving the Basement Pharmacy Exit to the stairwell was labeled "NO EXIT", and equipped with a magnetic lock that releases upon activation of the fire Alarm. The door does not have a posted sign or signs on or adjacent to the special locking exit door.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failure to keep the signs posted could delay the exiting of patients during a fire or emergency.

Based on observation and staff interview it was determined the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000,Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On December 17,18, and 19 of 2014, the surveyor, accompanied by the Director of Facilities and Facilities Specialists observed the storage of, eight pieces of medical equipment within the exit corridor. The storage was blocking the exit access located in one of two exits. The exit access when measured was reduced from eight feet to five feet six inches. Staff member stated the equipment had been stored from 7:00 AM until 12:35 PM.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on observation staff interview and record review the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

Findings include:

Three employees were interviewed, length of employment range from one year to two and a half years. Employees stated they have had no fire drills in there work areas. One employee stated they never participate in fire drills.


During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on record review and interview it was determined the facility failed to complete sensitivity testing on the facilities smoke detectors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.1.1.1.1 " The requirements of this chapter apply to the following: (1) New buildings or portions thereof used as health care occupancies. (2) Additions made to, or used as, a health care occupancy. " or Chapter 19, Section 19.1.1.1.1, "The requirements of this chapter apply to existing buildings or portions thereof currently occupied as health care. Existing health care facilities shall comply with the provisions of this chapter" Chapter 18, Section 18.3.4.1 or Chapter 19, Section 19.3.4.1 "General" "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.", Chapter 9, Section 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. NFPA 101, Chapter 4, Section 4.6.12.3, " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 72 National Fire Alarm Code, Chapter 7 Inspection Testing, and Maintenance/Paragraph 7-3.2 "Testing shall be performed in accordance with the schedules in this chapter or more frequently where required by authority having jurisdiction. Section 7-3.2.1 "Detectors sensitivity shall be checked within 1 year after installation and every alternate year thereafter. Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced."

Findings include:

On December 17, of 2014, the surveyor, accompanied by the Facilities Specialists requested the documentation of the non-addressable Floors 7 & 8 sensitivity testing.
The facility has no documentation.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failure to test and maintain the fire alarm systems smoke detectors could result in harm to the patients.

Based on observation, and documentation it was determined the facility failed to maintain the sprinkler heads from lint, obstructions, and standpipe systems for annual testing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7."."Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 5, Section 5-8.5.1.1, "Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard."

9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

NFPA 25 1998 Edition Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. Chapter 3 Standpipe and Systems.

NFPA 25 Section 3-2 Inspection. Section 3-2.1 Components of standpipe and hose systems shall be visually inspected quarterly or as specified in Table 3-1 and 3-2.3.

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities and Facilities Specialists reviewed the documentation and observed the following sprinkler system deficiencies:

1. The facilities documentation did not include the visual quarterly standpipe inspection.
2. Room/Door 8511, one of four sprinklers covered with lint.
3. Kitchen, main cook area, seventeen escutcheon plates not smoke tight
4. Cooks freezer 2502,one of two escutcheon plates missing.
5. 2502 M refrigerator, two of two escutcheon plates missing, and one of two sprinklers corroded.
6. Dish wash area, one of five escutcheon plates missing.
7. Breakfast prep area, one of five escutcheon plates missing.
8. Auditorium stage area, five of six escutcheon plates not smoke tight, gaps greater than 1/4 inch.
9. OR 11 (#2) and OR 12 (#?), Hanauport mounts impede the sprinklers.
10. Room/Door 1532, four of four sprinklers impeded
11. Room/Door, 0621, Pharmacy refrigerator, two sprinklers impeded by lights, and one escutcheon plate not smoke tight.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failure to maintain the sprinklers heads could result in a malfunction during a fire. Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Lint on the head could slow that response or disable the sprinkler head. Failure to test and maintain the standpipe systems in case of a fire could cause harm to the patients.
Installing obstructions next to the sprinkler head may prevent it from providing adequate coverage of the hazard. This may cause harm to the patients.

Based on observation the facility did not assure that the fire extinguisher was readily available for use in an emergency.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6, "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1." Section 9.7.4.1, "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed in accordance with NFPA 10 Standard for the Installation of Portable Fire Extinguishers. NFPA 10, Chapter 1, General Requirements, Section 1-6.3 "Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of a fire."

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities, Facilities Specialists, and staff observed the fire extinguisher located in the left side of the flammable bulk waste storage container blocked by containers of flammable waste and not readily available for use in an emergency.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to make a fire extinguisher readily available in case of a fire will cause injury.

Based on observation, it was determined the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19-3.2.6,"Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge."

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities and Facilities Specialists, inspected the kitchen exhaust system hood, the patient cook line has ten of ten filters with an excessive amount of grease buildup.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a delay in the fire suppression system to activate which could cause more damage to the kitchen and could cause harm to the residents.

Based on observation, staff interview and documentation it was determined the facility failed to provide the flame spread rating of the holiday directions covering the doors.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.7.5.4, "Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant."

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities and Facilities Specialists reviewed the documentation and observed the following combustible decorations:

1. Room/Door, 7643, completely wrapped with combustible paper decorations.
2. Imaging, break room, two of two doors wrapped with combustible paper decorations.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to maintain decorations in exit corridors could contribute to fire spread and cause harm to the patients.

Based on observation it was determined the facility failed to secure medical gas cylinders.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities and Facilities Specialists observed the following unsecured medical gas cylinders located in the following rooms/areas:

1. Diamond four west bed area, across from door DC 4155, four unsecured E-O2 bottles.
2. Heart storage room, three O2 bottles unsecured.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.

Based on observation and documentation it was determined the facility failed to maintain the " Emergency Shower".

NFPA 99, Health Care Facilities, Chapter 10, Section 10-6 "Emergency Shower." "Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching of flushing of the eyes and body shall be provided within the work area for immediate emergency use...."

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities, Facilities Specialists, and staff observed the bulk hazardous waste storage container. The "Emergency Shower" was blocked and not accessible, nor was documentation available of testing of the shower.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to provide an emergency shower with in the worked place will cause harm to Staff if a spill should occur.

Based on observation it was determined the facility failed to store flammable liquids in an approved flammable/combustible liquid cabinet.

NFPA 101 Life Safety Code, 2000 Chapter 19, Section 19.3.2 "Protection from Hazards,"
18.3.2.2 "Laboratories," and Table 19.3.2.1 "Physical plant maintenance shops," and "Storage Rooms"
or Chapter 19, Section, 19.3.2.1 "Hazardous Areas" "(4) Repair shops," "(7) Storage rooms,"
and (8) " Laboratories."

Chapter 19.3.2.2* Laboratories. Laboratories employing quantities of flammable, combustible or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99 Health Care Facilities, 1999 Chapter 10, Section 10-7-2* Storage and Use, Established laboratory practice shall limit working supplies of flammable or combustible liquid. The total volume of Class l, 11, and 111A, liquids outside of an approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class 1, 11, and 111A liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal...

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities, Facilities Specialists, and staff observed the following:

1. Auto clave room, a one gallon can with acetone stored on a shelf used to transfer flammable liquid.
2. Ten gallons of flammable waste stored under a counter in the lab, with no spill protection and not stored in a flammable cabinet.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

Failing to store flammable and combustible liquids properly may create a spill hazard, and will contribute to a fire, which will cause harm to patients and staff.

Based on observation it was determined the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances. The facility failed to provide a guard on the light bulbs; and the facility failed to allow access to the electrical equipment/panel.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions. ( NO STORAGE ALLOWED IN THE WORKING SPACE)

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On December 17,18, and 19 of 2014, the surveyors, accompanied by the Director of Facilities and Facilities Specialists observed the following electrical deficiencies:

1. Room/Door, 8590, electrical closet, light no guard.
2. Room/Door, 7301, Dr. office, three light fixtures no guards.
3. Room/Door, 2823, wellness Center, two lights no guards.
4. Wellness preventative break room, microwave plugged into a breaker bar.
5. By room 2702D, above the ceiling, the FD J-box is open, exposed energized electrical wires.
6. Room/Door 2603, closet with an unprotected light, no guard.
7. Lab in back of Acute care, light, no guard.
8. Lab, electrical panel 1415E blocked.
9. Basement, BME bed shop, extension cord used for 18 hrs to test equipment.

During the exit conference on December 19, 2014, the above findings were again acknowledged by the CEO, COO, CEO, Practice Plan,Director of Facilities Management, Manager, University Campus Facilities Management, Director, QI and Survey Readiness, and Associate Director of Quality Improvement.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.
Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.
Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.