HospitalInspections.org

Based on observations during the survey walk of the facility on 9/5/2012, accompanied by the O&M supervisor and HCI specialist, the facility failed to maintain the egress corridor. The egress corridor, outside of radiology ' s suite, had both oxygen and vacuum outlets.
Patient care can not occur in an egress corridor. Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5 unless otherwise permitted by the following: (1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (1) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous area.

Based on observations during the survey walk of the facility on 9/5/2012, accompanied by the O&M supervisor and HCI specialist, the facility failed to assure the integrity of the corridor. Radiology ' s main corridor door, near MRI, did not close in the door frame when the door was shut. ER department ' s door, near ER discharge, did not completely close. First floor surgical department ' s OR 12 door ' s positive latching hardware was not operational. First floor kitchen department ' s double doors, across from the lab, were not latching and had gaps between its meeting edges, allowing smoke into the egress corridor

Based on observation the facility failed to maintain the fire resistance rating of vertical opening.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there was a problem with the fire stair door not closing and latching on its own in the Main Building, 4th Floor, North Fire Stair.

Based on observations during the survey walk of the facility on 9/6/2012, accompanied by the COO, Facilities Director and Project Engineer, the facility failed to provide an exit sign marking the egress path out the building or suite. This occurred in the egress corridor, near center stair C. Respiratory therapy suite and sleep lab had no exit sign out of their individual suites.
Exit, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access

Based on observation the facility failed to maintain the fire resistance rating of the smoke barriers.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were penetrations of the smoke barriers in the following locations: 1) Main Building, 6th Floor, East Smoke Barrier, and West Smoke Barrier, and 2) Main Building, 5th Floor, East Smoke Barrier.

In the telecom rooms of the main building it was not clear that the vertical penetrations through the floor slab were completely sealed.

Based on observations during the survey walk of the facility on 9/6/2012, accompanied by the COO, Facilities Director and Project Engineer, the facility failed to maintain the smoke resistance of the smoke compartment barrier. Penetrations existed in the one hour rated barrier above the double doors at the corridor near the men & women locker rooms.
Ensure all penetrations through a one hour rated partition are fire sealed.

Based on observations during the survey walk of the facility on 9/5/2012 and 9/6/2012, accompanied by the COO, Facilities Director, O&M supervisor, HCI specialist and Project Engineer, the facility failed to assure the doors in rated barriers had the required smoke control amenities. Both sets of doors 1) NICU/L&D and 2) fire stairwell D's doors, near ICU and CCU, had a gap between their meeting edges, allowing smoke to transfer from one area to another area.
A smoke tight seal at the meeting edges of the doors when closed shall be provided

Based on observation the facility failed to provide an acceptable separation between hazardous areas and the rest of the facility.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were problems with hazardous area separation in the following locations: 1) Bldg. 2, 1st Floor, Gym supply needs closer, 2) Bldg. 2, 1st Floor, Occupational Therapy, 112, needs closer, 3) Bldg. 2, 1st Floor, Server Room/Storage, needs closer, 4) Bldg. 2, 1st Floor, Records Room, needs closer, and 5) Bldg. 2, 1st Floor, I.T. Storage (East), needs closer.


Based on observations during the survey walk of the facility on 9/6/2012, accompanied by the COO, Facilities Director and Project Engineer, the facility failed to maintain a rated barrier. First floor kitchen ' s elevator basement door was not self-closing. Second floor ' s soiled utility ' s door, on the restricted corridor side, did not close in the door frame when the door was shut. LDR ' s soiled utility door ' s latch was not operational. Second floor ' s soiled utility door, across from pharmacy, sticks against the frame and does not completely close

Based on observation the facility failed to provide an acceptable stair enclosure.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there was storage under the fire stair at Building 2, 1st Floor, Center Stair (across from waiting room).

Based on observations during the survey walk of the facility on 9/5/2012, accompanied by the O&M supervisor and HCI specialist, the facility failed to label the power source on fire alarm components in panel board 1FLL and 3EA. Also the breaker providing power to the main Fire Alarm Control Panel did not have a red marking and was not labeled in the panel board.
Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Based on observation the facility failed to maintain the sprinkler system in selected areas.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were the following issues.

There was storage of material within the 18 inch zone in Bldg. 2, 1st Floor, Storage Room (between electrical room and copy room).

In Bldg. 2, 1st Floor, the valves in the fire pump room were not all labeled.

In the Main Building, 6th Floor, the Tele Station Room did not have a sprinkler head.


Based on observations during the survey walk of the facility on 9/5/2012 and 9/6/2012, accompanied by the COO, Facilities Director, O&M supervisor, HCI specialist and Project Engineer, the facility failed to provide a sprinklered smoke compartment. The entire smoke compartment was sprinklered except for the first floor plant operation ' s IS closet and Tom Tanner ' s office and IS communication room. Verify sprinkler head(s) exists in Radiology ' s IS closet. Because of the amount of wires in the ceiling of that room, a sprinkler head could not be found. Second floor ' s janitor closet, near NICU, had no sprinklered head

" The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft. " - NFPA 50, 2001, 2.2.12.

Based on observation the facility failed to provide adequate distance between the bulk oxygen system and a parked vehicle.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there was a vehicle parked immediately adjacent to the bulk oxygen system at Building 2.

Nurse Call System

CMS requires a complete nurse call system and uses the State Regulations to define a complete system. By State Regulations duty stations are required in the following locations: clean work room, soiled work room, medication room, charting room, clean linen storage, nourishment room, equipment storage, exam and treatment rooms. H.L.R. 2007, Table 7, Notes 1, 2, and 3.

Based on observation the facility failed to provide a complete nurse call system as required by CMS and State Regulations.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were the following issues. There were duty stations missing in the following locations: 1) Bldg. 2, 2nd Floor, Clean Supply, 2) Bldg. 2, 2nd Floor, Equipment Storage, 3) Bldg. 2, 2nd Floor, Clean Supply (East), 4) Bldg. 2, 1st Floor, Copy Room (Equipment Storage Room), 5) Main Bldg., 5th Floor, Traction Storage, 6) Main Bldg., 5th Floor, Soiled Utility, 7) Main Bldg., 4th Floor, Supply Room, 8) Main Bldg., 4th Floor, Soiled Utility, and 9) Main Bldg., 4th Floor, Clean Linen.


Isolation Room Pressure Relationships for Infection Control

The pressure relationships between spaces are essential for odor and infection control. NFPA 101 references all NFPA publications. Chapter 6 of NFPA 90A, 1999 references ASHRAE documents as a mandatory part of the requirements of the standard. Current ventilation tables are given by ANSI/ASHRAE/ASHE Standard 170. In addition, State Licensing Regulations control pressure relationships. Infection isolation rooms that shall be negatively pressurized relative to adjacent spaces.

Based on observation the facility failed to provide an acceptable differential pressure relationship for isolation rooms and ante rooms. The isolation room should be negative relative to the ante room and the ante rooms must be negative relative to the corridor.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were numerous cases where the isolation room and/or the ante room did not have the correct pressure relationships and the alarms were not signaling trouble. They were in the following locations: 1) Bldg. 2, 2nd Floor, Isolation Room 272, 2) Main Bldg., 7th Floor, Isolation Room 733, 3) Main Bldg., 6th Floor, Isolation Room 633, and 4) Main Bldg., 4th Floor, Isolation Room 424.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, §133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that the facility had not been conducting receptacle test in patient care areas.


Disaster Drills:

" Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least on semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. " - NFPA 99, 1999, 11-5.3.9.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that the facility had not participated in a mass casualty response in 2011 or 2012.


Line Isolation Monitor Tests.

" The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. " - N.F.P.A. 99, 1999, 3-3.3.4.2

Based on observation the facility failed to provide an acceptable record of line isolation monitor tests.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there was the following issue with the tests. On several monthly intervals Operatory #3 had not been tested. No reason was given for not testing the operatory.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water indicating that they have a preferred customer status in the event of an emergency.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were no current fuel and water agreement letters.


Sprinkler Piping.

Based on observations during the survey walk of the facility on 9/6/2012, accompanied by the COO, Facilities Director and Project Engineer, the facility failed to maintain the sprinkler piping. A supply grill was supported by the sprinkler piping at the IS phone room.
Sprinkler piping or hangers shall not be used to support non-system components.

Based on observations during the survey walk of the facility on 9/5/2012 and 9/6/2012, accompanied by the COO, Facilities Director, O&M supervisor, HCI specialist and Project Engineer, the facility failed to assure that the essential electrical system was in full compliance. Boiler control, sump pump, Johnson Control and Carrier Control was supplied with power from the life safety branch (panel EA) of the essential electrical system. It could not be determined what system that Johnson Control and Carrier Control powered. Verify their function and determine if they need to be moved to the critical or equipment branch panel.
Loading dock and general storage doors were supplied with power from the equipment branch (panel EQL) of the essential electrical system. If these doors are used in the means of egress, they should be powered from the life safety branch. If these doors are used to open the doors for convenience of moving equipment and not as a means of egress, they can remain powered by the equipment branch.
Radiology ' s view box was supplied with power from the life safety branch.
RT outlet was supplied with power by third floor ' s life safety panel board ICUEA.
ER department ' s life safety branch powered the coffee and vending equipment.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.




Based on observations during the survey walk of the facility on 9/6/2012, accompanied by the COO, Facilities Director and Project Engineer, the facility failed to assure that the essential electrical system was in full compliance. Life safety branch (panel EA) of the essential electrical system was not labeled.
Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. They shall be labeled " LIFE SAFETY ' , CRITICAL ' or ' EQUIPMENT ' as applicable

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were the following issues. They were: 1) there was an open electrical box on the 2nd floor of Building 2 at the south smoke barrier, 2) Building 2, 1st Floor, Main Electrical Room, the EES panels were not labeled with the branch they served completely spelled out, 3) Building 2, 1st Floor, Main Electrical Room, panel 2EAA/12, must be crossed referenced to the FACP by spelling out " FIRE ALARM " adjacent to the breaker and colored red, 4) Building 2, 1st Floor, Main Electrical Room, panel 2ECB is a critical panel but breakers 15 and 17 have emergency generator circuits that must be in a life safety panel, 5) Main Building, 6th Floor, Electrical Room, panel 6ECL, Sec. 3 has circuits powering corridor lighting, this should be on the life safety branch of the EES, 6) Main Building, 5th Floor, Electrical Room, panel 5EA/13, serves the FACP and must be labeled " FIRE ALARM " and colored red, and 7) Main Building, 4th Floor, there were receptacles in the head walls and the other walls that were not hospital grade.

Based on observation the facility failed to provide an acceptable location for an alcohol based hand rub dispenser at some locations.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were alcohol base hand rubs within less than 6 inches from electrical devices. They were at the following locations: 1) Bldg. 2, 2nd Floor, Soiled Workroom, 2) Bldg. 2, 1st Floor, Physical Therapy, 114, and 3) Main Bldg., 7th Floor, Room 725.


Based on observations during the survey walk of the facility on 9/6/2012, accompanied by the COO, Facilities Director and Project Engineer, the facility failed to failed to provide an acceptable location for an alcohol based hand rub dispenser. There was an alcohol based hand rub within 6 " of electrical devices at CCU ' s department, near room 21

Based on observations during the survey walk of the facility on 9/5/2012, accompanied by the O&M supervisor and HCI specialist, the facility failed to maintain the egress corridor. The egress corridor, outside of radiology ' s suite, had both oxygen and vacuum outlets.
Patient care can not occur in an egress corridor. Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5 unless otherwise permitted by the following: (1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (1) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous area.

Based on observations during the survey walk of the facility on 9/5/2012, accompanied by the O&M supervisor and HCI specialist, the facility failed to assure the integrity of the corridor. Radiology ' s main corridor door, near MRI, did not close in the door frame when the door was shut. ER department ' s door, near ER discharge, did not completely close. First floor surgical department ' s OR 12 door ' s positive latching hardware was not operational. First floor kitchen department ' s double doors, across from the lab, were not latching and had gaps between its meeting edges, allowing smoke into the egress corridor

Based on observation the facility failed to maintain the fire resistance rating of vertical opening.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there was a problem with the fire stair door not closing and latching on its own in the Main Building, 4th Floor, North Fire Stair.

Based on observations during the survey walk of the facility on 9/6/2012, accompanied by the COO, Facilities Director and Project Engineer, the facility failed to provide an exit sign marking the egress path out the building or suite. This occurred in the egress corridor, near center stair C. Respiratory therapy suite and sleep lab had no exit sign out of their individual suites.
Exit, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access

Based on observation the facility failed to maintain the fire resistance rating of the smoke barriers.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were penetrations of the smoke barriers in the following locations: 1) Main Building, 6th Floor, East Smoke Barrier, and West Smoke Barrier, and 2) Main Building, 5th Floor, East Smoke Barrier.

In the telecom rooms of the main building it was not clear that the vertical penetrations through the floor slab were completely sealed.

Based on observations during the survey walk of the facility on 9/6/2012, accompanied by the COO, Facilities Director and Project Engineer, the facility failed to maintain the smoke resistance of the smoke compartment barrier. Penetrations existed in the one hour rated barrier above the double doors at the corridor near the men & women locker rooms.
Ensure all penetrations through a one hour rated partition are fire sealed.

Based on observations during the survey walk of the facility on 9/5/2012 and 9/6/2012, accompanied by the COO, Facilities Director, O&M supervisor, HCI specialist and Project Engineer, the facility failed to assure the doors in rated barriers had the required smoke control amenities. Both sets of doors 1) NICU/L&D and 2) fire stairwell D's doors, near ICU and CCU, had a gap between their meeting edges, allowing smoke to transfer from one area to another area.
A smoke tight seal at the meeting edges of the doors when closed shall be provided

Based on observation the facility failed to provide an acceptable separation between hazardous areas and the rest of the facility.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were problems with hazardous area separation in the following locations: 1) Bldg. 2, 1st Floor, Gym supply needs closer, 2) Bldg. 2, 1st Floor, Occupational Therapy, 112, needs closer, 3) Bldg. 2, 1st Floor, Server Room/Storage, needs closer, 4) Bldg. 2, 1st Floor, Records Room, needs closer, and 5) Bldg. 2, 1st Floor, I.T. Storage (East), needs closer.


Based on observations during the survey walk of the facility on 9/6/2012, accompanied by the COO, Facilities Director and Project Engineer, the facility failed to maintain a rated barrier. First floor kitchen ' s elevator basement door was not self-closing. Second floor ' s soiled utility ' s door, on the restricted corridor side, did not close in the door frame when the door was shut. LDR ' s soiled utility door ' s latch was not operational. Second floor ' s soiled utility door, across from pharmacy, sticks against the frame and does not completely close

Based on observation the facility failed to provide an acceptable stair enclosure.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there was storage under the fire stair at Building 2, 1st Floor, Center Stair (across from waiting room).

Based on observations during the survey walk of the facility on 9/5/2012, accompanied by the O&M supervisor and HCI specialist, the facility failed to label the power source on fire alarm components in panel board 1FLL and 3EA. Also the breaker providing power to the main Fire Alarm Control Panel did not have a red marking and was not labeled in the panel board.
Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Based on observation the facility failed to maintain the sprinkler system in selected areas.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were the following issues.

There was storage of material within the 18 inch zone in Bldg. 2, 1st Floor, Storage Room (between electrical room and copy room).

In Bldg. 2, 1st Floor, the valves in the fire pump room were not all labeled.

In the Main Building, 6th Floor, the Tele Station Room did not have a sprinkler head.


Based on observations during the survey walk of the facility on 9/5/2012 and 9/6/2012, accompanied by the COO, Facilities Director, O&M supervisor, HCI specialist and Project Engineer, the facility failed to provide a sprinklered smoke compartment. The entire smoke compartment was sprinklered except for the first floor plant operation ' s IS closet and Tom Tanner ' s office and IS communication room. Verify sprinkler head(s) exists in Radiology ' s IS closet. Because of the amount of wires in the ceiling of that room, a sprinkler head could not be found. Second floor ' s janitor closet, near NICU, had no sprinklered head

" The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft. " - NFPA 50, 2001, 2.2.12.

Based on observation the facility failed to provide adequate distance between the bulk oxygen system and a parked vehicle.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there was a vehicle parked immediately adjacent to the bulk oxygen system at Building 2.

Nurse Call System

CMS requires a complete nurse call system and uses the State Regulations to define a complete system. By State Regulations duty stations are required in the following locations: clean work room, soiled work room, medication room, charting room, clean linen storage, nourishment room, equipment storage, exam and treatment rooms. H.L.R. 2007, Table 7, Notes 1, 2, and 3.

Based on observation the facility failed to provide a complete nurse call system as required by CMS and State Regulations.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were the following issues. There were duty stations missing in the following locations: 1) Bldg. 2, 2nd Floor, Clean Supply, 2) Bldg. 2, 2nd Floor, Equipment Storage, 3) Bldg. 2, 2nd Floor, Clean Supply (East), 4) Bldg. 2, 1st Floor, Copy Room (Equipment Storage Room), 5) Main Bldg., 5th Floor, Traction Storage, 6) Main Bldg., 5th Floor, Soiled Utility, 7) Main Bldg., 4th Floor, Supply Room, 8) Main Bldg., 4th Floor, Soiled Utility, and 9) Main Bldg., 4th Floor, Clean Linen.


Isolation Room Pressure Relationships for Infection Control

The pressure relationships between spaces are essential for odor and infection control. NFPA 101 references all NFPA publications. Chapter 6 of NFPA 90A, 1999 references ASHRAE documents as a mandatory part of the requirements of the standard. Current ventilation tables are given by ANSI/ASHRAE/ASHE Standard 170. In addition, State Licensing Regulations control pressure relationships. Infection isolation rooms that shall be negatively pressurized relative to adjacent spaces.

Based on observation the facility failed to provide an acceptable differential pressure relationship for isolation rooms and ante rooms. The isolation room should be negative relative to the ante room and the ante rooms must be negative relative to the corridor.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were numerous cases where the isolation room and/or the ante room did not have the correct pressure relationships and the alarms were not signaling trouble. They were in the following locations: 1) Bldg. 2, 2nd Floor, Isolation Room 272, 2) Main Bldg., 7th Floor, Isolation Room 733, 3) Main Bldg., 6th Floor, Isolation Room 633, and 4) Main Bldg., 4th Floor, Isolation Room 424.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, §133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that the facility had not been conducting receptacle test in patient care areas.


Disaster Drills:

" Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least on semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. " - NFPA 99, 1999, 11-5.3.9.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that the facility had not participated in a mass casualty response in 2011 or 2012.


Line Isolation Monitor Tests.

" The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. " - N.F.P.A. 99, 1999, 3-3.3.4.2

Based on observation the facility failed to provide an acceptable record of line isolation monitor tests.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there was the following issue with the tests. On several monthly intervals Operatory #3 had not been tested. No reason was given for not testing the operatory.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water indicating that they have a preferred customer status in the event of an emergency.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were no current fuel and water agreement letters.


Sprinkler Piping.

Based on observations during the survey walk of the facility on 9/6/2012, accompanied by the COO, Facilities Director and Project Engineer, the facility failed to maintain the sprinkler piping. A supply grill was supported by the sprinkler piping at the IS phone room.
Sprinkler piping or hangers shall not be used to support non-system components.

Based on observations during the survey walk of the facility on 9/5/2012 and 9/6/2012, accompanied by the COO, Facilities Director, O&M supervisor, HCI specialist and Project Engineer, the facility failed to assure that the essential electrical system was in full compliance. Boiler control, sump pump, Johnson Control and Carrier Control was supplied with power from the life safety branch (panel EA) of the essential electrical system. It could not be determined what system that Johnson Control and Carrier Control powered. Verify their function and determine if they need to be moved to the critical or equipment branch panel.
Loading dock and general storage doors were supplied with power from the equipment branch (panel EQL) of the essential electrical system. If these doors are used in the means of egress, they should be powered from the life safety branch. If these doors are used to open the doors for convenience of moving equipment and not as a means of egress, they can remain powered by the equipment branch.
Radiology ' s view box was supplied with power from the life safety branch.
RT outlet was supplied with power by third floor ' s life safety panel board ICUEA.
ER department ' s life safety branch powered the coffee and vending equipment.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.




Based on observations during the survey walk of the facility on 9/6/2012, accompanied by the COO, Facilities Director and Project Engineer, the facility failed to assure that the essential electrical system was in full compliance. Life safety branch (panel EA) of the essential electrical system was not labeled.
Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. They shall be labeled " LIFE SAFETY ' , CRITICAL ' or ' EQUIPMENT ' as applicable

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Safety Officer, the Health Care Improvement/Quality Manager, the Project Engineer, the Director of Nursing Administration, and the C.O.O. during the hours of the inspection from 1:00 pm to 4:30 pm on 9/5/2012 and 9:30 am to 11:00 am on 9/6/2012 that there were the following issues. They were: 1) there was an open electrical box on the 2nd floor of Building 2 at the south smoke barrier, 2) Building 2, 1st Floor, Main Electrical Room, the EES panels were not labeled with the branch they served completely spelled out, 3) Building 2, 1st Floor, Main Electrical Room, panel 2EAA/12, must be crossed referenced to the FACP by spelling out " FIRE ALARM " adjacent to the breaker and colored red, 4) Building 2, 1st Floor, Main Electrical Room, panel 2ECB is a critical panel but breakers 15 and 17 have emergency generator circuits that must be in a life safety panel, 5) Main Building, 6th Floor, Electrical Room, panel 6ECL, Sec. 3 has circuits powering corridor lighting, this should be on the life safety branch of the EES, 6) Main Building, 5th Floor, Electrical Room, panel 5EA/13, serves the FACP and must be labeled " FIRE ALARM " and colored red, and 7) Main Building, 4th Floor, there were receptacles in the head walls and the other walls that were not hospital grade.