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Based on tests to doors and observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that patient's doors protecting corridors do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3 at patient's rooms #311 and #827.

Findings include:

During the tour for life safety from fire from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm, patient's sleeping room doors were tested with a facility Engineer (employee #5) and it was found that patient's sleeping rooms #311 and #827 did not latch when the doors were closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors must be verified at least monthly and appropriate documentation must be available upon request.

Based on tests to doors and observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the smoke barrier doors on the third and eight floors, X-Ray department and emergency room are not arranged to automatically close as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.2.1.8.2.

Findings include:

1. The smoke barrier doors located in the emergency room at hallway B were observed on 2/8/11 at 8:30 am with a facility Engineer (employee #5) with a patient on a stretcher blocking one of the door leafs. A family member of the patient also had a seat against this door and during the observation a nurse was trying to gain access to the patient's arm to connect an intravenous solution and her procedure cart was blocking the other leaf of the smoke barrier door, if the hold open devices are released (in the event that the smoke alarm is activated), this would not permit the smoke barrier doors from closing and this can allow smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

2. The smoke barrier doors located on the third floor near room #301 were observed on 2/9/11 at 1:15 pm with a facility Engineer (employee #5) with regular and biohazardous trash pails tie to one another and placed in front of one of the door leafs. If the hold open devices are released (in the event that the smoke alarm is activated), this would not permit the smoke barrier doors from closing and this can allow smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

3. The smoke barrier doors located on the eight floor (door #150) did not close flush to its frame when released from its hold open device as observed on 2/9/11 at 9:00 am, this can permit smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

4. The smoke barrier doors of the X-Ray department were observed on 2/10/11 at 10:55 am with a facility Engineer (employee #5) with a patient on a stretcher and a type H oxygen cylinder placed in front of one of the door leafs. If the hold open devices are released (in the event that the smoke alarm is activated), this would not permit the smoke barrier doors from closing and this can allow smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

5. No evidence was found on 2/11/11 at 10:00 am of periodic smoke barrier door verification. This verification shall include the release of the smoke barrier doors from their hold open devices when the fire alarm system is activated. This verification shall be performed and documented to ensure smoke barrier doors and hold open devices performance.

Based on observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the facility failed to provide an "exit" sign at the side exit door of the kitchen as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.10.1.2.

Findings include:

During the tour for life safety from fire of the kitchen with a facility Engineer (employee #5), exit components were inspected and it was found that the side exit door used by personnel to move through the adjacent hallway did not have an illuminated exit sign as observed on 2/10/11 at 8:55 am.

Based on tests to doors and observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the facility failed to ensure that the maintenance closet door on the third floor Sonogram department can resist the passage of smoke in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 8.3.4.1 as evidenced by a louver on this door.

Findings include:

The maintenance closet located on the third floor near the Sonogram department was observed on 2/10/11 at 9:45 am with a facility Engineer (employee #5), with a louver that opens into the corridor. In the event of a fire, this door would not resist the passage of smoke to the outside corridor.

Based on observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided in a medication preparation room, staircases and hallways and two emergency lamps in the laboratory department did not illuminate when tested as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm with a facility Engineer (employee #5) in the following areas:
a. In triage room II of the adult emergency rooms.
b. In the medication preparation room of the new observation cubicles of the adult emergency room.
c. In the treatment area of the adult emergency room.
d. In the pre-induction pediatric area of the operating department.
e. In the hallway in front of the pre-induction pediatric area of the operating department.
f. All staircases at the "West Wing Annex" and "La Milagrosa" sections of the hospital (examples are staircases: #12, #13, #14, #15, #16, #17, #18, etc).
g. In the hallway of the ninth floor.
h. At the "Center for Cancer" hallway and near the elevator of this floor.
i. At the hallway and elevator area where the new maternity section of the facility meets the old building delivery and neonatal unit.
j. At the Endoscopy department.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

2. The emergency battery operated lamps (EBOL) in the following areas were tested and did not illuminate as observed on 2/11/11 at 8:10 am:
a. Two EBOLs in the Laboratory department (numbers #273 and #274).

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with a facility Engineer (employee #5) and interview, it was determined that the facility failed to ensure that fire drills are are conducted under varying conditions and that kitchen employees are properly trained related to fire procedures as required by the 2000 edition of the Life Safety Code of the NFPA 19.7.1.2 and 5.5.

Findings include:

1. Written documents about conducted fire drills for the hospital were reviewed on 2/10/11 at 3:25 pm with a facility Engineer (employee #5) and provided evidence that fire drills are not performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve. Of the fire drills reviewed, none were found with task improvement.

2. Kitchen personnel (employees #7, #8 and #9) were interviewed on 2/10/11 at 9:00 am related to fire drill procedures in the event of a fire at the stoves and they did not know the standard steps to follow, where control valves are located or who is responsible for specific tasks.

Based on observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the facility failed to ensure that smoke detectors are available in required areas, some smoke detectors are to close to air vents and smoke detectors are too far from the smoke barrier doors in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm with a facility Engineer (employee #5):
a. In the room used for cardiac emergencies in the adult emergency room.
b. At the nursery department on the third floor.
c. At the pantry on the second floor of the "San Vicente" building.
d. In the room used to store six type E oxygen cylinders at the NICU/PICU.

2. The smoke detectors located on the ceiling of the laboratory in the adult emergency room were found on 2/8/11 at 9:20 am located within one foot from ceiling air conditioner vents; due to the air flow from these vents at least three feet is needed.

3. The smoke detectors located on the ceiling of the pharmacy department were found on 2/10/11 at 10:00 am located within one foot from ceiling air conditioner vents; due to the air flow from these vents at least three feet is needed.

4. Smoke detectors are not located within five (5) of at least one leaf of the smoke barrier doors as observed from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm with a facility Engineer (employee #5) at the following locations (all smoke barrier doors shall be verified):
a. The smoke barrier doors near patient's room #8601.
b. Smoke barrier doors #104.
c. Smoke barrier doors located near the MRI on the first floor (doors #50).

5. The emergency pull station located near the nursery department on the third floor was obstructed by the smoke barrier doors as observed on 2/10/11 at 3:05 pm.

Based on observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the facility failed to ensure that a portable fire extinguisher type ABC is maintained at the kitchen department as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

During observations made of the hospital with a facility Engineer (employee #5) from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm, it was found that the kitchen has multiple type K fire extinguishers, however they do not have a type ABC.

Based on observations during the survey for Life safety from fire with a facility Engineer (employee #5), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to the storage of oxygen tanks, transporting oxygen tanks, kitchen hood maintenance and improperly designed exit plans as required by the 2000 edition of the Life Safety Code of the NFPA.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm with a facility Engineer (employee #5) type H and Type E oxygen tanks were found in areas that do not meet minimum requirements:
a. In the X-ray room of the adult emergency room (a type E oxygen cylinder).
b. Two type E oxygen cylinders were found in the large observation area (CO).
c. Two type E oxygen cylinders were found in the holding area for hospital patients in the operating suite department.
d. Eight type E oxygen cylinders at the Delivery department.
e. Twelve type E oxygen cylinders at the central supply.
f. A type H and two type E oxygen cylinders were found at the Endoscopy department.
g. Six type E oxygen cylinders were found in a room at NICU/PICU.

2. During observations of the emergency room in the treatment area on 2/8/11 at 10:30 am an escort (employee #37) was observed wheeling in an empty stretcher that had a type E oxygen tank on it (the cylinder was not secured). Special care must be taken when transporting oxygen cylinders due to it high potential to explode.

3. During observations near the nuclear medicine department on 2/11/11 at 11:30 am an escort (employee #38) was observed wheeling in a stretcher with a patient that had a type E oxygen tank at the back of the stretcher that he was holding (the cylinder was not secured) and he was also pushing the stretcher. Special care must be taken when transporting oxygen cylinders due to it high potential to explode.

4. Floor plans throughout the hospital were observed from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm, too small to be easily read to identify where the individual is located and the nearest possible exit routes. Other findings related to the exit plans are the following:
a. Some exit plans are mounted too high on the walls and shall be placed to ensure visibility for all size persons.
b. The exit plans are removable and shall be fixed to the walls to avoid unauthorized removal.
c. The exit plans depict the entire floor and not just the area where the individual is located and the nearest exits. The entire floor lay out of the floor will distract persons from the needed information in the event of an emergency.
d. Some exit plans throughout the facility were evaluated for content and they were found to not be correct related to devices in the area (for example the third floor nursery exit plan and the exit plan outside of the Intensive Care Unit).

5. The exit door near patient's room 3701 was observed on 2/10/11 at 11:10 am with a facility Engineer (employee #5) and provided evidence that there was water on the floor and debris behind the door due to a broken pipe which did not allow the door to be fully opened.

6. During the observational tour of the kitchen on 2/10/11 at 8:30 am with a facility Engineer (employee #5) the following was determined:
a. The hood vents located above the cooking stoves were found with spaces between them which will not allow the vents to protect the duct system as designed.
b. Kitchen's hood exhaust system maintenance was requested, however no evidence was found of the updated required hood, duct and exhaust fans inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule.

Based on tests to doors and observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that patient's doors protecting corridors do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3 at patient's rooms #311 and #827.

Findings include:

During the tour for life safety from fire from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm, patient's sleeping room doors were tested with a facility Engineer (employee #5) and it was found that patient's sleeping rooms #311 and #827 did not latch when the doors were closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors must be verified at least monthly and appropriate documentation must be available upon request.

Based on tests to doors and observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the smoke barrier doors on the third and eight floors, X-Ray department and emergency room are not arranged to automatically close as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.2.1.8.2.

Findings include:

1. The smoke barrier doors located in the emergency room at hallway B were observed on 2/8/11 at 8:30 am with a facility Engineer (employee #5) with a patient on a stretcher blocking one of the door leafs. A family member of the patient also had a seat against this door and during the observation a nurse was trying to gain access to the patient's arm to connect an intravenous solution and her procedure cart was blocking the other leaf of the smoke barrier door, if the hold open devices are released (in the event that the smoke alarm is activated), this would not permit the smoke barrier doors from closing and this can allow smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

2. The smoke barrier doors located on the third floor near room #301 were observed on 2/9/11 at 1:15 pm with a facility Engineer (employee #5) with regular and biohazardous trash pails tie to one another and placed in front of one of the door leafs. If the hold open devices are released (in the event that the smoke alarm is activated), this would not permit the smoke barrier doors from closing and this can allow smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

3. The smoke barrier doors located on the eight floor (door #150) did not close flush to its frame when released from its hold open device as observed on 2/9/11 at 9:00 am, this can permit smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

4. The smoke barrier doors of the X-Ray department were observed on 2/10/11 at 10:55 am with a facility Engineer (employee #5) with a patient on a stretcher and a type H oxygen cylinder placed in front of one of the door leafs. If the hold open devices are released (in the event that the smoke alarm is activated), this would not permit the smoke barrier doors from closing and this can allow smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

5. No evidence was found on 2/11/11 at 10:00 am of periodic smoke barrier door verification. This verification shall include the release of the smoke barrier doors from their hold open devices when the fire alarm system is activated. This verification shall be performed and documented to ensure smoke barrier doors and hold open devices performance.

Based on observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the facility failed to provide an "exit" sign at the side exit door of the kitchen as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.10.1.2.

Findings include:

During the tour for life safety from fire of the kitchen with a facility Engineer (employee #5), exit components were inspected and it was found that the side exit door used by personnel to move through the adjacent hallway did not have an illuminated exit sign as observed on 2/10/11 at 8:55 am.

Based on tests to doors and observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the facility failed to ensure that the maintenance closet door on the third floor Sonogram department can resist the passage of smoke in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 8.3.4.1 as evidenced by a louver on this door.

Findings include:

The maintenance closet located on the third floor near the Sonogram department was observed on 2/10/11 at 9:45 am with a facility Engineer (employee #5), with a louver that opens into the corridor. In the event of a fire, this door would not resist the passage of smoke to the outside corridor.

Based on observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided in a medication preparation room, staircases and hallways and two emergency lamps in the laboratory department did not illuminate when tested as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm with a facility Engineer (employee #5) in the following areas:
a. In triage room II of the adult emergency rooms.
b. In the medication preparation room of the new observation cubicles of the adult emergency room.
c. In the treatment area of the adult emergency room.
d. In the pre-induction pediatric area of the operating department.
e. In the hallway in front of the pre-induction pediatric area of the operating department.
f. All staircases at the "West Wing Annex" and "La Milagrosa" sections of the hospital (examples are staircases: #12, #13, #14, #15, #16, #17, #18, etc).
g. In the hallway of the ninth floor.
h. At the "Center for Cancer" hallway and near the elevator of this floor.
i. At the hallway and elevator area where the new maternity section of the facility meets the old building delivery and neonatal unit.
j. At the Endoscopy department.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

2. The emergency battery operated lamps (EBOL) in the following areas were tested and did not illuminate as observed on 2/11/11 at 8:10 am:
a. Two EBOLs in the Laboratory department (numbers #273 and #274).

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with a facility Engineer (employee #5) and interview, it was determined that the facility failed to ensure that fire drills are are conducted under varying conditions and that kitchen employees are properly trained related to fire procedures as required by the 2000 edition of the Life Safety Code of the NFPA 19.7.1.2 and 5.5.

Findings include:

1. Written documents about conducted fire drills for the hospital were reviewed on 2/10/11 at 3:25 pm with a facility Engineer (employee #5) and provided evidence that fire drills are not performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve. Of the fire drills reviewed, none were found with task improvement.

2. Kitchen personnel (employees #7, #8 and #9) were interviewed on 2/10/11 at 9:00 am related to fire drill procedures in the event of a fire at the stoves and they did not know the standard steps to follow, where control valves are located or who is responsible for specific tasks.

Based on observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the facility failed to ensure that smoke detectors are available in required areas, some smoke detectors are to close to air vents and smoke detectors are too far from the smoke barrier doors in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm with a facility Engineer (employee #5):
a. In the room used for cardiac emergencies in the adult emergency room.
b. At the nursery department on the third floor.
c. At the pantry on the second floor of the "San Vicente" building.
d. In the room used to store six type E oxygen cylinders at the NICU/PICU.

2. The smoke detectors located on the ceiling of the laboratory in the adult emergency room were found on 2/8/11 at 9:20 am located within one foot from ceiling air conditioner vents; due to the air flow from these vents at least three feet is needed.

3. The smoke detectors located on the ceiling of the pharmacy department were found on 2/10/11 at 10:00 am located within one foot from ceiling air conditioner vents; due to the air flow from these vents at least three feet is needed.

4. Smoke detectors are not located within five (5) of at least one leaf of the smoke barrier doors as observed from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm with a facility Engineer (employee #5) at the following locations (all smoke barrier doors shall be verified):
a. The smoke barrier doors near patient's room #8601.
b. Smoke barrier doors #104.
c. Smoke barrier doors located near the MRI on the first floor (doors #50).

5. The emergency pull station located near the nursery department on the third floor was obstructed by the smoke barrier doors as observed on 2/10/11 at 3:05 pm.

Based on observations made during the survey for life safety from fire with a facility Engineer (employee #5), it was determined that the facility failed to ensure that a portable fire extinguisher type ABC is maintained at the kitchen department as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

During observations made of the hospital with a facility Engineer (employee #5) from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm, it was found that the kitchen has multiple type K fire extinguishers, however they do not have a type ABC.

Based on observations during the survey for Life safety from fire with a facility Engineer (employee #5), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to the storage of oxygen tanks, transporting oxygen tanks, kitchen hood maintenance and improperly designed exit plans as required by the 2000 edition of the Life Safety Code of the NFPA.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm with a facility Engineer (employee #5) type H and Type E oxygen tanks were found in areas that do not meet minimum requirements:
a. In the X-ray room of the adult emergency room (a type E oxygen cylinder).
b. Two type E oxygen cylinders were found in the large observation area (CO).
c. Two type E oxygen cylinders were found in the holding area for hospital patients in the operating suite department.
d. Eight type E oxygen cylinders at the Delivery department.
e. Twelve type E oxygen cylinders at the central supply.
f. A type H and two type E oxygen cylinders were found at the Endoscopy department.
g. Six type E oxygen cylinders were found in a room at NICU/PICU.

2. During observations of the emergency room in the treatment area on 2/8/11 at 10:30 am an escort (employee #37) was observed wheeling in an empty stretcher that had a type E oxygen tank on it (the cylinder was not secured). Special care must be taken when transporting oxygen cylinders due to it high potential to explode.

3. During observations near the nuclear medicine department on 2/11/11 at 11:30 am an escort (employee #38) was observed wheeling in a stretcher with a patient that had a type E oxygen tank at the back of the stretcher that he was holding (the cylinder was not secured) and he was also pushing the stretcher. Special care must be taken when transporting oxygen cylinders due to it high potential to explode.

4. Floor plans throughout the hospital were observed from 2/8/11 through 2/11/11 from 8:00 am till 4:00 pm, too small to be easily read to identify where the individual is located and the nearest possible exit routes. Other findings related to the exit plans are the following:
a. Some exit plans are mounted too high on the walls and shall be placed to ensure visibility for all size persons.
b. The exit plans are removable and shall be fixed to the walls to avoid unauthorized removal.
c. The exit plans depict the entire floor and not just the area where the individual is located and the nearest exits. The entire floor lay out of the floor will distract persons from the needed information in the event of an emergency.
d. Some exit plans throughout the facility were evaluated for content and they were found to not be correct related to devices in the area (for example the third floor nursery exit plan and the exit plan outside of the Intensive Care Unit).

5. The exit door near patient's room 3701 was observed on 2/10/11 at 11:10 am with a facility Engineer (employee #5) and provided evidence that there was water on the floor and debris behind the door due to a broken pipe which did not allow the door to be fully opened.

6. During the observational tour of the kitchen on 2/10/11 at 8:30 am with a facility Engineer (employee #5) the following was determined:
a. The hood vents located above the cooking stoves were found with spaces between them which will not allow the vents to protect the duct system as designed.
b. Kitchen's hood exhaust system maintenance was requested, however no evidence was found of the updated required hood, duct and exhaust fans inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule.