HospitalInspections.org

Based on observation, the facility failed to maintain a 2 hour fire wall separations between building separations.

Findings include:

The fire wall which separates the South Tower from the Surgical Tower was reviewed where it bypasses the women's bath on second floor. There is a portion of the fire wall which is incomplete as it is only sheeted on one surface of the metal studs near the back wall of the bath above the ceiling tile.

Based on observations, it was determined that the facility failed to ensure that all fire rated construction was complete.

Findings include:

On 07/31/2012 on the Fourth Floor at 8:40 a.m., there was a section of interior wall missing in room 483.

Based on observations, the facility did not maintain the fire resistive rating of ceiling assemblies.

Findings include:

1. On 7/30/2012 at 4:03 p.m., several ceiling penetrations, where phone cable conduits enter the ceiling, were observed around electrical conduits in 313B - the electrical room on the third floor.

2. On 7/30/2012 at 4:26 p.m., several ceiling penetrations were observed around electrical conduits in 349A - an electrical closet on the third floor.

3. On 7/30/2012 at 4:34 p.m., ceiling tile in 358, the Counselor's Office, was wet and stained black in color. When examined further, a sweaty/leaky valve was observed with the removal of the damaged tile.

4. On 7/31/2012 at 8:47 a.m., the two ceiling tiles in room G007 were off track exposing hanging wires, cables and conduits above.

5. On 7/31/2012 at 11:46 a.m., one ceiling tile in the print shop was stained and had a missing corner, measuring approximately two by three inches.

6. On 7/31/2012 at 2:37 p.m., the ceiling tile was damaged (broken off) around the ceiling sprinkler head cover exposing an annular space between the tile and the sprinkler head in the Clean Lab Room in the lab.

7. On 7/31/2012 at 11:40 a.m., a ceiling tile at the west wall side in G071, old central supply room, was wet and stained. When examined, leaky/sweaty pipes were observed above the wet ceiling tile.

Based on observation, the facility failed to maintain walls in accordance with NFPA 101, Chapter 18.1.6.2.

Findings include:

In accordance with NFPA 101 and Section 18.1.6.2, health care occupancies shall be limited to the types of building construction shown in Table 18.1.6.2. (See 8.2.1.)
Exception: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class A requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly having not less than a 2-hour fire resistance rating that includes not less than 21/2 in. (6.4 cm) of concrete or gypsum fill. Structural elements supporting the 2-hour fire resistance-rated floor assembly shall be required to have only the fire resistance rating required of the building.
Table 18.1.6.2 Construction Type Limitations

Construction Type Stories
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X X NP
II(000) X NP NP NP
III(211) X NP NP NP
III(200) NP NP NP NP
IV(2HH) X NP NP NP
V(111) X NP NP NP
V(000) NP NP NP NP
X: Permitted type of construction.
NP: Not permitted.

Room 2417 on the south tower was observed at 8:00 a.m. on 7/31/2012. The sheet rock walls were damaged in two places where the wall board was damaged by carts and stored items.

Based on observation, the facility failed to remove raw wood surfaces after completing construction between floors.

Findings include:

The interior spaces above the Reading Room #4 were observed at 11:30 a.m. on 7/31/2012. Wood construction had been used to enclose a chute between floors on first and second floor. The raw wood had not been removed after concrete was poured over the wood forms between the floors.

Based on observations, the facility did not maintain the fire resistive construction of all corridor walls to resist the passage of smoke.

Findings include:

On 7/31/2012 at 8:04 a.m., an unsealed pipe/conduit, approximately one and one-half inch in diameter, penetrated the corridor wall above the door and the ceiling tiles in G101 Communication room.

Based on observations, it was determined that the facility failed to ensure that all corridor doors were not impeded from closing.

Findings include:

1. On 07/31/2012 at 8:17 a.m. on Fourth Floor, a water bottle rack blocked the corridor door from closing.

2. On 07/31/2012 at 11:30 a.m. on the Second Floor, the corridor door with self-closing hardware to room 2420 (HVAC room) would not closing to positive latching.

3. On 07/31/2012 at 1:35 p.m., one of two main entrance doors to the cafeteria would not close to positive latching.

4. On 07/31/2012 at 4:15 p.m., one of two corridor doors to the Biomedical/Housekeeping Department did not close to positive latching.


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5. The corridor door to Room 4 labeled with (143) on the frame above the door in the Emergency Room hall which exits to the east near the heliport was observed to have roller latching hardware as observed at 1:30 p.m. on 7/1/2012.

There is an exception for only bathroom doors having roller latches in existing health care facilities.

Based on observations, the facility did not maintain the one-hour fire resistance rating of all vertical openings at stairways.

Findings include:

On 7/31/2012 at 8:30 a.m., the door to the stairway for the employee entrance at the ground level was exercised. The door was held by a magnetic device. The door did not latch when released from the magnetic device three times.

Based on observations, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 18.3.1.1 of NFPA 101, 2000 edition; any vertical opening shall be enclosed or protected in accordance with Section 8.2.5 of the LSC. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 edition; 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/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

Data room 6134 on the sixth floor was observed at 4:30 p.m. on 7/30/2012. There were two vertical conduits through the ceiling of the data room between floors six and seven which were not sealed to maintain the fire resistance of a fire barrier. Vertical openings between floors must be enclosed with construction having a fire resistance rating of at least two hours when construction type of Type 1 (332).

Based on observations, it was determined that the facility failed to ensure that all doors requiring self-closing hardware closed to positive latching.

Findings include:

1. On 07/31/2012 at 7:31 a.m. on the Fifth Floor, the self-closing door at the west end stairwell did not close to positive latching.

2. On 08/01/2012 at 8:17 a.m. on the First Floor, a stairway door would not close to positive latching.

Based on observations, it was determined that the facility failed to ensure that all exit locations are adequately identified.

Findings include:

In accordance with NFPA 101, Section 7.10.1.4; access to exits is marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants.

On 08/01/2012 at 6:30 a.m. in the Operating Room (OR) Suite, there is no visible exit sign from the internal corridor by OR #6 to identity means of exiting to the other side of the smoke barrier doors.

Based on observation, the facility failed to identify exit access to exits with readily visible signs to reach exits which are not readily apparent to all occupants.

Findings include:

In accordance with NFPA 101, Chapter 7.10.1.4, access to exits is marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants.

The exiting for the Benefis Foundation was reviewed at 10:15 a.m. on 7/31/2012. There were no exit signs to direct one toward the south end of the building through the Radiology break room. In review, it was estimated that three additional signs would be required to make the exit access readily apparent to the occupants.

An interview with the Foundation Director revealed that board members met each month to carry on duties of board members.

Based on observations, it was determined that the facility failed to ensure that all smoke barriers are intact.

Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

1. On 07/30/2012 at 3:05 p.m., the west door of the smoke barrier doors on Eighth Floor did not close to positive latching when the door was released.

2. On 07/30/2012 on the Seventh Floor, there was an unsealed smoke barrier penetration in the smoke barrier.

3. On 07/31/2012 at 8:15 a.m. on the Fourth Floor, there was an unsealed penetration above smoke barrier doors.

4.On 7/31/2012 at 8:15 a.m. on the Fourth Floor, there was a two to three inch unsealed penetration in the smoke barrier separating the "gutted section " from the rest of the Fourth Floor.

5. On 07/31/2012 at 10:25 a.m., one of two smoke barrier doors located by the Security Office would not close to positive latching.

6. On 08/01/ 2012 at 6:30 a.m. in the OR Suite, one of two smoke barrier doors did not close to positive latching.

Based on observations, the facility failed to maintain the fire resistance rating of smoke barriers.
Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

The Data room on 1st floor was observed for penetrations at 9:45 a.m. on 7/31/2012. A two inch conduit through the wall was not sealed properly at the smoke barrier wall.

Based on observations, the facility did not maintain the fire/smoke resistance rating of walls and barriers.

Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

1. On 7/31/2012 at 10:37 a.m., the smoke barrier on the south wall of the 2nd floor over the restroom had an unsealed penetration measuring approximately four by four inches with communication wiring running through it and a two inch round penetration that was not properly sealed with fire stop material.

2. On 7/31/2012 at 11:28 a.m., the smoke barrier wall in the equipment depot room on the 1st floor had a one and one-half inch penetration that had been previously sealed with caulk; however, the caulk was hanging below the penetration.


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3. During the examination of the fire/smoke walls and barriers on 7/31/2012, the following concerns were observed at the ground level and the first floor (Staff member B accompanied the surveyor during the observations):

a) At 11:33 a.m., the fire rated sealant had became loose around a four inch conduit above the smoke barrier doors in the main corridor by G201, exposing the penetration on both sides of the wall.

b) At 12:02 p.m., an unsealed penetration around a pipe was found above the double doors, above valve 17, between rooms G102 and G103.

c) At 12:02 p.m., a three inch unsealed PVC pipe penetration was observed above the ceiling tiles above G101.

d) At 1:39 p.m., an unsealed two inch conduit penetration above the time clock, above the ceiling tiles, across from G058 was found.

e) At 2:00 p.m., two, two inch pipe penetrations through the concrete wall above the ceiling tiles on the north wall of the cubicle west of G034 were found unsealed.

f) At 2:07 p.m., an unsealed two inch open ended conduit, with a red colored cable, extended through the smoke wall above the ceiling tiles west of G030.

g) At 3:02 p.m., two unsealed air conditioning lines and one open ended conduit extended through the smoke wall to the west of room 1300 at the cardio/rehab wall on the first floor.

h) At 3:07 p.m., an unsealed wall penetration in the smoke wall, above the ceiling tiles, across from electrical closet 126, was not found.

Based on observations, the facility did not ensure all smoke/fire rated construction was protected from the passage of smoke by rated doors.

Findings include:

In accordance with NFPA 101 and 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 not less than 1/2 hour.

On 7/31/2012 at 8:45 a.m., the rated smoke barrier doors, found in the smoke/fire separation construction in the elevator corridor at Ground Level, were examined. The doors did not positively latch. At 3:55 p.m., the doors were examined again with the activation of the fire alarm. The doors failed to latch at this time also.

Based on observations, the facility failed to ensure that all corridor doors serving hazardous areas were equipped with with closing hardware.

Findings include:

In accordance with NFPA 101 and Section 19.3.2.1 Hazardous Areas; any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

On 07/31/2012 at 8:35 a.m. on the Fourth Floor, it was observed that room 475 was being used for combustible storage. The corridor door to this room was not equipped with self-closing hardware.

Based on observation, the facility did not ensure oxygen was stored properly.

Findings include:

In accordance with the guidance from the Centers for Medicare and Medicaid Services Survey and Certification Letter S&C-07-10 dated 1/12/2007, any nonflammable medical gas over 300 cu. ft. in volume (over 12 E Cylinders) cannot be located outside of an enclosure at locations open to the corridor such as at a nurse's station or in a exit corridor. And in accordance with NFPA 101 Life Safety Code (2000 edition), Chapter 38, Section 38.3.2, hazardous areas shall be protected in accordance with 8.4. Special Hazard Protection. Based on this guidance then a room with less than 3000 cubic feet of oxygen storage would have to meet NFPA 99 Section 4-3.1.1.2 (c) as follows: Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with. Section 4-3.1.1.2 states the walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.

On 8/1/2012 at 8:30 a.m., fifteen E size oxygen cylinders were stored in the nurses station in front of the Sample Medication room of the Pulmonary department on the third floor with other combustible materials, open to the exit/evacuation corridor. Additionally, these racked oxygen cylinders were stored on the carpeted floor. Oxygen must not be stored at locations open to the exit corridor and near combustible materials.

Based on observation, the facility did not maintain the fire/smoke rating of all hazardous areas.

Findings include:

On 7/31/2012 at 7:23 a.m., several unsealed wall penetrations around pipes and conduits were observed on the west wall of the Electrician Desk Room. The room shared a wall with the exit corridor on the west side.

Based on observations, the facility failed to ensure that all means of egress in stairwells were not obstructed.

Findings include:

In accordance with NFPA 101, Sections 19.3.1.1 and 8.2.5.2; exit components (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building.

1. On 07/30/2012 at 4:35 p.m. on the Fifth Floor of the North Tower, the west end stairwell across from room #508 was obstructed by a five gallon bucket and a "rolled up" section of rope.

2. On 07/31/2012 at 7:35 a.m. in the East stairwell of the North Tower, the means of egress in the stairwell was partially blocked by the presence of a yellow five gallon bucket sitting on the floor of a landing.

Based on observation, the facility failed to install self-closing devices on access doors which enclosed the sprinkler riser in the south stairway.

Findings include:

In accordance with NFPA 13, 1998 Edition, and Section 5-13.1.1; All concealed spaces enclosed wholly or partly by exposed combustible construction shall be protected by sprinklers. Exception No. 12: Pipe chases under 10 ft2 (0.93 m2) formed by studs or wood joists, provided that in multifloor buildings the chases are firestopped at each floor using materials equivalent to the floor construction. Such pipe chases shall contain no sources of ignition, piping shall be noncombustible, and pipe penetrations at each floor shall be properly sealed.

The enclosure for the sprinkler riser was observed at 1:50 p.m. on 7/30/2012 in the south stairway. The doors to the enclosure were not self-closing as required for a concealed space which is unsprinkled.

Based on observations, the facility failed to maintain all vertical openings, such as stair towers, with a fire resistant rating.

Findings include:

In accordance with Section 7.1.3.2.1 of NFPA 101, 2000 Edition; where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
Exception No. 1: In existing non-high-rise buildings, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 2: In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.

On 7/31/2012 at 8:55 a.m., an one-half inch unsealed open ended conduit pipe was observed in the south wall of the Rehab Unit stairwell.

Based on observations, the facility did not ensure that alternate exit discharges were clearly marked at all times at construction zones.

Findings include:

On 7/31/2012 at 10:50 a.m., the Roof Garden construction project was examined with staff member B. The first floor emergency exiting route was temporary closed. The public was directed from first floor to the ground level for emergency exiting at this juncture. However, the public was also directed to the first floor from the ground level for emergency exiting to the construction site where temporarily no emergency exiting was possible.

Based on observation, the facility did not ensure that a battery-powered emergency lighting was provided in the generator transfer switch room.

Findings include:

In accordance with NFPA 101 Life Safety Code 2000 Edition, Chapter 38, Section 38.2.9, emergency lighting shall be provided in accordance with Section 7.9 in any building where "the building is two or more stories in height above the level of discharge, the occupancy is subject to 50 or more occupants above or below the level of exit discharge. . . "

In accordance with 7.9 of the NFPA 101 Life Safety Code (LSC) 2000 Edition, the room housing the emergency generator and the generator transfer switches shall be provided with battery-powered emergency lighting. Additionally, in accordance with 7.9.3 of the LSC, a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

On 8/1/2012 at 9:38 a.m., the generator transfer switch room was inspected. The room did not have battery powered emergency lighting.

Based on observation, the facility failed to maintain the installed smoke detection system in accordance with the manufacturer's required specifications and NFPA 72, 1999 Edition.

Findings include:

In accordance with NFPA 72 and Section 7-3.1, visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.
Exception No. 1: Devices or equipment that is inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be inspected during scheduled shutdowns if approved by the authority having jurisdiction. Extended intervals shall not exceed 18 months.
Exception No. 2: If automatic inspection is performed at a frequency of not less than weekly by a remotely monitored fire alarm control unit specifically listed for such application, the visual inspection frequency shall be permitted to be annual. Table 7-3.1 shall apply. Table 7-3.1 Visual Inspection Frequencies requires that smoke detectors shall be visually inspected at least semiannually.

1. The stair tower on the south side of the South Tower was observed at 1:30 p.m. on 7/30/2012. The smoke detector on the ceiling of the stair tower was covered with a paper bag.

2. Electrical room 6175 on the South Tower sixth floor was observed at 3:00 p.m. on 7/30/2012. The room smoke detector was covered with a rubber glove.

Based on observation, the facility did not ensure that all portions of the building were protected by the automatic sprinkler system.

Findings include:

Sprinklers shall be installed under fixed obstructions over 4 feet wide such as ducts, decks, open grate flooring cutting tables, and overhead doors per section 5-5.5.3.1 of NFPA 13, 1999 Edition.

On 7/30/2012 at 3:40 p.m., there was no sprinkler coverage under the air over flow duct, where it was approximately 11 feet wide in the West Campus building penthouse.

Based on observations, the facility failed to assure that the automatic sprinkler system provided for complete coverage of all portions of the building.

Findings include:

In accordance with NFPA 13, Section 5-5.5.2, sprinklers shall be located so as to minimize obstructions to discharge as defined in Sections 5-5.5.2 and 5-5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard.

On 8/1/12 at 9:30 a.m., the walk-in cooler C-37 in the kitchen had a sprinkler head situated behind the condenser system. The sprinkler head was not adequate to provide coverage for the entire walk in cooler.

Based on observations, the facility failed to maintain the sprinkler system and its components in accordance with the standards of NFPA 13, 1999 Edition.

Findings include:

In accordance with NFPA 13 and Section 3-2.7.2, escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

1. On 7/31/2012 at 11:00 a.m., the escutcheon ring was missing from the ceiling sprinkler head in Clark room telephone room G238 ceiling.

2. On 7/31/2012 at 11:16 a.m., there was an annular space between the ceiling tile and the escutcheon ring in room G214B Information Systems.

Based on observations, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition.

Findings include:

In accordance with NFPA 25 and Section 2-2.1.1, sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. Further, unacceptable obstructions to spray patterns shall be corrected per section 2-2.1.2 of NFPA 25.

1. The south stairway in the South Tower was observed at 1:30 p.m. on 7/30/2012. There was tape over two sprinkler heads near the ceiling of this stairway.

2. The electrical room 6175 on the sixth floor was observed at 3:00 p.m. on 7/30/2012. The sprinkler head installed in this room was covered with duct tape.

3. The nutrition room 6142 on the sixth floor was observed at 3:30 p.m. on 7/30/2012. The sprinkler head installed in this room was covered with duct tape.

Based on observations, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition.

Findings include:

Unacceptable obstructions to spray patterns shall be corrected per section 2-2.1.2 of NFPA 25, 1998 Edition. Obstructions to spray patterns include horizontal obstructions near the ceiling, vertical obstructions, suspended or floor-mounted obstructions, and clearances between sprinklers and storage below. The distance from sprinklers to privacy curtains, free standing partitions, room dividers, and similar obstructions in light hazard occupancies shall be in accordance with Table 5-6.5.2.3 and Figure 5-6.5.2.3 of NFPA 13, 1999 Edition.

On 08/1/2012 at 9:30 a.m., the walk in cooler C29 and F28 had the orange clips used for installation of sprinkler heads still attached, preventing the sprinkler from activating.

Based on observations, it was determined that the facility failed to ensure that all requirements of NFPA 10 were being followed.

Findings include:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, (1998 Edition); portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet (60 Inches) above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet (42 inches) above the floor.

1. In the stairwell of "Stairway #2" which opens from the "gutted" section of the Fourth Floor, there were two unsecured fire extinguishers sitting on the stair landing.



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In accordance with 4-4.1 of NFPA 10 (1998 Edition) fire extinguishers shall be subject to maintenance at intervals of not more than 1 year. Furthermore, in accordance with 4-4.4 of NFPA 10, each extinguisher shall have a tag or label attached that indicates the month and year the maintenance was performed.

2. The two "K" type portable fire extinguishers located in the kitchen of the hospital had not received an annual service since July 2011.

Based on observation, the facility did not ensure all fire extinguishers were maintained properly.

Findings include:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, (1998 Edition); portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet (60 Inches) above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet (42 inches) above the floor.

On 8/1/2012 at 8:21 a.m., a fire extinguisher was free standing in the electrical room 4048 on the 4th floor.

Based on observations, the facility did not maintain portable extinguishers in accordance with the standards of NFPA 10.

Findings include:

In accordance with NFPA 10, 1998 Edition, and Section 5-6.4, fire extinguisher shells of the low-pressure type that pass a hydrostatic test shall have the test information recorded on a suitable metallic label or equally durable material with a minimum size of 2 in. 3 1/2 in. (5.1 cm 8.9 cm). The label shall be affixed to the shell by means of a heatless process and all old hydrostatic test labels shall be removed. These labels shall be of the type that self-destructs when removal from a fire extinguisher shell is attempted. The label shall include the following information:
(a) Month and year the test was performed, indicated by a perforation, such as is done by a hand punch
(b) Test pressure used
(c) Name or initials of person performing the test, and name of agency performing the test

1. On 7/31/2012 at 7:25 a.m., fire extinguisher #43 found in the generator room had a label affixed to the shell indicating it was last hydrotested in March of 2005. The fire extinguisher lacked a label distinguishing that the 6-year maintenance test had been performed on this unit in 2011.

In accordance with 1-6.7 and 1-6.10 of NFPA 10, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet (60 Inches) above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet (42 inches) above the floor.

2. On 7/31/2012 at 8:03 a.m., a fire extinguisher was sitting on the floor in the G101, Communication room.

3. On 7/31/2012 at 9:07 a.m., a fire extinguisher was sitting on the floor in the kitchen.

NFPA 10 and Section 5-2 , indicates that at intervals not exceeding those specified in Table 5-2, fire extinguishers shall be hydrostatically retested. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. (For nonrechargeable fire extinguishers, see the exception to 4-4.3.) Table 5-2 states that for wetting agent the frequencies is every 5 years.

4. On 7/31/2012 at 9:13 a.m., the K portable fire extinguisher was examined in the kitchen. The unit was manufactured in 2001. The unit was last hydrotested in 2006. It did not have a label indicating a hydrotest had been done in 2011 as required for K extinguishers.

NFPA 10 and specifically Section 2-3.2.1 requires the following: "A placard shall be conspicuously placed near the extinguisher that states that the fire protection system of the kitchen hood shall be activated prior to using the fire extinguisher."

5. At 9:15 a.m., the placard for this K extinguisher unit was not observed above or near the K extinguisher where it was hanging in the dish room. The placard was left by itself on the wall at the previous hanging location of this unit. The placard was placed on the wall approximately four feet away from the unit.

Based on observations, the facility did not maintain exit corridors free from obstructions that would interfere with their instant use in case of fire or other emergency.

Findings include:

In accordance with the Centers for Medicare and Medicaid Services Survey and Certification letters S&C-04-41 and S&C-10-18, items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor.

On 7/31/2012 at 7:55 a.m., several furniture pieces, TVs and other cardboard boxes of stored items were observed on the Loading/Garbage exit corridor. When asked during the observation, one house keeping staff stated that these obstructions were in the exit corridor over a month.

Based on observation, the facility did not ensure that all oxidizing gases were stored properly.

Findings include:

Locations for storage of nonflammable gases, including oxygen, of less than 3000 cubic feet shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting per section 4-3.1.1.2(c) of NFPA 99, 1999 Edition. If natural venting is used, the vent openings shall each be a minimum of 72 square inches in total free area. Where the location of the storage door opens onto an exit access corridor, louvered openings shall not be used.

On 7/31/2012 at 11:55 a.m., the oxygen storage room was examined and observed that the mechanical ventilation was not in operational condition. The motor to the ventilation unit was broken down. There were 44 E size cylinders stored in the room at the time of the observation.

Based on observation, the facility did not ensure all requirements of NFPA 99, 1999 Edition were met for oxygen storage.

Findings include:

In accordance with NFPA 99, Section 4-3.1.1.2(a)(4) requires that the electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code (NEC), for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

The oxygen storeroom on fourth floor of PCU was observed at 2:00 p.m. on 7/31/2012. The light switch was not located at least five feet above the floor, but was at approximately four feet.

Based on observation and interview with maintenance staff, the facility did not ensure that bulk medical gas systems that had been renovated or had components breached were inspected and tested in accordance with NFPA 99, 1999 Edition and NFPA 50, 1996 Edition.

Findings include:

In accordance with NFPA 99 and section (b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3) the following applies:
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites. Further in accordance with NFPA 50, Chapter 4-2.1; each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Further, in accordance with NFPA 99, 1999 Edition, and Section 4-3.4.1.1, inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
This inspection and testing shall include all components of the system or portions thereof including, but not limited to, gas bulk source(s), manifolds, compressed air source systems (e.g., compressors, dryers, filters, regulators), source alarms and monitoring safeguards, master alarms, pipelines, isolation valves, area alarms, zone valves, and station inlets (vacuum) and outlets (pressure gases).
All systems that are breached and components that are subject to additions, renovations, or replacement (e.g., new gas sources-bulk, manifolds, compressors, dryers, alarms) shall be inspected and appropriately tested.
Systems shall be deemed breached at the point of pipeline intrusion by physical separation or by system component removal, replacement, or addition. The breached portions of the systems subject to inspection and testing shall be confined to only the specific altered zone and components in the immediate zone or area that is located upstream for vacuum systems and downstream for pressure gases at the point or area of intrusion.
The inspection and testing reports shall be verified and a certificate and submitted directly to the party that contracted for the testing. That party shall then submit the report through channels to the responsible authority and any others that are required. These reports shall contain detailed listings of all findings and results.
The responsible facility authority shall review these inspection and testing records prior to the use of all systems. This responsible facility authority shall ensure that all findings and results of the inspection and testing have been successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility.
Before piping systems are initially put into use, the health care facility authority shall be responsible for ascertaining that the gas delivered at the outlet is that shown on the outlet label and that the proper connecting fittings are checked against their labels. This can be accomplished by accepting the results of 4-3.4.1.3, System Verification.
Manufactured assemblies shall, prior to arrival at the installation site, be pretested to comply with 4-3.4.1.2(a) through 4-3.4.1.2(e), except that 4-3.4.1.2(c) shall be permitted to be performed by any leak testing method that will assure a pressure decay of less than 1 percent in 24 hours. The manufacturer shall provide documentation attesting to the performance and successful completion of these tests.

Inspection and testing reports for the bulk medical gas system were reviewed on 7/31/2012. The most recent report was dated 6/16/2007 for the west campus building. NFPA 99, Chapter 4-2.1 requires bulk oxygen systems to be inspected annually by a certified verifier.

Interview with maintenance staff at 4:35 p.m. on 8/1/2012, revealed that no further testing had been done on the medical gas system since the 6/16/2007 report. Many areas of the surgical tower had been renovated and a new inspection and testing certification had not been done on the updated medical gas system to ensure the systems integrity has been achieved and maintained.

Based on observation and interview with maintenance staff, the facility did not ensure that bulk medical gas systems that had been renovated or had components breached were inspected and tested in accordance with NFPA 99, 1999 Edition and NFPA 50, 1996 Edition.

Findings include:

In accordance with NFPA 99 and section (b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3) the following applies:
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites. Further in accordance with NFPA 50, Chapter 4-2.1; each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Further, in accordance with NFPA 99, 1999 Edition, and Section 4-3.4.1.1, inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
This inspection and testing shall include all components of the system or portions thereof including, but not limited to, gas bulk source(s), manifolds, compressed air source systems (e.g., compressors, dryers, filters, regulators), source alarms and monitoring safeguards, master alarms, pipelines, isolation valves, area alarms, zone valves, and station inlets (vacuum) and outlets (pressure gases).
All systems that are breached and components that are subject to additions, renovations, or replacement (e.g., new gas sources-bulk, manifolds, compressors, dryers, alarms) shall be inspected and appropriately tested.
Systems shall be deemed breached at the point of pipeline intrusion by physical separation or by system component removal, replacement, or addition. The breached portions of the systems subject to inspection and testing shall be confined to only the specific altered zone and components in the immediate zone or area that is located upstream for vacuum systems and downstream for pressure gases at the point or area of intrusion.
The inspection and testing reports shall be verified and a certificate and submitted directly to the party that contracted for the testing. That party shall then submit the report through channels to the responsible authority and any others that are required. These reports shall contain detailed listings of all findings and results.
The responsible facility authority shall review these inspection and testing records prior to the use of all systems. This responsible facility authority shall ensure that all findings and results of the inspection and testing have been successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility.
Before piping systems are initially put into use, the health care facility authority shall be responsible for ascertaining that the gas delivered at the outlet is that shown on the outlet label and that the proper connecting fittings are checked against their labels. This can be accomplished by accepting the results of 4-3.4.1.3, System Verification.
Manufactured assemblies shall, prior to arrival at the installation site, be pretested to comply with 4-3.4.1.2(a) through 4-3.4.1.2(e), except that 4-3.4.1.2(c) shall be permitted to be performed by any leak testing method that will assure a pressure decay of less than 1 percent in 24 hours. The manufacturer shall provide documentation attesting to the performance and successful completion of these tests.

Inspection and testing reports for the bulk medical gas system were reviewed on 7/31/2012. The most recent report was dated 6/16/2007 for the west campus building.

Interview with maintenance staff at 4:35 p.m. on 8/1/2012, revealed that no further testing had been done on the medical gas system since the 6/16/2007 report. Many areas of the north tower had been renovated and a new inspection and testing certification had not been done on the updated medical gas system to ensure the systems integrity has been acheived and maintained.

Based on observation and interview with maintenance staff, the facility did not ensure that bulk medical gas systems that had been renovated or had components breached were inspected and tested in accordance with NFPA 99, 1999 Edition and NFPA 50, 1996 Edition.

Findings include:

In accordance with NFPA 99 and section (b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3) the following applies:
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites. Further in accordance with NFPA 50, Chapter 4-2.1; each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Further, in accordance with NFPA 99, 1999 Edition, and Section 4-3.4.1.1, inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
This inspection and testing shall include all components of the system or portions thereof including, but not limited to, gas bulk source(s), manifolds, compressed air source systems (e.g., compressors, dryers, filters, regulators), source alarms and monitoring safeguards, master alarms, pipelines, isolation valves, area alarms, zone valves, and station inlets (vacuum) and outlets (pressure gases).
All systems that are breached and components that are subject to additions, renovations, or replacement (e.g., new gas sources-bulk, manifolds, compressors, dryers, alarms) shall be inspected and appropriately tested.
Systems shall be deemed breached at the point of pipeline intrusion by physical separation or by system component removal, replacement, or addition. The breached portions of the systems subject to inspection and testing shall be confined to only the specific altered zone and components in the immediate zone or area that is located upstream for vacuum systems and downstream for pressure gases at the point or area of intrusion.
The inspection and testing reports shall be verified and a certificate and submitted directly to the party that contracted for the testing. That party shall then submit the report through channels to the responsible authority and any others that are required. These reports shall contain detailed listings of all findings and results.
The responsible facility authority shall review these inspection and testing records prior to the use of all systems. This responsible facility authority shall ensure that all findings and results of the inspection and testing have been successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility.
Before piping systems are initially put into use, the health care facility authority shall be responsible for ascertaining that the gas delivered at the outlet is that shown on the outlet label and that the proper connecting fittings are checked against their labels. This can be accomplished by accepting the results of 4-3.4.1.3, System Verification.
Manufactured assemblies shall, prior to arrival at the installation site, be pretested to comply with 4-3.4.1.2(a) through 4-3.4.1.2(e), except that 4-3.4.1.2(c) shall be permitted to be performed by any leak testing method that will assure a pressure decay of less than 1 percent in 24 hours. The manufacturer shall provide documentation attesting to the performance and successful completion of these tests.

Inspection and testing reports for the bulk medical gas system were reviewed on 7/31/2012. The most recent report was dated 6/16/2007 for the west campus building.

Interview with maintenance staff at 4:35 p.m. on 8/1/2012, revealed that no further testing had been done on the medical gas system since the 6/16/2007 report. Many areas of the west campus had been renovated and a new inspection and testing certification had not been done on the updated medical gas system to ensure the systems integrity has been achieved and maintained.

Based on observation and interview with maintenance staff, the facility did not ensure that bulk medical gas systems that had been renovated or had components breached were inspected and tested in accordance with NFPA 99, 1999 Edition and NFPA 50, 1996 Edition.

Findings include:

In accordance with NFPA 99 and section (b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3) the following applies:
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites. Further in accordance with NFPA 50, Chapter 4-2.1; each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Further, in accordance with NFPA 99, 1999 Edition, and Section 4-3.4.1.1, inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
This inspection and testing shall include all components of the system or portions thereof including, but not limited to, gas bulk source(s), manifolds, compressed air source systems (e.g., compressors, dryers, filters, regulators), source alarms and monitoring safeguards, master alarms, pipelines, isolation valves, area alarms, zone valves, and station inlets (vacuum) and outlets (pressure gases).
All systems that are breached and components that are subject to additions, renovations, or replacement (e.g., new gas sources-bulk, manifolds, compressors, dryers, alarms) shall be inspected and appropriately tested.
Systems shall be deemed breached at the point of pipeline intrusion by physical separation or by system component removal, replacement, or addition. The breached portions of the systems subject to inspection and testing shall be confined to only the specific altered zone and components in the immediate zone or area that is located upstream for vacuum systems and downstream for pressure gases at the point or area of intrusion.
The inspection and testing reports shall be verified and a certificate and submitted directly to the party that contracted for the testing. That party shall then submit the report through channels to the responsible authority and any others that are required. These reports shall contain detailed listings of all findings and results.
The responsible facility authority shall review these inspection and testing records prior to the use of all systems. This responsible facility authority shall ensure that all findings and results of the inspection and testing have been successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility.
Before piping systems are initially put into use, the health care facility authority shall be responsible for ascertaining that the gas delivered at the outlet is that shown on the outlet label and that the proper connecting fittings are checked against their labels. This can be accomplished by accepting the results of 4-3.4.1.3, System Verification.
Manufactured assemblies shall, prior to arrival at the installation site, be pretested to comply with 4-3.4.1.2(a) through 4-3.4.1.2(e), except that 4-3.4.1.2(c) shall be permitted to be performed by any leak testing method that will assure a pressure decay of less than 1 percent in 24 hours. The manufacturer shall provide documentation attesting to the performance and successful completion of these tests.

Inspection and testing reports for the bulk medical gas system were reviewed on 7/31/2012. The most recent report was dated July 2009 for the South Tower on East Campus. NFPA 99, Section 4-2.1 requires bulk oxygen systems to be inspected annually by a certified verifier.

Interview with maintenance staff at 4:35 p.m. on 8/1/2012, revealed that no further testing had been done on the medical gas system since the July 2009 report.

Based on observation, the facility did not secure empty acetylene tanks and did not ensure an electric heater was safely used and stored away from combustibles.

Findings include:

Freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per sections 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99, 1999 Edition.

1. On 7/31/12 at 7:33 a.m., an acetylene tank was observed outside the boiler room. The pressurized tank was free standing in a corner of a fenced area and was not secured properly.

In accordance to NFPA 70, Chapter 4 -424-20(a) which states:
Thermostatically controlled switching devices and combination thermostats and manually controlled switches shall be permitted to serve as both controllers and disconnecting means, provided all of the following conditions are met:
1. Provided with a marked "off " position
2. Directly open all ungrounded conductors when manually placed in the " off " position
3. Designed so that the circuit cannot be energized automatically after the device has been manually placed in the "off" position
4. Located as specified in Section 424-19.

2. On 7/31/12, an observation of an electric heater in office 1514 revealed a foot rest pushed against the heater. The controls for the electric heater were attached to the front of the desk and the control knob was missing, making it visually impossible to determine if the heater was on or off.

Based on observations, it was determined that the facility failed to ensure that all gas/vacuum lines were properly deactivated.

Findings include:

On 07/31/2012 at 9:12 a.m. on the " vacated " Third Floor, a gas/vacuum panel was examined. Although gas /vacuums system were to have been deactivated, " Line Pressure Abnormal " was illuminated. The audible signal was active and needed to be silenced by staff personnel.

Based on observations, it was determined that the facility failed to ensure that all requirements for identifying the location of oxygen storage was properly labeled and identified.

Findings include:

In accordance with NFPA 99, 1999 Edition, Section 8-3.1.11.3 Signs; a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

All room locations of oxygen storage in the North Tower lack the mininum posting requirements.

Based on observation, the facility did not ensure medical gas storage areas had proper signage for No Smoking.

Findings include:

In accordance with NFPA 99, 1999 Edition, Section 8-3.1.11.3 Signs; a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

At 11:55 a.m. on 7/31/2012, the oxygen storage room located next to the Print Shop on the ground level lacked the minimum signage requirements for oxygen store rooms. The room contained 44 E size oxygen cylinders.

Based on observations, the facility failed to post a non-smoking or no smoking sign at a location where oxygen was being stored.

Findings include:

In accordance with Section 18.3.2.4 of NFPA 101 and Section 8-3.1.11.3 of NFPA 99 requires that a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

On 7/31/2012 at 12:30 p.m., the oxygen storage rooms in the South Tower lacked signage denoting the minimum wording.

Based on observations, the facility failed to post a non-smoking or no smoking sign at a location where oxygen was being stored.

Findings include:

In accordance with Section 19.3.2.4 of NFPA 101 and Section 8-3.1.11.3 of NFPA 99 requires that a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

On 8/1/2012 at 1:30 p.m., the oxygen storage rooms in the Surgical Tower lacked signage denoting the minimum of "Caution, Oxidizing Gas(es) Stored Within, No Smoking".

Based on observations, it was determined that the facility failed to ensure that all requirements of the National Electrical Code (NFPA 70) were followed.

Findings include:

Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals per Article 400-10 of NFPA 70.

1. On 07/30/2012 on the Sixth Floor at 4:03 p.m., there was an unsecured power strip hanging for an electrical outlet in the staff break room.

In accordance with Article 110-26 and table 110-26(a) of NFPA 70 there shall be maintained a clear working space of at least 36" around electrical equipment such as panel boards to permit ready and safe operations of such equipment. This working space can not be used for storage purposes.

2. On 08/01/2012 at 9:46 a.m. on the First Floor in room 1047A, electrical panel "D.W 1120/208 3PH OMB-1" had access blocked by cardboard boxes, metal equipment and other materials in front of the panel.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

3. On 08/01/2012 at 9:13 a.m. on First Floor in room 1317 HVAC, there was no legend posted in electrical panel "Panel AG MSB-4."

4. On 08/01/2012 at 9:14 a.m. on First Floor in room 1227, there was wooden pallet blocking access to electrical panel "Panel EL 120/208V/30W"

In completed installations, each box shall have a cover, faceplate, or fixture canopy according to Artilce 370-25.

5. On 08/01/2012 at 9:15 a.m. on First Floor in room 1227, there was an uncovered electrical junction box exposing four unconnected wires.

6. On 7/31/2012 at 1:25 p.m. on the First Floor in room 2420, there was an electrical outlet which lacked a cover plate.

7. On 7/31/2012 at 4:25 p.m. on the First Floor in the Biomedical/Housekeeping Department, there was an electrical junction box which lacked a cover plate.

Based on observations, the facility did not maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition.

Findings include:

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

1. On 8/1/2012 at 8:33 a.m., circuit breaker 30 in electrical panel L312 (3rd Floor) was in the on position; however, it was marked as a spare on the panel directory.

2. On 8/1/2012 at 8:45 a.m., circuit breakers 11, 12, 13, & 15 in electrical panel L317 were in the on position; however, they were marked as spares on the panel directory.

3. On 8/1/2012 at 9:00 a.m., circuit breaker 25 in electrical panel L213 was in the on position; however, it was marked as a spare in the panel directory.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition.

Findings include:

In accordance with NFPA 70 and Article 380-3(a); switches and circuit breakers shall be of the externally operable type mounted in an enclosure listed for the intended use.

The electrical room on seventh floor of the South Tower was observed at 1:55 p.m. on 7/30/2012. The electrical panel labeled CR74 had a cover which was loosely installed. The clips which held the face of the panel in the closed position did not seal tight to ensure that the electrical panel was tightly closed.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings. In accordance with UL listing for power strips. Relocatable power taps as identified under UL standard 1363 and listings starting with XBYS. There must be a reset or test button identified for the circuit breaker to be reset.

A medical staff office in the business section of the Surgical Tower was observed at 3:00 p.m. on 7/31/2012. An orange extension cord was found connected to a small stapler in this office.

Note: The extension cord was removed from under the desk in the medical staff office by maintenance staff at the time of the survey process.

Based on observation, the facility did not maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition and NFPA 99, 1999 Edition.

Findings include:

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

1. On 7/30/12 at 4:17 p.m., the following was observed in Electrical Room 313B:

a) Circuit breaker #42 was in the on position but was marked as a spare in the panel directory and circuit breaker #12 was in the on position and was crossed out in the panel directory.

b) Circuit breaker #44 was in the on position but marked as a spare in the panel directory.

In completed installations, each box shall have a cover, faceplate, or fixture canopy according to Article 370-25.

2. On 7/31/12 at 7:15 a.m., an electrical outlet was observed on the east wall of the electrician desk room, without an outlet cover.


18076


3. On 7/30/2012 at 4:15 p.m. the following was observed in electrical room 313B:

a) Electrical Panel E3A had the circuit breaker #s 26, 28, and 30 were in the on position, but they were not identified on the panel directory.

b) Electrical Panel EM3A had circuit breaker #48 in the on position and the electrical panel directory was blank. Secondly, circuit breaker #65 was in the off position, the electrical panel directory was blank.

4. On 7/31/2012 at 1:45 p.m., circuit breaker #s 2 through 18 in an electrical panel in G040 were all in the on positions. The unit lacked a panel directory identifying circuits.

Based on observation, the facility failed to maintain a 2 hour fire wall separations between building separations.

Findings include:

The fire wall which separates the South Tower from the Surgical Tower was reviewed where it bypasses the women's bath on second floor. There is a portion of the fire wall which is incomplete as it is only sheeted on one surface of the metal studs near the back wall of the bath above the ceiling tile.

Based on observations, it was determined that the facility failed to ensure that all fire rated construction was complete.

Findings include:

On 07/31/2012 on the Fourth Floor at 8:40 a.m., there was a section of interior wall missing in room 483.

Based on observations, the facility did not maintain the fire resistive rating of ceiling assemblies.

Findings include:

1. On 7/30/2012 at 4:03 p.m., several ceiling penetrations, where phone cable conduits enter the ceiling, were observed around electrical conduits in 313B - the electrical room on the third floor.

2. On 7/30/2012 at 4:26 p.m., several ceiling penetrations were observed around electrical conduits in 349A - an electrical closet on the third floor.

3. On 7/30/2012 at 4:34 p.m., ceiling tile in 358, the Counselor's Office, was wet and stained black in color. When examined further, a sweaty/leaky valve was observed with the removal of the damaged tile.

4. On 7/31/2012 at 8:47 a.m., the two ceiling tiles in room G007 were off track exposing hanging wires, cables and conduits above.

5. On 7/31/2012 at 11:46 a.m., one ceiling tile in the print shop was stained and had a missing corner, measuring approximately two by three inches.

6. On 7/31/2012 at 2:37 p.m., the ceiling tile was damaged (broken off) around the ceiling sprinkler head cover exposing an annular space between the tile and the sprinkler head in the Clean Lab Room in the lab.

7. On 7/31/2012 at 11:40 a.m., a ceiling tile at the west wall side in G071, old central supply room, was wet and stained. When examined, leaky/sweaty pipes were observed above the wet ceiling tile.

Based on observation, the facility failed to maintain walls in accordance with NFPA 101, Chapter 18.1.6.2.

Findings include:

In accordance with NFPA 101 and Section 18.1.6.2, health care occupancies shall be limited to the types of building construction shown in Table 18.1.6.2. (See 8.2.1.)
Exception: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class A requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly having not less than a 2-hour fire resistance rating that includes not less than 21/2 in. (6.4 cm) of concrete or gypsum fill. Structural elements supporting the 2-hour fire resistance-rated floor assembly shall be required to have only the fire resistance rating required of the building.
Table 18.1.6.2 Construction Type Limitations

Construction Type Stories
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X X NP
II(000) X NP NP NP
III(211) X NP NP NP
III(200) NP NP NP NP
IV(2HH) X NP NP NP
V(111) X NP NP NP
V(000) NP NP NP NP
X: Permitted type of construction.
NP: Not permitted.

Room 2417 on the south tower was observed at 8:00 a.m. on 7/31/2012. The sheet rock walls were damaged in two places where the wall board was damaged by carts and stored items.

Based on observation, the facility failed to remove raw wood surfaces after completing construction between floors.

Findings include:

The interior spaces above the Reading Room #4 were observed at 11:30 a.m. on 7/31/2012. Wood construction had been used to enclose a chute between floors on first and second floor. The raw wood had not been removed after concrete was poured over the wood forms between the floors.

Based on observations, the facility did not maintain the fire resistive construction of all corridor walls to resist the passage of smoke.

Findings include:

On 7/31/2012 at 8:04 a.m., an unsealed pipe/conduit, approximately one and one-half inch in diameter, penetrated the corridor wall above the door and the ceiling tiles in G101 Communication room.

Based on observations, it was determined that the facility failed to ensure that all corridor doors were not impeded from closing.

Findings include:

1. On 07/31/2012 at 8:17 a.m. on Fourth Floor, a water bottle rack blocked the corridor door from closing.

2. On 07/31/2012 at 11:30 a.m. on the Second Floor, the corridor door with self-closing hardware to room 2420 (HVAC room) would not closing to positive latching.

3. On 07/31/2012 at 1:35 p.m., one of two main entrance doors to the cafeteria would not close to positive latching.

4. On 07/31/2012 at 4:15 p.m., one of two corridor doors to the Biomedical/Housekeeping Department did not close to positive latching.


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5. The corridor door to Room 4 labeled with (143) on the frame above the door in the Emergency Room hall which exits to the east near the heliport was observed to have roller latching hardware as observed at 1:30 p.m. on 7/1/2012.

There is an exception for only bathroom doors having roller latches in existing health care facilities.

Based on observations, the facility did not maintain the one-hour fire resistance rating of all vertical openings at stairways.

Findings include:

On 7/31/2012 at 8:30 a.m., the door to the stairway for the employee entrance at the ground level was exercised. The door was held by a magnetic device. The door did not latch when released from the magnetic device three times.

Based on observations, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 18.3.1.1 of NFPA 101, 2000 edition; any vertical opening shall be enclosed or protected in accordance with Section 8.2.5 of the LSC. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 edition; 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/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

Data room 6134 on the sixth floor was observed at 4:30 p.m. on 7/30/2012. There were two vertical conduits through the ceiling of the data room between floors six and seven which were not sealed to maintain the fire resistance of a fire barrier. Vertical openings between floors must be enclosed with construction having a fire resistance rating of at least two hours when construction type of Type 1 (332).

Based on observations, it was determined that the facility failed to ensure that all doors requiring self-closing hardware closed to positive latching.

Findings include:

1. On 07/31/2012 at 7:31 a.m. on the Fifth Floor, the self-closing door at the west end stairwell did not close to positive latching.

2. On 08/01/2012 at 8:17 a.m. on the First Floor, a stairway door would not close to positive latching.

Based on observations, it was determined that the facility failed to ensure that all exit locations are adequately identified.

Findings include:

In accordance with NFPA 101, Section 7.10.1.4; access to exits is marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants.

On 08/01/2012 at 6:30 a.m. in the Operating Room (OR) Suite, there is no visible exit sign from the internal corridor by OR #6 to identity means of exiting to the other side of the smoke barrier doors.

Based on observation, the facility failed to identify exit access to exits with readily visible signs to reach exits which are not readily apparent to all occupants.

Findings include:

In accordance with NFPA 101, Chapter 7.10.1.4, access to exits is marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants.

The exiting for the Benefis Foundation was reviewed at 10:15 a.m. on 7/31/2012. There were no exit signs to direct one toward the south end of the building through the Radiology break room. In review, it was estimated that three additional signs would be required to make the exit access readily apparent to the occupants.

An interview with the Foundation Director revealed that board members met each month to carry on duties of board members.

Based on observations, it was determined that the facility failed to ensure that all smoke barriers are intact.

Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

1. On 07/30/2012 at 3:05 p.m., the west door of the smoke barrier doors on Eighth Floor did not close to positive latching when the door was released.

2. On 07/30/2012 on the Seventh Floor, there was an unsealed smoke barrier penetration in the smoke barrier.

3. On 07/31/2012 at 8:15 a.m. on the Fourth Floor, there was an unsealed penetration above smoke barrier doors.

4.On 7/31/2012 at 8:15 a.m. on the Fourth Floor, there was a two to three inch unsealed penetration in the smoke barrier separating the "gutted section " from the rest of the Fourth Floor.

5. On 07/31/2012 at 10:25 a.m., one of two smoke barrier doors located by the Security Office would not close to positive latching.

6. On 08/01/ 2012 at 6:30 a.m. in the OR Suite, one of two smoke barrier doors did not close to positive latching.

Based on observations, the facility failed to maintain the fire resistance rating of smoke barriers.
Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

The Data room on 1st floor was observed for penetrations at 9:45 a.m. on 7/31/2012. A two inch conduit through the wall was not sealed properly at the smoke barrier wall.

Based on observations, the facility did not maintain the fire/smoke resistance rating of walls and barriers.

Findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

1. On 7/31/2012 at 10:37 a.m., the smoke barrier on the south wall of the 2nd floor over the restroom had an unsealed penetration measuring approximately four by four inches with communication wiring running through it and a two inch round penetration that was not properly sealed with fire stop material.

2. On 7/31/2012 at 11:28 a.m., the smoke barrier wall in the equipment depot room on the 1st floor had a one and one-half inch penetration that had been previously sealed with caulk; however, the caulk was hanging below the penetration.


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3. During the examination of the fire/smoke walls and barriers on 7/31/2012, the following concerns were observed at the ground level and the first floor (Staff member B accompanied the surveyor during the observations):

a) At 11:33 a.m., the fire rated sealant had became loose around a four inch conduit above the smoke barrier doors in the main corridor by G201, exposing the penetration on both sides of the wall.

b) At 12:02 p.m., an unsealed penetration around a pipe was found above the double doors, above valve 17, between rooms G102 and G103.

c) At 12:02 p.m., a three inch unsealed PVC pipe penetration was observed above the ceiling tiles above G101.

d) At 1:39 p.m., an unsealed two inch conduit penetration above the time clock, above the ceiling tiles, across from G058 was found.

e) At 2:00 p.m., two, two inch pipe penetrations through the concrete wall above the ceiling tiles on the north wall of the cubicle west of G034 were found unsealed.

f) At 2:07 p.m., an unsealed two inch open ended conduit, with a red colored cable, extended through the smoke wall above the ceiling tiles west of G030.

g) At 3:02 p.m., two unsealed air conditioning lines and one open ended conduit extended through the smoke wall to the west of room 1300 at the cardio/rehab wall on the first floor.

h) At 3:07 p.m., an unsealed wall penetration in the smoke wall, above the ceiling tiles, across from electrical closet 126, was not found.

Based on observations, the facility did not ensure all smoke/fire rated construction was protected from the passage of smoke by rated doors.

Findings include:

In accordance with NFPA 101 and 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 not less than 1/2 hour.

On 7/31/2012 at 8:45 a.m., the rated smoke barrier doors, found in the smoke/fire separation construction in the elevator corridor at Ground Level, were examined. The doors did not positively latch. At 3:55 p.m., the doors were examined again with the activation of the fire alarm. The doors failed to latch at this time also.

Based on observations, the facility failed to ensure that all corridor doors serving hazardous areas were equipped with with closing hardware.

Findings include:

In accordance with NFPA 101 and Section 19.3.2.1 Hazardous Areas; any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

On 07/31/2012 at 8:35 a.m. on the Fourth Floor, it was observed that room 475 was being used for combustible storage. The corridor door to this room was not equipped with self-closing hardware.

Based on observation, the facility did not ensure oxygen was stored properly.

Findings include:

In accordance with the guidance from the Centers for Medicare and Medicaid Services Survey and Certification Letter S&C-07-10 dated 1/12/2007, any nonflammable medical gas over 300 cu. ft. in volume (over 12 E Cylinders) cannot be located outside of an enclosure at locations open to the corridor such as at a nurse's station or in a exit corridor. And in accordance with NFPA 101 Life Safety Code (2000 edition), Chapter 38, Section 38.3.2, hazardous areas shall be protected in accordance with 8.4. Special Hazard Protection. Based on this guidance then a room with less than 3000 cubic feet of oxygen storage would have to meet NFPA 99 Section 4-3.1.1.2 (c) as follows: Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with. Section 4-3.1.1.2 states the walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.

On 8/1/2012 at 8:30 a.m., fifteen E size oxygen cylinders were stored in the nurses station in front of the Sample Medication room of the Pulmonary department on the third floor with other combustible materials, open to the exit/evacuation corridor. Additionally, these racked oxygen cylinders were stored on the carpeted floor. Oxygen must not be stored at locations open to the exit corridor and near combustible materials.

Based on observation, the facility did not maintain the fire/smoke rating of all hazardous areas.

Findings include:

On 7/31/2012 at 7:23 a.m., several unsealed wall penetrations around pipes and conduits were observed on the west wall of the Electrician Desk Room. The room shared a wall with the exit corridor on the west side.

Based on observations, the facility failed to ensure that all means of egress in stairwells were not obstructed.

Findings include:

In accordance with NFPA 101, Sections 19.3.1.1 and 8.2.5.2; exit components (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building.

1. On 07/30/2012 at 4:35 p.m. on the Fifth Floor of the North Tower, the west end stairwell across from room #508 was obstructed by a five gallon bucket and a "rolled up" section of rope.

2. On 07/31/2012 at 7:35 a.m. in the East stairwell of the North Tower, the means of egress in the stairwell was partially blocked by the presence of a yellow five gallon bucket sitting on the floor of a landing.

Based on observation, the facility failed to install self-closing devices on access doors which enclosed the sprinkler riser in the south stairway.

Findings include:

In accordance with NFPA 13, 1998 Edition, and Section 5-13.1.1; All concealed spaces enclosed wholly or partly by exposed combustible construction shall be protected by sprinklers. Exception No. 12: Pipe chases under 10 ft2 (0.93 m2) formed by studs or wood joists, provided that in multifloor buildings the chases are firestopped at each floor using materials equivalent to the floor construction. Such pipe chases shall contain no sources of ignition, piping shall be noncombustible, and pipe penetrations at each floor shall be properly sealed.

The enclosure for the sprinkler riser was observed at 1:50 p.m. on 7/30/2012 in the south stairway. The doors to the enclosure were not self-closing as required for a concealed space which is unsprinkled.

Based on observations, the facility failed to maintain all vertical openings, such as stair towers, with a fire resistant rating.

Findings include:

In accordance with Section 7.1.3.2.1 of NFPA 101, 2000 Edition; where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
Exception No. 1: In existing non-high-rise buildings, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 2: In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.

On 7/31/2012 at 8:55 a.m., an one-half inch unsealed open ended conduit pipe was observed in the south wall of the Rehab Unit stairwell.

Based on observations, the facility did not ensure that alternate exit discharges were clearly marked at all times at construction zones.

Findings include:

On 7/31/2012 at 10:50 a.m., the Roof Garden construction project was examined with staff member B. The first floor emergency exiting route was temporary closed. The public was directed from first floor to the ground level for emergency exiting at this juncture. However, the public was also directed to the first floor from the ground level for emergency exiting to the construction site where temporarily no emergency exiting was possible.

Based on observation, the facility did not ensure that a battery-powered emergency lighting was provided in the generator transfer switch room.

Findings include:

In accordance with NFPA 101 Life Safety Code 2000 Edition, Chapter 38, Section 38.2.9, emergency lighting shall be provided in accordance with Section 7.9 in any building where "the building is two or more stories in height above the level of discharge, the occupancy is subject to 50 or more occupants above or below the level of exit discharge. . . "

In accordance with 7.9 of the NFPA 101 Life Safety Code (LSC) 2000 Edition, the room housing the emergency generator and the generator transfer switches shall be provided with battery-powered emergency lighting. Additionally, in accordance with 7.9.3 of the LSC, a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

On 8/1/2012 at 9:38 a.m., the generator transfer switch room was inspected. The room did not have battery powered emergency lighting.

Based on observation, the facility failed to maintain the installed smoke detection system in accordance with the manufacturer's required specifications and NFPA 72, 1999 Edition.

Findings include:

In accordance with NFPA 72 and Section 7-3.1, visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.
Exception No. 1: Devices or equipment that is inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be inspected during scheduled shutdowns if approved by the authority having jurisdiction. Extended intervals shall not exceed 18 months.
Exception No. 2: If automatic inspection is performed at a frequency of not less than weekly by a remotely monitored fire alarm control unit specifically listed for such application, the visual inspection frequency shall be permitted to be annual. Table 7-3.1 shall apply. Table 7-3.1 Visual Inspection Frequencies requires that smoke detectors shall be visually inspected at least semiannually.

1. The stair tower on the south side of the South Tower was observed at 1:30 p.m. on 7/30/2012. The smoke detector on the ceiling of the stair tower was covered with a paper bag.

2. Electrical room 6175 on the South Tower sixth floor was observed at 3:00 p.m. on 7/30/2012. The room smoke detector was covered with a rubber glove.

Based on observation, the facility did not ensure that all portions of the building were protected by the automatic sprinkler system.

Findings include:

Sprinklers shall be installed under fixed obstructions over 4 feet wide such as ducts, decks, open grate flooring cutting tables, and overhead doors per section 5-5.5.3.1 of NFPA 13, 1999 Edition.

On 7/30/2012 at 3:40 p.m., there was no sprinkler coverage under the air over flow duct, where it was approximately 11 feet wide in the West Campus building penthouse.

Based on observations, the facility failed to assure that the automatic sprinkler system provided for complete coverage of all portions of the building.

Findings include:

In accordance with NFPA 13, Section 5-5.5.2, sprinklers shall be located so as to minimize obstructions to discharge as defined in Sections 5-5.5.2 and 5-5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard.

On 8/1/12 at 9:30 a.m., the walk-in cooler C-37 in the kitchen had a sprinkler head situated behind the condenser system. The sprinkler head was not adequate to provide coverage for the entire walk in cooler.

Based on observations, the facility failed to maintain the sprinkler system and its components in accordance with the standards of NFPA 13, 1999 Edition.

Findings include:

In accordance with NFPA 13 and Section 3-2.7.2, escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

1. On 7/31/2012 at 11:00 a.m., the escutcheon ring was missing from the ceiling sprinkler head in Clark room telephone room G238 ceiling.

2. On 7/31/2012 at 11:16 a.m., there was an annular space between the ceiling tile and the escutcheon ring in room G214B Information Systems.

Based on observations, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition.

Findings include:

In accordance with NFPA 25 and Section 2-2.1.1, sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. Further, unacceptable obstructions to spray patterns shall be corrected per section 2-2.1.2 of NFPA 25.

1. The south stairway in the South Tower was observed at 1:30 p.m. on 7/30/2012. There was tape over two sprinkler heads near the ceiling of this stairway.

2. The electrical room 6175 on the sixth floor was observed at 3:00 p.m. on 7/30/2012. The sprinkler head installed in this room was covered with duct tape.

3. The nutrition room 6142 on the sixth floor was observed at 3:30 p.m. on 7/30/2012. The sprinkler head installed in this room was covered with duct tape.

Based on observations, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition.

Findings include:

Unacceptable obstructions to spray patterns shall be corrected per section 2-2.1.2 of NFPA 25, 1998 Edition. Obstructions to spray patterns include horizontal obstructions near the ceiling, vertical obstructions, suspended or floor-mounted obstructions, and clearances between sprinklers and storage below. The distance from sprinklers to privacy curtains, free standing partitions, room dividers, and similar obstructions in light hazard occupancies shall be in accordance with Table 5-6.5.2.3 and Figure 5-6.5.2.3 of NFPA 13, 1999 Edition.

On 08/1/2012 at 9:30 a.m., the walk in cooler C29 and F28 had the orange clips used for installation of sprinkler heads still attached, preventing the sprinkler from activating.

Based on observations, it was determined that the facility failed to ensure that all requirements of NFPA 10 were being followed.

Findings include:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, (1998 Edition); portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet (60 Inches) above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet (42 inches) above the floor.

1. In the stairwell of "Stairway #2" which opens from the "gutted" section of the Fourth Floor, there were two unsecured fire extinguishers sitting on the stair landing.



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In accordance with 4-4.1 of NFPA 10 (1998 Edition) fire extinguishers shall be subject to maintenance at intervals of not more than 1 year. Furthermore, in accordance with 4-4.4 of NFPA 10, each extinguisher shall have a tag or label attached that indicates the month and year the maintenance was performed.

2. The two "K" type portable fire extinguishers located in the kitchen of the hospital had not received an annual service since July 2011.

Based on observation, the facility did not ensure all fire extinguishers were maintained properly.

Findings include:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, (1998 Edition); portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet (60 Inches) above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet (42 inches) above the floor.

On 8/1/2012 at 8:21 a.m., a fire extinguisher was free standing in the electrical room 4048 on the 4th floor.

Based on observations, the facility did not maintain portable extinguishers in accordance with the standards of NFPA 10.

Findings include:

In accordance with NFPA 10, 1998 Edition, and Section 5-6.4, fire extinguisher shells of the low-pressure type that pass a hydrostatic test shall have the test information recorded on a suitable metallic label or equally durable material with a minimum size of 2 in. 3 1/2 in. (5.1 cm 8.9 cm). The label shall be affixed to the shell by means of a heatless process and all old hydrostatic test labels shall be removed. These labels shall be of the type that self-destructs when removal from a fire extinguisher shell is attempted. The label shall include the following information:
(a) Month and year the test was performed, indicated by a perforation, such as is done by a hand punch
(b) Test pressure used
(c) Name or initials of person performing the test, and name of agency performing the test

1. On 7/31/2012 at 7:25 a.m., fire extinguisher #43 found in the generator room had a label affixed to the shell indicating it was last hydrotested in March of 2005. The fire extinguisher lacked a label distinguishing that the 6-year maintenance test had been performed on this unit in 2011.

In accordance with 1-6.7 and 1-6.10 of NFPA 10, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet (60 Inches) above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet (42 inches) above the floor.

2. On 7/31/2012 at 8:03 a.m., a fire extinguisher was sitting on the floor in the G101, Communication room.

3. On 7/31/2012 at 9:07 a.m., a fire extinguisher was sitting on the floor in the kitchen.

NFPA 10 and Section 5-2 , indicates that at intervals not exceeding those specified in Table 5-2, fire extinguishers shall be hydrostatically retested. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. (For nonrechargeable fire extinguishers, see the exception to 4-4.3.) Table 5-2 states that for wetting agent the frequencies is every 5 years.

4. On 7/31/2012 at 9:13 a.m., the K portable fire extinguisher was examined in the kitchen. The unit was manufactured in 2001. The unit was last hydrotested in 2006. It did not have a label indicating a hydrotest had been done in 2011 as required for K extinguishers.

NFPA 10 and specifically Section 2-3.2.1 requires the following: "A placard shall be conspicuously placed near the extinguisher that states that the fire protection system of the kitchen hood shall be activated prior to using the fire extinguisher."

5. At 9:15 a.m., the placard for this K extinguisher unit was not observed above or near the K extinguisher where it was hanging in the dish room. The placard was left by itself on the wall at the previous hanging location of this unit. The placard was placed on the wall approximately four feet away from the unit.

Based on observations, the facility did not maintain exit corridors free from obstructions that would interfere with their instant use in case of fire or other emergency.

Findings include:

In accordance with the Centers for Medicare and Medicaid Services Survey and Certification letters S&C-04-41 and S&C-10-18, items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor.

On 7/31/2012 at 7:55 a.m., several furniture pieces, TVs and other cardboard boxes of stored items were observed on the Loading/Garbage exit corridor. When asked during the observation, one house keeping staff stated that these obstructions were in the exit corridor over a month.

Based on observation, the facility did not ensure that all oxidizing gases were stored properly.

Findings include:

Locations for storage of nonflammable gases, including oxygen, of less than 3000 cubic feet shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting per section 4-3.1.1.2(c) of NFPA 99, 1999 Edition. If natural venting is used, the vent openings shall each be a minimum of 72 square inches in total free area. Where the location of the storage door opens onto an exit access corridor, louvered openings shall not be used.

On 7/31/2012 at 11:55 a.m., the oxygen storage room was examined and observed that the mechanical ventilation was not in operational condition. The motor to the ventilation unit was broken down. There were 44 E size cylinders stored in the room at the time of the observation.

Based on observation, the facility did not ensure all requirements of NFPA 99, 1999 Edition were met for oxygen storage.

Findings include:

In accordance with NFPA 99, Section 4-3.1.1.2(a)(4) requires that the electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code (NEC), for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

The oxygen storeroom on fourth floor of PCU was observed at 2:00 p.m. on 7/31/2012. The light switch was not located at least five feet above the floor, but was at approximately four feet.

Based on observation and interview with maintenance staff, the facility did not ensure that bulk medical gas systems that had been renovated or had components breached were inspected and tested in accordance with NFPA 99, 1999 Edition and NFPA 50, 1996 Edition.

Findings include:

In accordance with NFPA 99 and section (b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3) the following applies:
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites. Further in accordance with NFPA 50, Chapter 4-2.1; each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Further, in accordance with NFPA 99, 1999 Edition, and Section 4-3.4.1.1, inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
This inspection and testing shall include all components of the system or portions thereof including, but not limited to, gas bulk source(s), manifolds, compressed air source systems (e.g., compressors, dryers, filters, regulators), source alarms and monitoring safeguards, master alarms, pipelines, isolation valves, area alarms, zone valves, and station inlets (vacuum) and outlets (pressure gases).
All systems that are breached and components that are subject to additions, renovations, or replacement (e.g., new gas sources-bulk, manifolds, compressors, dryers, alarms) shall be inspected and appropriately tested.
Systems shall be deemed breached at the point of pipeline intrusion by physical separation or by system component removal, replacement, or addition. The breached portions of the systems subject to inspection and testing shall be confined to only the specific altered zone and components in the immediate zone or area that is located upstream for vacuum systems and downstream for pressure gases at the point or area of intrusion.
The inspection and testing reports shall be verified and a certificate and submitted directly to the party that contracted for the testing. That party shall then submit the report through channels to the responsible authority and any others that are required. These reports shall contain detailed listings of all findings and results.
The responsible facility authority shall review these inspection and testing records prior to the use of all systems. This responsible facility authority shall ensure that all findings and results of the inspection and testing have been successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility.
Before piping systems are initially put into use, the health care facility authority shall be responsible for ascertaining that the gas delivered at the outlet is that shown on the outlet label and that the proper connecting fittings are checked against their labels. This can be accomplished by accepting the results of 4-3.4.1.3, System Verification.
Manufactured assemblies shall, prior to arrival at the installation site, be pretested to comply with 4-3.4.1.2(a) through 4-3.4.1.2(e), except that 4-3.4.1.2(c) shall be permitted to be performed by any leak testing method that will assure a pressure decay of less than 1 percent in 24 hours. The manufacturer shall provide documentation attesting to the performance and successful completion of these tests.

Inspection and testing reports for the bulk medical gas system were reviewed on 7/31/2012. The most recent report was dated 6/16/2007 for the west campus building. NFPA 99, Chapter 4-2.1 requires bulk oxygen systems to be inspected annually by a certified verifier.

Interview with maintenance staff at 4:35 p.m. on 8/1/2012, revealed that no further testing had been done on the medical gas system since the 6/16/2007 report. Many areas of the surgical tower had been renovated and a new inspection and testing certification had not been done on the updated medical gas system to ensure the systems integrity has been achieved and maintained.

Based on observation and interview with maintenance staff, the facility did not ensure that bulk medical gas systems that had been renovated or had components breached were inspected and tested in accordance with NFPA 99, 1999 Edition and NFPA 50, 1996 Edition.

Findings include:

In accordance with NFPA 99 and section (b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3) the following applies:
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites. Further in accordance with NFPA 50, Chapter 4-2.1; each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Further, in accordance with NFPA 99, 1999 Edition, and Section 4-3.4.1.1, inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
This inspection and testing shall include all components of the system or portions thereof including, but not limited to, gas bulk source(s), manifolds, compressed air source systems (e.g., compressors, dryers, filters, regulators), source alarms and monitoring safeguards, master alarms, pipelines, isolation valves, area alarms, zone valves, and station inlets (vacuum) and outlets (pressure gases).
All systems that are breached and components that are subject to additions, renovations, or replacement (e.g., new gas sources-bulk, manifolds, compressors, dryers, alarms) shall be inspected and appropriately tested.
Systems shall be deemed breached at the point of pipeline intrusion by physical separation or by system component removal, replacement, or addition. The breached portions of the systems subject to inspection and testing shall be confined to only the specific altered zone and components in the immediate zone or area that is located upstream for vacuum systems and downstream for pressure gases at the point or area of intrusion.
The inspection and testing reports shall be verified and a certificate and submitted directly to the party that contracted for the testing. That party shall then submit the report through channels to the responsible authority and any others that are required. These reports shall contain detailed listings of all findings and results.
The responsible facility authority shall review these inspection and testing records prior to the use of all systems. This responsible facility authority shall ensure that all findings and results of the inspection and testing have been successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility.
Before piping systems are initially put into use, the health care facility authority shall be responsible for ascertaining that the gas delivered at the outlet is that shown on the outlet label and that the proper connecting fittings are checked against their labels. This can be accomplished by accepting the results of 4-3.4.1.3, System Verification.
Manufactured assemblies shall, prior to arrival at the installation site, be pretested to comply with 4-3.4.1.2(a) through 4-3.4.1.2(e), except that 4-3.4.1.2(c) shall be permitted to be performed by any leak testing method that will assure a pressure decay of less than 1 percent in 24 hours. The manufacturer shall provide documentation attesting to the performance and successful completion of these tests.

Inspection and testing reports for the bulk medical gas system were reviewed on 7/31/2012. The most recent report was dated 6/16/2007 for the west campus building.

Interview with maintenance staff at 4:35 p.m. on 8/1/2012, revealed that no further testing had been done on the medical gas system since the 6/16/2007 report. Many areas of the north tower had been renovated and a new inspection and testing certification had not been done on the updated medical gas system to ensure the systems integrity has been acheived and maintained.

Based on observation and interview with maintenance staff, the facility did not ensure that bulk medical gas systems that had been renovated or had components breached were inspected and tested in accordance with NFPA 99, 1999 Edition and NFPA 50, 1996 Edition.

Findings include:

In accordance with NFPA 99 and section (b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3) the following applies:
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites. Further in accordance with NFPA 50, Chapter 4-2.1; each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Further, in accordance with NFPA 99, 1999 Edition, and Section 4-3.4.1.1, inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
This inspection and testing shall include all components of the system or portions thereof including, but not limited to, gas bulk source(s), manifolds, compressed air source systems (e.g., compressors, dryers, filters, regulators), source alarms and monitoring safeguards, master alarms, pipelines, isolation valves, area alarms, zone valves, and station inlets (vacuum) and outlets (pressure gases).
All systems that are breached and components that are subject to additions, renovations, or replacement (e.g., new gas sources-bulk, manifolds, compressors, dryers, alarms) shall be inspected and appropriately tested.
Systems shall be deemed breached at the point of pipeline intrusion by physical separation or by system component removal, replacement, or addition. The breached portions of the systems subject to inspection and testing shall be confined to only the specific altered zone and components in the immediate zone or area that is located upstream for vacuum systems and downstream for pressure gases at the point or area of intrusion.
The inspection and testing reports shall be verified and a certificate and submitted directly to the party that contracted for the testing. That party shall then submit the report through channels to the responsible authority and any others that are required. These reports shall contain detailed listings of all findings and results.
The responsible facility authority shall review these inspection and testing records prior to the use of all systems. This responsible facility authority shall ensure that all findings and results of the inspection and testing have been successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility.
Before piping systems are initially put into use, the health care facility authority shall be responsible for ascertaining that the gas delivered at the outlet is that shown on the outlet label and that the proper connecting fittings are checked against their labels. This can be accomplished by accepting the results of 4-3.4.1.3, System Verification.
Manufactured assemblies shall, prior to arrival at the installation site, be pretested to comply with 4-3.4.1.2(a) through 4-3.4.1.2(e), except that 4-3.4.1.2(c) shall be permitted to be performed by any leak testing method that will assure a pressure decay of less than 1 percent in 24 hours. The manufacturer shall provide documentation attesting to the performance and successful completion of these tests.

Inspection and testing reports for the bulk medical gas system were reviewed on 7/31/2012. The most recent report was dated 6/16/2007 for the west campus building.

Interview with maintenance staff at 4:35 p.m. on 8/1/2012, revealed that no further testing had been done on the medical gas system since the 6/16/2007 report. Many areas of the west campus had been renovated and a new inspection and testing certification had not been done on the updated medical gas system to ensure the systems integrity has been achieved and maintained.

Based on observation and interview with maintenance staff, the facility did not ensure that bulk medical gas systems that had been renovated or had components breached were inspected and tested in accordance with NFPA 99, 1999 Edition and NFPA 50, 1996 Edition.

Findings include:

In accordance with NFPA 99 and section (b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3) the following applies:
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites. Further in accordance with NFPA 50, Chapter 4-2.1; each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Further, in accordance with NFPA 99, 1999 Edition, and Section 4-3.4.1.1, inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
This inspection and testing shall include all components of the system or portions thereof including, but not limited to, gas bulk source(s), manifolds, compressed air source systems (e.g., compressors, dryers, filters, regulators), source alarms and monitoring safeguards, master alarms, pipelines, isolation valves, area alarms, zone valves, and station inlets (vacuum) and outlets (pressure gases).
All systems that are breached and components that are subject to additions, renovations, or replacement (e.g., new gas sources-bulk, manifolds, compressors, dryers, alarms) shall be inspected and appropriately tested.
Systems shall be deemed breached at the point of pipeline intrusion by physical separation or by system component removal, replacement, or addition. The breached portions of the systems subject to inspection and testing shall be confined to only the specific altered zone and components in the immediate zone or area that is located upstream for vacuum systems and downstream for pressure gases at the point or area of intrusion.
The inspection and testing reports shall be verified and a certificate and submitted directly to the party that contracted for the testing. That party shall then submit the report through channels to the responsible authority and any others that are required. These reports shall contain detailed listings of all findings and results.
The responsible facility authority shall review these inspection and testing records prior to the use of all systems. This responsible facility authority shall ensure that all findings and results of the inspection and testing have been successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility.
Before piping systems are initially put into use, the health care facility authority shall be responsible for ascertaining that the gas delivered at the outlet is that shown on the outlet label and that the proper connecting fittings are checked against their labels. This can be accomplished by accepting the results of 4-3.4.1.3, System Verification.
Manufactured assemblies shall, prior to arrival at the installation site, be pretested to comply with 4-3.4.1.2(a) through 4-3.4.1.2(e), except that 4-3.4.1.2(c) shall be permitted to be performed by any leak testing method that will assure a pressure decay of less than 1 percent in 24 hours. The manufacturer shall provide documentation attesting to the performance and successful completion of these tests.

Inspection and testing reports for the bulk medical gas system were reviewed on 7/31/2012. The most recent report was dated July 2009 for the South Tower on East Campus. NFPA 99, Section 4-2.1 requires bulk oxygen systems to be inspected annually by a certified verifier.

Interview with maintenance staff at 4:35 p.m. on 8/1/2012, revealed that no further testing had been done on the medical gas system since the July 2009 report.

Based on observation, the facility did not secure empty acetylene tanks and did not ensure an electric heater was safely used and stored away from combustibles.

Findings include:

Freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per sections 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99, 1999 Edition.

1. On 7/31/12 at 7:33 a.m., an acetylene tank was observed outside the boiler room. The pressurized tank was free standing in a corner of a fenced area and was not secured properly.

In accordance to NFPA 70, Chapter 4 -424-20(a) which states:
Thermostatically controlled switching devices and combination thermostats and manually controlled switches shall be permitted to serve as both controllers and disconnecting means, provided all of the following conditions are met:
1. Provided with a marked "off " position
2. Directly open all ungrounded conductors when manually placed in the " off " position
3. Designed so that the circuit cannot be energized automatically after the device has been manually placed in the "off" position
4. Located as specified in Section 424-19.

2. On 7/31/12, an observation of an electric heater in office 1514 revealed a foot rest pushed against the heater. The controls for the electric heater were attached to the front of the desk and the control knob was missing, making it visually impossible to determine if the heater was on or off.

Based on observations, it was determined that the facility failed to ensure that all gas/vacuum lines were properly deactivated.

Findings include:

On 07/31/2012 at 9:12 a.m. on the " vacated " Third Floor, a gas/vacuum panel was examined. Although gas /vacuums system were to have been deactivated, " Line Pressure Abnormal " was illuminated. The audible signal was active and needed to be silenced by staff personnel.

Based on observations, it was determined that the facility failed to ensure that all requirements for identifying the location of oxygen storage was properly labeled and identified.

Findings include:

In accordance with NFPA 99, 1999 Edition, Section 8-3.1.11.3 Signs; a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

All room locations of oxygen storage in the North Tower lack the mininum posting requirements.

Based on observation, the facility did not ensure medical gas storage areas had proper signage for No Smoking.

Findings include:

In accordance with NFPA 99, 1999 Edition, Section 8-3.1.11.3 Signs; a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

At 11:55 a.m. on 7/31/2012, the oxygen storage room located next to the Print Shop on the ground level lacked the minimum signage requirements for oxygen store rooms. The room contained 44 E size oxygen cylinders.

Based on observations, the facility failed to post a non-smoking or no smoking sign at a location where oxygen was being stored.

Findings include:

In accordance with Section 18.3.2.4 of NFPA 101 and Section 8-3.1.11.3 of NFPA 99 requires that a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

On 7/31/2012 at 12:30 p.m., the oxygen storage rooms in the South Tower lacked signage denoting the minimum wording.

Based on observations, the facility failed to post a non-smoking or no smoking sign at a location where oxygen was being stored.

Findings include:

In accordance with Section 19.3.2.4 of NFPA 101 and Section 8-3.1.11.3 of NFPA 99 requires that a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

On 8/1/2012 at 1:30 p.m., the oxygen storage rooms in the Surgical Tower lacked signage denoting the minimum of "Caution, Oxidizing Gas(es) Stored Within, No Smoking".

Based on observations, it was determined that the facility failed to ensure that all requirements of the National Electrical Code (NFPA 70) were followed.

Findings include:

Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals per Article 400-10 of NFPA 70.

1. On 07/30/2012 on the Sixth Floor at 4:03 p.m., there was an unsecured power strip hanging for an electrical outlet in the staff break room.

In accordance with Article 110-26 and table 110-26(a) of NFPA 70 there shall be maintained a clear working space of at least 36" around electrical equipment such as panel boards to permit ready and safe operations of such equipment. This working space can not be used for storage purposes.

2. On 08/01/2012 at 9:46 a.m. on the First Floor in room 1047A, electrical panel "D.W 1120/208 3PH OMB-1" had access blocked by cardboard boxes, metal equipment and other materials in front of the panel.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

3. On 08/01/2012 at 9:13 a.m. on First Floor in room 1317 HVAC, there was no legend posted in electrical panel "Panel AG MSB-4."

4. On 08/01/2012 at 9:14 a.m. on First Floor in room 1227, there was wooden pallet blocking access to electrical panel "Panel EL 120/208V/30W"

In completed installations, each box shall have a cover, faceplate, or fixture canopy according to Artilce 370-25.

5. On 08/01/2012 at 9:15 a.m. on First Floor in room 1227, there was an uncovered electrical junction box exposing four unconnected wires.

6. On 7/31/2012 at 1:25 p.m. on the First Floor in room 2420, there was an electrical outlet which lacked a cover plate.

7. On 7/31/2012 at 4:25 p.m. on the First Floor in the Biomedical/Housekeeping Department, there was an electrical junction box which lacked a cover plate.

Based on observations, the facility did not maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition.

Findings include:

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

1. On 8/1/2012 at 8:33 a.m., circuit breaker 30 in electrical panel L312 (3rd Floor) was in the on position; however, it was marked as a spare on the panel directory.

2. On 8/1/2012 at 8:45 a.m., circuit breakers 11, 12, 13, & 15 in electrical panel L317 were in the on position; however, they were marked as spares on the panel directory.

3. On 8/1/2012 at 9:00 a.m., circuit breaker 25 in electrical panel L213 was in the on position; however, it was marked as a spare in the panel directory.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition.

Findings include:

In accordance with NFPA 70 and Article 380-3(a); switches and circuit breakers shall be of the externally operable type mounted in an enclosure listed for the intended use.

The electrical room on seventh floor of the South Tower was observed at 1:55 p.m. on 7/30/2012. The electrical panel labeled CR74 had a cover which was loosely installed. The clips which held the face of the panel in the closed position did not seal tight to ensure that the electrical panel was tightly closed.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings. In accordance with UL listing for power strips. Relocatable power taps as identified under UL standard 1363 and listings starting with XBYS. There must be a reset or test button identified for the circuit breaker to be reset.

A medical staff office in the business section of the Surgical Tower was observed at 3:00 p.m. on 7/31/2012. An orange extension cord was found connected to a small stapler in this office.

Note: The extension cord was removed from under the desk in the medical staff office by maintenance staff at the time of the survey process.

Based on observation, the facility did not maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition and NFPA 99, 1999 Edition.

Findings include:

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

1. On 7/30/12 at 4:17 p.m., the following was observed in Electrical Room 313B:

a) Circuit breaker #42 was in the on position but was marked as a spare in the panel directory and circuit breaker #12 was in the on position and was crossed out in the panel directory.

b) Circuit breaker #44 was in the on position but marked as a spare in the panel directory.

In completed installations, each box shall have a cover, faceplate, or fixture canopy according to Article 370-25.

2. On 7/31/12 at 7:15 a.m., an electrical outlet was observed on the east wall of the electrician desk room, without an outlet cover.


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3. On 7/30/2012 at 4:15 p.m. the following was observed in electrical room 313B:

a) Electrical Panel E3A had the circuit breaker #s 26, 28, and 30 were in the on position, but they were not identified on the panel directory.

b) Electrical Panel EM3A had circuit breaker #48 in the on position and the electrical panel directory was blank. Secondly, circuit breaker #65 was in the off position, the electrical panel directory was blank.

4. On 7/31/2012 at 1:45 p.m., circuit breaker #s 2 through 18 in an electrical panel in G040 were all in the on positions. The unit lacked a panel directory identifying circuits.