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Based on observation, the facility failed to ensure doors protecting a corridor opening closed without impediment. Doors protecting corridor openings play an integral role in interrupting the spread of smoke. Doors that do not close tight in their frames render the door ineffective to contain the spread of smoke.

Finding:

1.) On December 10, 2013 at 9:35 a.m., the Emergency Department's waiting room's self closing door located at an exit corridor was held fully open by a rubber wedge placed in front of the door.

2.) On December 12, 2013 at 9:55 a.m., the Clinical Lab's self closing door located at an exit corridor failed to fully close. Closer observation revealed the door was misaligned and rubbing against the door frame.

NFPA 13 Standard for the Installation of Sprinkler Systems 1999 edition

3-2.9.1 A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or have been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types of temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100 degrees Fahrenheit (38 degrees Celsius).

3-2.9.3 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:

(1) For systems having less than 300 sprinklers - not fewer than 6 sprinklers
(2) For systems with 300 to 1000 sprinklers - not fewer than 12 sprinklers
(3) For systems with over 1000 sprinklers - not fewer than 24 sprinklers

5-5.1 The requirements for spacing, location, and position of sprinklers shall be based on the following principles:

(1) Sprinklers installed throughout the premises.

5-5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of
Water-Based Fire Protection Systems 1998 Edition

1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 degrees Fahrenheit (38 degrees Celsius).

2-4.1.5 The stock of spare sprinklers shall be as follows:
(a) For protected facilities having under 300 sprinklers - no fewer than 6 sprinklers
(b) For protected facilities having 300 to 1000 sprinklers - no fewer than 12 sprinklers
(c) For protected facilities having over 1000 sprinklers - no fewer than 24 sprinklers

2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint or coating applied after shipment from the place of manufacture.

These requirements were not met as evidenced by:

Based on observation and interview, the facility failed to maintain sprinklers in accordance with NFPA 13 and 25 by having an obstruction less than 18 inches below a sprinkler deflector, having plaster on a sprinkler head deflector, failing to ensure spare sprinklers representative of each sprinkler type installed at the facility were maintained at the facility, and by not having sprinkler coverage in the walk in refrigerator and freezer.

Findings:

1.) On December 10, 2013 at 9:50 a.m., there were boxes stored to the ceiling above the height of the sprinkler head deflector at the ED clean utility room.

2.) The sprinkler head deflector in the ED clean supply room had an accumulation of plaster.

3.) On December 11, 2013 between 3:00 p.m. and 7:00 p.m., a review of an inspection report dated 11/8/13, indicated that two red glass bulb quick response sprinkler heads needed to be added to the spare sprinkler box.

During an interview at the same time as the review, the Director of Facilities stated the the two sprinkler heads had not yet been added to the spare sprinkler box.

4.) A review of an inspection report dated 9/9/10 indicated the cooler/freezer in the basement had no sprinkler coverage.

During the same time as the review, an observation of the walk-in cooler and freezer revealed there was no sprinkler coverage in the walk-in cooler and freezer of the fully sprinklered hospital.

NFPA's formal interpretation 78-6 Reference 5-1 indicates that it is the intent of 5-1 to require sprinkler protection in walk-in type coolers and freezers in fully sprinklered buildings.

NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites 2001 Edition

2.1.2 The system shall be located so that it is readily accessible to mobile supply equipment at ground level and to authorized personnel. Bulk oxygen systems shall not be located on rooftops of buildings or other structures.

Based on observation the facility failed to ensure the fill pipe for the cryogenic liquefied oxygen system was unobstructed and readily accessible to mobile supply equipment.

Finding:

On December 9, 2013 at 12:05 p.m., it was observed that access to the cryogenic liquefied oxygen fill pipe was through an aperture in a concrete block wall that enclosed the cryogenic liquefied system. Closer observation revealed there was a cylinder storage cart with sixteen oxygen e cylinders stored between the fill pipe and the access through the wall.

NFPA 70 National Electrical Code 1999 Edition

110.26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.

(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(a). Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.

Table 110.26(a) Working Spaces

0-150 Nominal Voltage to Ground
Condition 1, 2 and 3 3 feet minimum clear distance

151-600 Nominal Voltage to Ground
Condition 1 3 feet minimum clear distance
Condition 2 3 1/2 feet minimum clear distance
Condition 3 4 feet minimum clear distance

Notes:
1. For SI units, 1 ft = 0.3048
2. Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by 110.26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.

(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

305-3.(d) Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed.

370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

400-8. Uses not permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:

(1) As a substitute for the fixed wiring of a structure

410-56(e) Position of Receptacle Faces. After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0,381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.


These requirements were not met as evidenced by:

Based on observation, the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70 by having an extension cord as a substitute for fixed wiring, an electrical receptacle that was loose and did not seat against the mounting surface, having an electrical receptacle with a broken faceplate that did not cover the full opening, missing a cover plate at an electrical box, and by failing to have a 3 foot minimum clear distance in front of an electrical panel

NFPA 70 contains provisions necessary for safety and its purpose is the practical safeguarding of persons and property from hazards arising from the use of electricity. Hazards often occur because of overloading of wiring systems by methods or usage not in conformity with this code. To meet power supply needs in buildings with an inadequate supply of readily available electrical receptacles or for the convenience of employees, extension cords and/or power strips are often used to provide more receptacles and/or reach greater distances. Electrical receptacles that are securely mounted and maintained in a workmanlike manner and that have faceplates that are flush with the mounting surface protect from loose electrical wires and accidental contact with electrical wires. Damaged electrical receptacle faceplates and missing cover plates can expose energized electrical parts creating a risk of electric shock or burn injuries and fire. Sufficient access and working space in front of electrical panels help provide ready and safe operation and maintenance of the equipment.

Findings:

1.) On December 10, 2014, at 3:55 p.m., accompanied by the Director of Facilities, there was an extension cord used to connect a television to an electrical receptacle at the wall in patient sleeping room 33.

During an interview at the same time as the observation, the Director of Facilities stated, "Yes I know we can't have it."

2.) Between 4:08 p.m. and 4:30 p.m., there was a loose electrical receptacle with the the cover pulled away from the wall behind bed B in room 27 Telemetry unit.

3.) Between 4:30 p.m. and 4:40 p.m., a piece of a receptacle plate was missing from an electrical receptacle under the Med Surge nurse's station counter.

4.) At 6:45 p.m., the was a missing electrical cover plate at the electrical box mounted at a smoke barrier wall located near the ED department waiting room. Closer observation revealed there was electrical wiring in the electrical box.

5.) On December 12, 2013 at 12:10 p.m., accompanied by the maintenance supervisor, a walk-in refrigerator was observed to be located in front of an electrical panel. Closer observation revealed the distance between electrical panel and the walk-in refrigerator was less than three feet.

Based on observation, the facility failed to ensure doors protecting a corridor opening closed without impediment. Doors protecting corridor openings play an integral role in interrupting the spread of smoke. Doors that do not close tight in their frames render the door ineffective to contain the spread of smoke.

Finding:

1.) On December 10, 2013 at 9:35 a.m., the Emergency Department's waiting room's self closing door located at an exit corridor was held fully open by a rubber wedge placed in front of the door.

2.) On December 12, 2013 at 9:55 a.m., the Clinical Lab's self closing door located at an exit corridor failed to fully close. Closer observation revealed the door was misaligned and rubbing against the door frame.

NFPA 13 Standard for the Installation of Sprinkler Systems 1999 edition

3-2.9.1 A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or have been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types of temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100 degrees Fahrenheit (38 degrees Celsius).

3-2.9.3 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:

(1) For systems having less than 300 sprinklers - not fewer than 6 sprinklers
(2) For systems with 300 to 1000 sprinklers - not fewer than 12 sprinklers
(3) For systems with over 1000 sprinklers - not fewer than 24 sprinklers

5-5.1 The requirements for spacing, location, and position of sprinklers shall be based on the following principles:

(1) Sprinklers installed throughout the premises.

5-5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of
Water-Based Fire Protection Systems 1998 Edition

1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 degrees Fahrenheit (38 degrees Celsius).

2-4.1.5 The stock of spare sprinklers shall be as follows:
(a) For protected facilities having under 300 sprinklers - no fewer than 6 sprinklers
(b) For protected facilities having 300 to 1000 sprinklers - no fewer than 12 sprinklers
(c) For protected facilities having over 1000 sprinklers - no fewer than 24 sprinklers

2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint or coating applied after shipment from the place of manufacture.

These requirements were not met as evidenced by:

Based on observation and interview, the facility failed to maintain sprinklers in accordance with NFPA 13 and 25 by having an obstruction less than 18 inches below a sprinkler deflector, having plaster on a sprinkler head deflector, failing to ensure spare sprinklers representative of each sprinkler type installed at the facility were maintained at the facility, and by not having sprinkler coverage in the walk in refrigerator and freezer.

Findings:

1.) On December 10, 2013 at 9:50 a.m., there were boxes stored to the ceiling above the height of the sprinkler head deflector at the ED clean utility room.

2.) The sprinkler head deflector in the ED clean supply room had an accumulation of plaster.

3.) On December 11, 2013 between 3:00 p.m. and 7:00 p.m., a review of an inspection report dated 11/8/13, indicated that two red glass bulb quick response sprinkler heads needed to be added to the spare sprinkler box.

During an interview at the same time as the review, the Director of Facilities stated the the two sprinkler heads had not yet been added to the spare sprinkler box.

4.) A review of an inspection report dated 9/9/10 indicated the cooler/freezer in the basement had no sprinkler coverage.

During the same time as the review, an observation of the walk-in cooler and freezer revealed there was no sprinkler coverage in the walk-in cooler and freezer of the fully sprinklered hospital.

NFPA's formal interpretation 78-6 Reference 5-1 indicates that it is the intent of 5-1 to require sprinkler protection in walk-in type coolers and freezers in fully sprinklered buildings.

NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites 2001 Edition

2.1.2 The system shall be located so that it is readily accessible to mobile supply equipment at ground level and to authorized personnel. Bulk oxygen systems shall not be located on rooftops of buildings or other structures.

Based on observation the facility failed to ensure the fill pipe for the cryogenic liquefied oxygen system was unobstructed and readily accessible to mobile supply equipment.

Finding:

On December 9, 2013 at 12:05 p.m., it was observed that access to the cryogenic liquefied oxygen fill pipe was through an aperture in a concrete block wall that enclosed the cryogenic liquefied system. Closer observation revealed there was a cylinder storage cart with sixteen oxygen e cylinders stored between the fill pipe and the access through the wall.

NFPA 70 National Electrical Code 1999 Edition

110.26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.

(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(a). Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.

Table 110.26(a) Working Spaces

0-150 Nominal Voltage to Ground
Condition 1, 2 and 3 3 feet minimum clear distance

151-600 Nominal Voltage to Ground
Condition 1 3 feet minimum clear distance
Condition 2 3 1/2 feet minimum clear distance
Condition 3 4 feet minimum clear distance

Notes:
1. For SI units, 1 ft = 0.3048
2. Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by 110.26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.

(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

305-3.(d) Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed.

370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

400-8. Uses not permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:

(1) As a substitute for the fixed wiring of a structure

410-56(e) Position of Receptacle Faces. After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0,381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.


These requirements were not met as evidenced by:

Based on observation, the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70 by having an extension cord as a substitute for fixed wiring, an electrical receptacle that was loose and did not seat against the mounting surface, having an electrical receptacle with a broken faceplate that did not cover the full opening, missing a cover plate at an electrical box, and by failing to have a 3 foot minimum clear distance in front of an electrical panel

NFPA 70 contains provisions necessary for safety and its purpose is the practical safeguarding of persons and property from hazards arising from the use of electricity. Hazards often occur because of overloading of wiring systems by methods or usage not in conformity with this code. To meet power supply needs in buildings with an inadequate supply of readily available electrical receptacles or for the convenience of employees, extension cords and/or power strips are often used to provide more receptacles and/or reach greater distances. Electrical receptacles that are securely mounted and maintained in a workmanlike manner and that have faceplates that are flush with the mounting surface protect from loose electrical wires and accidental contact with electrical wires. Damaged electrical receptacle faceplates and missing cover plates can expose energized electrical parts creating a risk of electric shock or burn injuries and fire. Sufficient access and working space in front of electrical panels help provide ready and safe operation and maintenance of the equipment.

Findings:

1.) On December 10, 2014, at 3:55 p.m., accompanied by the Director of Facilities, there was an extension cord used to connect a television to an electrical receptacle at the wall in patient sleeping room 33.

During an interview at the same time as the observation, the Director of Facilities stated, "Yes I know we can't have it."

2.) Between 4:08 p.m. and 4:30 p.m., there was a loose electrical receptacle with the the cover pulled away from the wall behind bed B in room 27 Telemetry unit.

3.) Between 4:30 p.m. and 4:40 p.m., a piece of a receptacle plate was missing from an electrical receptacle under the Med Surge nurse's station counter.

4.) At 6:45 p.m., the was a missing electrical cover plate at the electrical box mounted at a smoke barrier wall located near the ED department waiting room. Closer observation revealed there was electrical wiring in the electrical box.

5.) On December 12, 2013 at 12:10 p.m., accompanied by the maintenance supervisor, a walk-in refrigerator was observed to be located in front of an electrical panel. Closer observation revealed the distance between electrical panel and the walk-in refrigerator was less than three feet.