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Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility walls and ceilings. This affected 1 of 11 floors in the Main Hospital and 1 of 1 floors in the West Wing, which could result in the spread of smoke or fire to other locations in the facility.


Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/09/13 through 12/13/13, the building construction were observed.

Main Hospital-Hillcrest on 12/11/13:
1. At 1:42 p.m. in the west wall of the kitchen office (Room 1-202) was an approximately 2 inch by 3 inch unsealed penetration.


21101

Hillcrest Hospital, West Wing Behavioral Health on 12/12/13:
2. At 1:44 p.m., there were two penetrations approximately 1/2 inch each in the wall next to electrical panel P1 in the printing room 330.

3. At 1:48 p.m., there were 4 penetrations in the left wall approximately 1/4 inch each inside storage room 325.

MOBS on 12/12/13:

8. At 10:45 a.m., the self-closing hardware to the corridor door to Room 3-301 was disconnected.

9. At 1:31 p.m., the self-closing corridor door to Room 1-124 was impeded from closing with a chair in front of the door.

10. At 1:49 p.m., the self-closing corridor door to Room 3-356 was impeded from closing with a kick stop in the downward position in front of the door.

Based on observation, the facility failed to maintain their automatic closing fire doors. This was evidenced by fire doors that failed to close and positive latch when tested. This failure affected 2 of 11 floors in the Main Hospital and had the potential to allow the spread of smoke or flames in the event of a fire.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/09/13 through 12/13/13, the doors held open by magnetic hold-open devices were tested and observed.


Main Hospital-Hillcrest on 12/11/13:
1. At 10:11 a.m., the smoke barrier door 2-132 in the lab failed to latch when released from the magnet. One of two sets of doors in the lab latched.

2. At 2:41 p.m., the smoke barrier door to the Alcohol Storage Room B131 failed to latch when tested.

Based on observation, the facility failed to display exits signs in all egress paths as evidenced by no sign displayed in 1 of 3 paths. This could delay egress in 1 of 3 floors in the Medical Office Building South (MOBS) and cause potential harm to patients in the event of a fire emergency.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/09/13 through 12/13/13, the egress paths and exit signs were observed.


Main Hospital-Hillcrest on 12/12/13:
At 11:26 a.m., there was no exit sign displayed on the east wall from the egress path above the smoke barrier doors near Room 3-331. The Facilities director acknowledged the finding.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls as evidenced by unsealed penetrations. The penetrations could result in the reduction in the facility's ability to protect in place and increase the risk of injury to the the patients due to smoke and fire. This affects 2 of 3 floors in the Medical Office Building South (MOBS).

NFPA 101, Life Safety Code (2000 Edition)
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/12/13, the smoke barrier walls were observed.

MOBS on 12/12/13:
1. At 2:45 p.m., there were four 3 inch unsealed pipes in the Basement smoke barrier wall near elevator 18.

2. At 2:50 p.m., there was a 2 inch by 2 inch unsealed penetration in the south smoke barrier wall from the pharmacy toward the elevator lobby on the first floor.

3. At 2:58 p.m., there was an approximately 4 feet by 3 feet unfinished section of the smoke barrier wall on the second floor west wall near elevator 18.

Thornton Hospital on 12/11/13-Third floor:
10. At 9:32 a.m., the smoke barrier door leaf near room 3-C15 failed to latch upon activation of the fire alarm system. The door was tested twice by Engineering Staff and failed both times.

Based on observation and interview, the facility failed to protect the corridors from their hazardous areas. This was evidenced by rooms which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building, and were not equipped with a self-closing mechanism on the door. This deficient practice affected 1 of 11 floors of the Main Hospital, and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/09/13 through 12/13/13, the hazardous area enclosures were observed.


Main Hospital-Hillcrest on 12/12/13:
At 11:19 a.m., the door to the room identified as Bio-Hazardous Room 3-323 was without a self- closing mechanism on it. The room contained hazardous materials in three 32 gallon barrels and was over 50 square feet.

Based on observation, the facility failed to ensure that stairways were not used for storage as evidenced by an item stored in the stairway. This could become an obstruction to the egress path, fuel a fire and cause potential harm to patients, staff and visitors evacuating during a fire emergency. This affected 3 of 3 floors in the Medical Office Building South (MOBS).

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.8. (d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.
Exception No. 1: Openings in exit passageways in covered mall buildings as provided in Chapters 36 and 37 shall be permitted.
Exception No. 2: In buildings of Type I or Type II construction, existing fire-protection rated doors shall be permitted to interstitial spaces provided that such space meets the following criteria:
(a) The space is used solely for distribution of pipes, ducts, and conduits.
(b) The space contains no storage.
(ac) The space is separated from the exit enclosure in accordance with 8.2.3.
(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling
of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/09/13 through 12/13/13, the facility exit components were examined.

MOBS on 12/12/13:
At 2:03 p.m., there was an approximately 35 gallon cement trash can (full of trash) in the bottom of stairwell number 1.

Based on observation and document review, the facility failed to maintain their exit signs. This was evidenced by an exit sign that was not illuminated. This affected 1 of 3 floors in the Medical Office Building South (MOBS), and could result in a delay in evacuation due to limited exit sign visibility.

NFPA 101 Life Safety Code, 2000 edition
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
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 1.5 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.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/12/13, the exit signs in the facility were observed and maintenance documents were reviewed.

MOBS on 12/12/13:
At 1:43 p.m., the exit sign BH1-10 near Room L-002 was not illuminated when observed.

Based on observation, the facility failed to ensure that sprinkler heads were not obstructed. This was evidenced by an obstruction to a sprinkler head. This affected 1 of 11 floors in the Main Hospital and could result in sprinkler failure in the event of a fire.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition.
5-5.5.3* Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/09/13 through 12/13/13, the sprinkler system was tested and observed.

Main Hospital-Hillcrest on 12/09/13:
At 3:33 p.m., the sprinkler spray pattern in Room 8-821B was impeded with a large piece of foam rubber stored 12 inches from the sprinkler.

Moores Cancer Center on 12/11/13:
5. At 2:21 p.m., the sprinkler escutcheon ring was missing in the Administration office. This was acknowledged by staff during the survey.

6. At 2:52 p.m., the sprinkler escutcheon ring was missing inside Imagining exam room 1144. This was acknowledged by staff during the survey.

Thornton Hospital on 12/10/13- Lower Level:

5. At 2:06 p.m., the fire extinguisher located in the back of room L-C07, did not have the month of November singed or check off for the monthly visual inspection. This was acknowledged by staff during the survey.

Based on observation and interview, the facility failed to prohibit the use of portable space heating devices. This was evidenced by a portable space heater that was in a doctors sleeping room and not used in accordance to the manufactures specifications. This failure could increase the risk of a potential fire and affected patients, staff and visitors in the West Wing Behavioral Health Building.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/09/13 through 12/13/13, the portable space heaters were observed.

Hillcrest-West Wing Behavioral Health Building on 12/12/13:
At 2:08 p.m., there was a portable space heater in the off position, that was left unattended and plugged into the wall receptacle in doctors sleeping room 545. The manufactures specification tag on the space heater noted that the heater is required to be unplugged from electrical devices if left unattended. This was acknowledged by staff during survey.

Based on observation and interview, the facility failed to ensure that all means of egress were continuously maintained free of obstructions to full instant use in the case of fire or other emergency. This was evidenced by items that were stored in the corridor exit access that impeded the egress path. This could result in a delay in evacuation in the event of a fire, or other emergency, and affected 1 of 11 floors in the Main Hospital.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/09/13 through 12/13/13, the exit corridors were observed and a staff person was interviewed.

Main Hospital-Hillcrest on 12/10/13:
At 11:09 a.m., there were two 120 gallon containers and three tier shelving unit full of boxes stored in the hallway near Room 2-211. At 11:11 a.m., the RN Manager said during an interview that the items were stored in that location for approximately two hours.

Based on observation, the facility failed to ensure that their trash receptacles that exceeded 32 gallons were not stored in the hallway. This would fuel a fire and cause potential harm to patients in the event of a fire emergency. This effected 1 of 11 floors in the Main Hospital.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/9/13 through 12/13/13, the trash and soiled linen receptacles were observed.

Main Hospital-Hillcrest on 12/10/13:
At 11:09 a.m., there were two unattended containers approximately 120 gallon containers stored in the hallway near Room 2-211 that were full of trash and cardboard.

Based on observation, the facility failed to ensure that their oxygen cylinders were secured from tipping over and storage areas were identified and protected as evidenced by an unsecured oxygen cylinder, a light switch lower than 5 feet from the ground, and no sign in an oxygen storage room. This affected 2 of 11 floors in the Main Hospital. This had the potential for the cylinder to get damaged and result in an explosion and possible electrical ignited fire.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

NFPA 99, Standard For Health Care Facilities 1999 edition
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 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

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/09/13 through 12/13/13, the oxygen storage areas were observed.

Main Hospital-Hillcrest on 12/09/13:
1. At 3:03 p.m., there was an unsecured E-cylinder in Room 9-932. The E-cylinder was free standing on the floor.

Main Hospital-Hillcrest North on 12/10/13:
2. At 9:34 a.m., there was no oxygen storage sign on the door to Room 5-152 with 14 E-cylinders in Room.

3. At 1:50 p.m., the light switch in Room 2-203 was mounted 4 feet from the ground. The room contained over 20 E-cylinders and H-cylinders.

Based on observation, the facility failed to ensure that medical gas shut off valves were readily accessible. This was evidenced by impediments in front of an emergency oxygen valve. This would delay personnel from shutting off oxygen during a fire emergency and cause potential harm to patients. This effected 1 of 11 floors in the Main Hospital.

NFPA 99 Standard for Healthcare Facilities, 1999 Edition
4-3.1.2.3 Gas Shutoff Valves, Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled ' ' SOURCE VALVE FOR THE (SOURCE NAME). ' '
(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/11/13 through 12/13/13, the emergency oxygen shut off valves were observed.

Main Hospital-Hillcrest on 12/11/13:
At 11:14 a.m., the emergency oxygen shut off valve outside of Room 1-531 (Cathlab) was impeded from access with an unattended bed in front of the device.

Based on observation, the facility failed to ensure the integrity of the smoke barrier wall contruction was maintained. This was evidenced by unsealed pipes and conduits in the smoke barrier walls. This affected 3 of 11 floors in the Main Hospital, and could result in the spread of smoke or fire to other smoke compartments.

NFPA 101 Life Safety Code, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall on 12/09/13 through 12/13/13, the facility's smoke barrier walls were observed.

Main Hospital-Hillcrest on 12/09/13:
1. At 11:35 a.m., there was a 2 1/2 inch unsealed pipe (antenna chase) in the Penthouse Room.


Main Hospital-Hillcrest on 12/10/13:
2. At 10:02 a.m., there were three 3/4 inch and one 1/2 inch unsealed pipes in the west wall of Room 4-304.

3. At 10:11 a.m., there was a 3/4 inch unsealed pipe in the north wall of Room 4-727.

Moores Cancer Center on 12/11/13:
21. At 2:09 p.m., there was a power strip plugged into another power strip under the desk in room 1314. This was acknowledged by staff during survey.

22. At 2:13 p.m., there was an extension cord with no overcurrent protection plugged into a power strip in the Radiation-Oncology Department room 1411-G. This was acknowledged by staff during the survey.

Thornton Hospital on 12/09/13- Third Floor:
2. At 2:35 p.m., the ABHR dispenser located in Respiratory Care room 3-007, was installed approximately 10 to 12 inches above a power strip that was located on top of a desk.

Based on observation, the facility failed to ensure that Alcohol Based Hand Rub (ABHR) dispensers were not installed adjacent to an ignition source. Thsi was evidenced by a dispenser installed adjacent to an electrical outlet. This affected 1 of 11 floors of the Main Hospital and 1 of 4 floors at Thornton Hospital. This had the potential for an electrically ignited alcohol based fire.
Findings:

During a tour of the facility with the Supervisor of Building Operations, Supervisor of Plant Operations, Safety Director, Facilities Director, Fire Marshall, Security System Coordinator on 12/09/13 through 12/13/13, the facility ABHR dispensers were observed.

Main Hospital-Hillcrest on 12/09/13:
1. At 2:53 p.m. there was an ABHR dispenser located near Room 9-931 that was mounted above an electrical outlet.