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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.


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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 and interview, the facility failed to ensure that corridor doors were maintained to close and latch. This was evidenced by corridor doors that failed to close, were impeded from closing, missing hardware, and latching hardware that was impeded. This affected 6 of 11 floors in the Main Hospital and 2 of 3 floors of the Medical Office Building South (MOBS). This could allow the spread of smoke or flames, in the event of a fire causing potential harm to patients, staff and visitors.

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 corridor doors were tested and observed and staff were interviewed.

Main Hospital-Hillcrest on 12/09/13:
1. At 1:41 p.m., the self-closing corridor door to the Room 11-1137 failed to close and latch.

2. At 3:36 p.m., the door to Room 8-823 was impeded from closing with a trash can in between the door frame and the door. The door was opened to its fullest extent without closing and latching without assistance (removing the trash can).

Main Hospital-Hillcrest on 12/10/13:
3. At 9:04 a.m., the door to Room 6-624 was impeded from closing with a trash can in between the door frame and the door. The door was opened to its fullest extent without closing and latching without assistance (removing the trash can).

4. At 3:54 p.m., the latching hardware to the door to Room 1-434 was impeded from closing with white tape over the latch. At 3:55 p.m., RN A1 said during an interview that "the lock to the door stopped working yesterday and that is why the tape is over the door latch".

Main Hospital-Hillcrest on 12/11/13:
5. At 11:06 a.m., the self-closing door to ultrasound Room 4 (Room 1-612) was failing to latch when tested.

6. At 11:10 a.m., the self-closing door to Room 1-525 failed to latch when tested.

Main Hospital-Hillcrest on 12/12/13:
7. At 8:04 a.m., the self-closing door to Room 1-408 was impeded from closing with an unattended bed 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, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed latch, failed to release from the magnets, and were impeded from closing. This could result in failure to contain smoke during a fire leading to harm to the patients. This affected 3 of 11 floors in the Main Hospital and 1 of 4 floors at Thornton Hospital.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

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 12/10/13 through 12/13/13, the facility smoke barrier doors were observed.


Main Hospital-Hillcrest on 12/10/13:
1. At 4:09 p.m., the smoke barrier door 1-400D was impeded from closing with an unattended linen cart in front of the door path.


Main Hospital-Hillcrest on 12/11/13:
2. At 8:21 a.m., the smoke barrier door 1-324 was impeded from closing with an unattended cart in front of the door path.

3. At 9:12 a.m., the south smoke barrier door 7-308 was not latching when tested. The top portion of the door would bounce and stay unlatched.

4. At 11:17 a.m., the Hosp-1-9 smoke barrier doors were not latching when tested.

5. At 11:20 a.m., the smoke barrier door 1-400D (ED) was not latching when tested.

6. At 1:23 p.m., the north smoke barrier door near Room 1-112 failed to release from its hold open magnet device and closing.
7. At 1:44 p.m. there was a rolling fire door(WON) connected to the fire alarm system that was impeded with a three file sorter in the door path by Room 2-402A.

8. At 2:30 p.m., the smoke barrier doors L-315A failed to release from the magnet hold open devices and close.

9. At 2:50 p.m., the west smoke barrier door Hosp B-4 failed to latch when tested.

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.

Based on observation, the facility failed to ensure that their automatic sprinkler system was inspected, tested and maintained in accordance with NFPA 25, 1998 edition. This was evidenced by sprinklers covered with foreign matter. This affected 1 of 11 floors in the Main Hospital and 1 of 1 floors in the West Wing. This could result in the failure of the sprinkler system in the event of a fire, increasing the risk of harm to the patients.

NFPA 101, Life Safety Code, 2000 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

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.

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 12/11/13:
1. At 1:56 p.m., there were two sprinklers near the southwest portion of the grill area in the Cafeteria that were 100% covered with foreign matter.




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Hillcrest West Wing Behavioral Health Building on 12/12/13:
2. At 1:41 p.m., the sprinkler escutcheon ring was missing in room 310 closet.

3. At 1:51 p.m., there were 2 of 2 sprinkler escutcheon rings that had gaps and were not flush with the ceiling in room 446A.

4. At 2:11 p.m., there was a sprinkler escutcheon ring missing in clean utility room 613.

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.

Medical Office Building South (MOBS) on 12/13/13:

4. At 11:22 a.m., the was no documented evidence of the fire extinguisher near Room 3-333 was being inspected at intervals of thirty days or less for five consecutive months (May, June, July, August, and September 2013). The fire extinguisher was last inspected on 4/13 and 12/13.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers as evidenced by extinguisher with an inspection date greater than monthly intervals, a fire extinguisher mounted greater than 60 inches high, and a fire extinguisher that was blocked from access. This affected 3 of 11 floors in the Main Hospital,1 of 3 floors of the Medical Office Building South (MOBS) and 1 of 4 floors at Thornton Hospital, this had the potential for some persons not to be able to access the extinguisher, or potential for a fire extinguisher to fail.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

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 fire extinguishers were observed and a staff person was interviewed.

Main Hospital-Hillcrest on 12/09/13:
1. At 11:38 a.m., there was no documented evidence for the monthly inspection of the fire extinguisher in the Penthouse for the months of August, September, October, and November of 2013. The fire extinguisher was last inspected on 7/13 and 12/13. At 11:40 a.m., the Supervisor of Plant Operations said during an interview that the fire extinguisher was replaced sometime this month from one that is stored as replacement fire extinguishers. Those fire extinguishers are not checked monthly.

Main Hospital-Hillcrest on 12/10/13:
2. At 10:41 a.m., the fire extinguisher near Room 3-145 was impeded from access with a linen cart in front of the device.

Main Hospital-Hillcrest on 12/12/13:
3. At 8:12 a.m., the fire extinguisher on the oxygen fence was mounted 6 feet 8 inches from the top of the extinguisher to the ground.

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 12/10/13- Lower Level:

19. At 1:10 p.m., there was a power strip plugged into another power strip behind the printer desk and a missing electrical face plate in room L116. This was acknowledged by staff during survey.

20. At 1:58 p.m., in the Telecom Data Processing room L113, there was a power strip plugged into a power strip. This was acknowledged by staff during the survey.

MOBS on 12/12/13:

17. At 11:40 a.m., there was a six plug adapter in Room 2-201 (Registration) attached to the wall with a multi-plug power strip plugged in.

18. At 1:22 p.m., there was a electrical outlet with the top portion of the cover that was broken off in Room 1-132. Approximately 1/3 of the top portion of the cover plate was missing.

Based on observation, the facility failed to maintain the electrical safety in accordance with NFPA 70, 1999 edition. This was evidenced by using extension cords, multi-plug adapters with appliances plugged in, multi-plug adapter plugged into multi-plugged adapters, broken outlet faceplates, and blocked electrical panels. This affected patient, staff and visitors in 8 of 11 floors of the Main Hospital, 1 of 1 floors in the West Wing, 1 of 3 floors in the Medical Office Building South (MOBS), and 1 of 4 floors at Thornton Hospital. This failure could increase the risk of an electrical fire and delay access to obstructed electrical panels.

NFPA 70 National Electrical Code, (1999) Edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

NFPA 70, National Electrical Code (1999) Edition, article 110-26(a)(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.

NFPA 70, National Electrical Code (1999) Edition, article 110-26(3)(b) Clear Spaces. Working space required by this section shall not be used for storage.

NFPA 70, National Electrical Code(1999) Edition 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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's electrical equipment and wiring were observed.

Main Hospital-Hillcrest on 12/09/13:
1. At 2:18 p.m., there was a broken red outlet cover near Room 10-257A. The top 1/4 of the four plug outlet cover was broken.

2. At 2:41 p.m., the electrical panel in Room 9-305 was blocked from access with an unattended bed in front of the panel.

3. At 3:26 p.m., electrical panel 8LB1 in Room 8-151 was impeded from access with a 32 gallon trash can in front of the panel.

Main Hospital-Hillcrest on 12/10/13:
4. 8:28 a.m., there was a white extension cord plugged into a green multi-plug adapter in use in Room 7-722.

5. At 8:45 a.m., there was a refrigerator and microwave plugged into a multi-plug adapter and not directly into an electrical wall outlet in Room 6-311.

6. At 9:21 a.m., there was a multi-plug adapter plugged into another multi-plug adapter in Room 5-307.

7. At 9:47 a.m., there was a refrigerator plugged into an orange extension cord in Room 4-310.

8. At 2:36 p.m., there was a 4 plug electrical box without a faceplate on it in Room 2-325.

9. At 3:10 p.m., the electrical panel OR8E was impeded from access with a profusion machine (Medical device).

10. At 4:03 p.m., there was an orange extension cord in use in Room 1-407.

Main Hospital-Hillcrest on 12/11/13:
11. At 8:22 a.m., there was an orange extension cord where a printer and computer in Room 1-324 plugged into.




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Hillcrest West Wing-Behavioral Health Building on 12/12/13:

12. At 1:28 p.m., there was a power strip plugged into another power strip next to the desk in the volunteer's room 101. This was acknowledged by staff during the survey.

13. At 1:34 p.m., in the Medical Student Lounge room 105, the refrigerator and microwave was plugged into a power strip and not directly into the wall receptacle. This was acknowledged by staff during the survey.

14. At 1:58 p.m. there was a power strip plugged into a power strip in room 510.

15. At 2:17 p.m., there was a power strip plugged into a power strip in doctor's office room 601.

16. At 2:32 p.m., there was a power strip plugged into a power strip, then plugged into a 6 outlet wall adapter that had no over current protection. This was acknowledged by staff during 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.

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.


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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 and interview, the facility failed to ensure that corridor doors were maintained to close and latch. This was evidenced by corridor doors that failed to close, were impeded from closing, missing hardware, and latching hardware that was impeded. This affected 6 of 11 floors in the Main Hospital and 2 of 3 floors of the Medical Office Building South (MOBS). This could allow the spread of smoke or flames, in the event of a fire causing potential harm to patients, staff and visitors.

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 corridor doors were tested and observed and staff were interviewed.

Main Hospital-Hillcrest on 12/09/13:
1. At 1:41 p.m., the self-closing corridor door to the Room 11-1137 failed to close and latch.

2. At 3:36 p.m., the door to Room 8-823 was impeded from closing with a trash can in between the door frame and the door. The door was opened to its fullest extent without closing and latching without assistance (removing the trash can).

Main Hospital-Hillcrest on 12/10/13:
3. At 9:04 a.m., the door to Room 6-624 was impeded from closing with a trash can in between the door frame and the door. The door was opened to its fullest extent without closing and latching without assistance (removing the trash can).

4. At 3:54 p.m., the latching hardware to the door to Room 1-434 was impeded from closing with white tape over the latch. At 3:55 p.m., RN A1 said during an interview that "the lock to the door stopped working yesterday and that is why the tape is over the door latch".

Main Hospital-Hillcrest on 12/11/13:
5. At 11:06 a.m., the self-closing door to ultrasound Room 4 (Room 1-612) was failing to latch when tested.

6. At 11:10 a.m., the self-closing door to Room 1-525 failed to latch when tested.

Main Hospital-Hillcrest on 12/12/13:
7. At 8:04 a.m., the self-closing door to Room 1-408 was impeded from closing with an unattended bed 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, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed latch, failed to release from the magnets, and were impeded from closing. This could result in failure to contain smoke during a fire leading to harm to the patients. This affected 3 of 11 floors in the Main Hospital and 1 of 4 floors at Thornton Hospital.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

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 12/10/13 through 12/13/13, the facility smoke barrier doors were observed.


Main Hospital-Hillcrest on 12/10/13:
1. At 4:09 p.m., the smoke barrier door 1-400D was impeded from closing with an unattended linen cart in front of the door path.


Main Hospital-Hillcrest on 12/11/13:
2. At 8:21 a.m., the smoke barrier door 1-324 was impeded from closing with an unattended cart in front of the door path.

3. At 9:12 a.m., the south smoke barrier door 7-308 was not latching when tested. The top portion of the door would bounce and stay unlatched.

4. At 11:17 a.m., the Hosp-1-9 smoke barrier doors were not latching when tested.

5. At 11:20 a.m., the smoke barrier door 1-400D (ED) was not latching when tested.

6. At 1:23 p.m., the north smoke barrier door near Room 1-112 failed to release from its hold open magnet device and closing.
7. At 1:44 p.m. there was a rolling fire door(WON) connected to the fire alarm system that was impeded with a three file sorter in the door path by Room 2-402A.

8. At 2:30 p.m., the smoke barrier doors L-315A failed to release from the magnet hold open devices and close.

9. At 2:50 p.m., the west smoke barrier door Hosp B-4 failed to latch when tested.

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.

Based on observation, the facility failed to ensure that their automatic sprinkler system was inspected, tested and maintained in accordance with NFPA 25, 1998 edition. This was evidenced by sprinklers covered with foreign matter. This affected 1 of 11 floors in the Main Hospital and 1 of 1 floors in the West Wing. This could result in the failure of the sprinkler system in the event of a fire, increasing the risk of harm to the patients.

NFPA 101, Life Safety Code, 2000 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

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.

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 12/11/13:
1. At 1:56 p.m., there were two sprinklers near the southwest portion of the grill area in the Cafeteria that were 100% covered with foreign matter.




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Hillcrest West Wing Behavioral Health Building on 12/12/13:
2. At 1:41 p.m., the sprinkler escutcheon ring was missing in room 310 closet.

3. At 1:51 p.m., there were 2 of 2 sprinkler escutcheon rings that had gaps and were not flush with the ceiling in room 446A.

4. At 2:11 p.m., there was a sprinkler escutcheon ring missing in clean utility room 613.

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.

Medical Office Building South (MOBS) on 12/13/13:

4. At 11:22 a.m., the was no documented evidence of the fire extinguisher near Room 3-333 was being inspected at intervals of thirty days or less for five consecutive months (May, June, July, August, and September 2013). The fire extinguisher was last inspected on 4/13 and 12/13.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers as evidenced by extinguisher with an inspection date greater than monthly intervals, a fire extinguisher mounted greater than 60 inches high, and a fire extinguisher that was blocked from access. This affected 3 of 11 floors in the Main Hospital,1 of 3 floors of the Medical Office Building South (MOBS) and 1 of 4 floors at Thornton Hospital, this had the potential for some persons not to be able to access the extinguisher, or potential for a fire extinguisher to fail.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

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 fire extinguishers were observed and a staff person was interviewed.

Main Hospital-Hillcrest on 12/09/13:
1. At 11:38 a.m., there was no documented evidence for the monthly inspection of the fire extinguisher in the Penthouse for the months of August, September, October, and November of 2013. The fire extinguisher was last inspected on 7/13 and 12/13. At 11:40 a.m., the Supervisor of Plant Operations said during an interview that the fire extinguisher was replaced sometime this month from one that is stored as replacement fire extinguishers. Those fire extinguishers are not checked monthly.

Main Hospital-Hillcrest on 12/10/13:
2. At 10:41 a.m., the fire extinguisher near Room 3-145 was impeded from access with a linen cart in front of the device.

Main Hospital-Hillcrest on 12/12/13:
3. At 8:12 a.m., the fire extinguisher on the oxygen fence was mounted 6 feet 8 inches from the top of the extinguisher to the ground.

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 12/10/13- Lower Level:

19. At 1:10 p.m., there was a power strip plugged into another power strip behind the printer desk and a missing electrical face plate in room L116. This was acknowledged by staff during survey.

20. At 1:58 p.m., in the Telecom Data Processing room L113, there was a power strip plugged into a power strip. This was acknowledged by staff during the survey.

MOBS on 12/12/13:

17. At 11:40 a.m., there was a six plug adapter in Room 2-201 (Registration) attached to the wall with a multi-plug power strip plugged in.

18. At 1:22 p.m., there was a electrical outlet with the top portion of the cover that was broken off in Room 1-132. Approximately 1/3 of the top portion of the cover plate was missing.

Based on observation, the facility failed to maintain the electrical safety in accordance with NFPA 70, 1999 edition. This was evidenced by using extension cords, multi-plug adapters with appliances plugged in, multi-plug adapter plugged into multi-plugged adapters, broken outlet faceplates, and blocked electrical panels. This affected patient, staff and visitors in 8 of 11 floors of the Main Hospital, 1 of 1 floors in the West Wing, 1 of 3 floors in the Medical Office Building South (MOBS), and 1 of 4 floors at Thornton Hospital. This failure could increase the risk of an electrical fire and delay access to obstructed electrical panels.

NFPA 70 National Electrical Code, (1999) Edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

NFPA 70, National Electrical Code (1999) Edition, article 110-26(a)(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.

NFPA 70, National Electrical Code (1999) Edition, article 110-26(3)(b) Clear Spaces. Working space required by this section shall not be used for storage.

NFPA 70, National Electrical Code(1999) Edition 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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's electrical equipment and wiring were observed.

Main Hospital-Hillcrest on 12/09/13:
1. At 2:18 p.m., there was a broken red outlet cover near Room 10-257A. The top 1/4 of the four plug outlet cover was broken.

2. At 2:41 p.m., the electrical panel in Room 9-305 was blocked from access with an unattended bed in front of the panel.

3. At 3:26 p.m., electrical panel 8LB1 in Room 8-151 was impeded from access with a 32 gallon trash can in front of the panel.

Main Hospital-Hillcrest on 12/10/13:
4. 8:28 a.m., there was a white extension cord plugged into a green multi-plug adapter in use in Room 7-722.

5. At 8:45 a.m., there was a refrigerator and microwave plugged into a multi-plug adapter and not directly into an electrical wall outlet in Room 6-311.

6. At 9:21 a.m., there was a multi-plug adapter plugged into another multi-plug adapter in Room 5-307.

7. At 9:47 a.m., there was a refrigerator plugged into an orange extension cord in Room 4-310.

8. At 2:36 p.m., there was a 4 plug electrical box without a faceplate on it in Room 2-325.

9. At 3:10 p.m., the electrical panel OR8E was impeded from access with a profusion machine (Medical device).

10. At 4:03 p.m., there was an orange extension cord in use in Room 1-407.

Main Hospital-Hillcrest on 12/11/13:
11. At 8:22 a.m., there was an orange extension cord where a printer and computer in Room 1-324 plugged into.




21101

Hillcrest West Wing-Behavioral Health Building on 12/12/13:

12. At 1:28 p.m., there was a power strip plugged into another power strip next to the desk in the volunteer's room 101. This was acknowledged by staff during the survey.

13. At 1:34 p.m., in the Medical Student Lounge room 105, the refrigerator and microwave was plugged into a power strip and not directly into the wall receptacle. This was acknowledged by staff during the survey.

14. At 1:58 p.m. there was a power strip plugged into a power strip in room 510.

15. At 2:17 p.m., there was a power strip plugged into a power strip in doctor's office room 601.

16. At 2:32 p.m., there was a power strip plugged into a power strip, then plugged into a 6 outlet wall adapter that had no over current protection. This was acknowledged by staff during survey.