HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of their fire barrier walls on horizontal corridor connections by providing at least a 2-hour fire barrier wall protection rating. This was evidenced by penetrations in the fire barrier wall between the Service Building (Svc Building) and Old Administration (OA) Building, affected 1 of 5 floors in S.B. and 1 of 5 floors in OA Building at the Highlands Campus. This had the potential to allow the spread of smoke and fire from one building to another building, resulting in injury to patients, staff, and visitors.

Findings:

During a tour of the facility with Staff-2 from 4/3/2012 through 4/6/2012, the fire barrier walls were observed.

Highland Campus - Svc Building and OA Building
1. On 4/3/2012, at 3:44 p.m., on the Basement Floor between Svc Building and OA Building, the fire barrier wall had two openings above the cross corridor fire doors. The first opening measured approximately 6 x 2-feet and the second opening measured approximately 1-1/2 x 1 feet. Both buildings where nonconforming to requirements of the Life Safety Code.

Based on interview and observation, the facility failed to maintain the building construction, as evidenced by penetrations found in walls and ceilings. This deficient condition affected two of six floors in Building K at the Highlands Campus and could result in the spread of smoke from one area of the facility to another area.

NFPA 101 Life Safety Code, 2000 edition
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire 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 fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following
conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with staff members, the building construction was observed.
Highlands Campus - Building K
1. On 4/03/12, at 11:35 a.m., on the 7th floor in room 7067, there were three penetrations along the left hand wall of Infusion Room B. Two penetrations were approximqately 5" X 2" and one was approximately 3" by 2".
2. On 4/03/12, at 11:52 a.m., on the 7th floor room 7118, there was a hole in the wall behind bed 4 of the Cast Room. The opening in the wall was approximately 8" X 5".
3. On 4/03/12, at 2:51 p.m., on the 4th floor by the State Disability Coordinator Office door, there was a three inch penetration in the ceiling above the door.

Based on observation, the facility failed to maintain the integrity of the building construction of corridor walls. This was evidenced by penetrations on corridor walls. This affected 1 of 5 floors in the OA Building at the Highlands Campus, 1 of 5 floors in the Svc Building at the Highlands Campus and 1 of 10 floors in Building H at the Highlands Campus. This could result in the spread of fire and smoke and had the potential for harming patients, visitors, and staff.

Findings:

During a tour of the facility with Staff-2, the corridor walls were observed.

Highland Campus - OA Building
1. On 4/3/2012, at 3:04 p.m., on the Basement Floor above the door to the Environmental Services Manager's Office, the corridor wall had a penetration that measured approximately 2-inches.
2. On 4/3/2012, at 3:05 p.m., on the Basement Floor by the Environmental Services Manager's Office, the corridor wall had two penetrations that went into the elevator room. The penetrations measured approximately 2-inches each.
3. On 4/3/2012, at 3:06 p.m., on the Basement Floor by the Environmental Services Manager's Office, the corridor ceiling had a penetration that measured approximately 2 x 4-feet.
4. On 4/3/2012, at 3:07 p.m., on the Basement Floor above the cross corridor doors by the Information Technology area, the north corridor wall had two penetrations that measured approximately 1/2-inch each.
5. On 4/3/2012, at 3:13 p.m., on the Basement Floor by the storage closet containing telecom equipment in the Information Technology area, the corridor wall had two penetrations that measured approximately 1/2-inch each.
6. On 4/3/2012, at 3:15 p.m., on the Basement Floor in the Information Technology area, the corridor walls contained multiple penetrations going into offices. The penetrations ranged from 1/2-inch to 1-inch with some surrounding conduit pipes.
7. On 4/3/2012, at 3:19 p.m., on the Basement Floor in the Environmental Services area, the corridor walls contained multiple penetrations that ranged from 1/2-inch to 1-inch.

Highland Campus - Service Building
1. On 4/4/2012, at 9:48 a.m., on the 3rd Floor by the Department of Medicine Office, the corridor wall had a penetration by the door to the room located north from Classroom-C. The penetration measured approximately 1-inch and it had a cable running through it.




27893

Highland Campus - Building H
1. On 4/3/12, at 11:53 a.m., on the 9th floor near the back hallway for the Nursery, there was 1 approximately 5 inch by 1 inch unsealed penetration near the base of the corridor wall.
2. On 4/3/12, at 2:42 p.m., on the 8th floor near Room 8212, there were 2 approximately 1/2 inch diameter unsealed penetrations in the corridor wall.
3. On 4/4/12, at 2:32 p.m., on the 1st floor near the back of Central Supply, there were 32 approximately 1/2 inch diameter unsealed penetrations in the corridor wall.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that did not latch when closed, by self closing doors that failed to positively latch when tested and by doors that were obstructed and could not be readily closed. These conditions affected 7 of 10 floors in Building H of the Highlands Campus, 1 of 1 floor in the John George Building and 1 of 2 floors in Building H at the Fairmont Campus which had the potential to allow the migration of smoke.

NFPA 101 Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.
7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.


27893

Findings:

During a facility tour with staff, the doors in the facility were observed.

Highland Campus - Building H
1. On 4/3/12, at 12:09 p.m., on the 9th floor, the corridor door to Waiting Room 9103 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a magazine stand placed directly in the swing path of the door. The magazine stand was relocated and the door was allowed to close. The door failed to close. The door failed to close due to a chair located directly in the swing path of the door.
2. On 4/3/12, at 2:00 p.m., on the 8th floor, the corridor door to the Clean Linen Closet across from Room 8113 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by a linen cart stored in that room.
3. On 4/3/12, at 2:06 p.m., on the 8th floor, a 20 minute fire rated cross corridor door near Room 8119 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a chair placed directly in the swing path of the door.
4. On 4/3/12, at 2:12 p.m., on the 8th floor, the door to Shower Room 8201A was equipped with a roller style latch.
5. On 4/3/12, at 2:21 p.m., on the 8th floor, the corridor door to the Office across from Room 8209 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a door wedge placed under the door leaf.
6. On 4/3/12, at 3:05 p.m., on the 7th floor, the corridor door to the Clean Utility Room across from Room 7402 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
7. On 4/3/12, at 3:43 p.m., on the 6th floor, the corridor door to Room 6211 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
8. On 4/3/12, at 3:49 p.m., on the 6th floor, the corridor door to the Data Hub-A Room was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
9. On 4/3/12, at 3:52 p.m., on the 6th floor, the corridor door to the Video Storage Room near Room 6101 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
10. On 4/3/12, at 4:02 p.m., on the 6th floor, the corridor door to the Waiting Room near room 6316 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
11. On 4/3/12, at 4:06 p.m., on the 6th floor, the corridor door to the Janitor Closet near Room 6304 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
12. On 4/4/12, at 9:33 a.m., on the 5th floor, the corridor door to the Staff Break Room 5113 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
13. On 4/4/12, at 9:49 a.m., on the 5th floor, the corridor door to the Medication Room near Room 5410 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
14. On 4/4/12, at 10:05 a.m., on the 5th floor, the corridor door to the Central Supply Room near Room 5213 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
15. On 4/4/12, at 10:10 a.m., on the 5th floor, the corridor door to Data Hub-A Room across from Room 5202 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
16. On 4/4/12, at 10:13 a.m., on the 4th floor, the corridor door to the Intensive Care Unit (ICU) Family Waiting Room was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a chair positioned directly in the swing path of the door. The chair was relocated and the door was allowed to close. The door failed to latch. The door failed to latch due to insufficient closing force from the self-closing device.
17. On 4/4/12, at 10:17 a.m., on the 4th floor, the corridor door to Staff Office 4153 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
18. On 4/4/12, at 10:21 a.m., on the 4th floor, the corridor door to the Equipment Storage Room across from ICU Room 2 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
19. On 4/4/12, at 10:24 a.m., on the 4th floor, 2 of 2 corridor doors to the ICU Clean Utility Room were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. 2 of 2 doors failed to latch. The doors were obstructed from latching by the door frames.
20. On 4/4/12, at 10:29 a.m., on the 4th floor, the fire rated door to the Old Report Room near ICU Room 14 was observed. The interior face of the door had an approximately 2 foot by 3 foot cork board attached to it. There was no documentation that indicated the cork board was flame resistant or had been treated with a fire retardant substance.
21. On 4/4/12, at 10:30 a.m., on the 4th floor, the corridor door to the Employee Bathroom near ICU Room 16 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
22. On 4/4/12, at 10:45 a.m., on the 4th floor, the corridor door to Room D failed to latch when in the closed position.
23. On 4/4/12 at 11:11 a.m., on the 4th floor, the 20 minute fire rated cross corridor door leading from the ICU to a Storage Area was observed. The door was equipped with a self-closing device and panic hardware. The door failed to latch when in the closed position.

Fairmont Campus - Building H
1. On 4/4/12, at 4:29 p.m., on the 2nd floor, the corridor door to Dining Room 218 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to insufficient closing force from the self-closing device.
2. On 4/4/12, at 4:31 p.m., on the 2nd floor, the corridor door to Janitor Closet Room 227 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
3. On 4/4/12, at 4:34 p.m., on the 2nd floor, the corridor door to Room 222 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Fairmont Campus - John George Building
1. On 4/5/12, at 10:47 a.m., the corridor door to Room C16 was obstructed from closing by a towel placed over the top of the door leaf.

Based on observation, the facility failed to protect their vertical openings. This was evidenced by doors to vertical shaft rooms that were obstructed from closing or latching and by doors to stairwells that did not latch when closed. This affected 10 of 10 floors in Building H at the Highlands Campus, 1 of 4 floors in the E Wing at the Highlands Campus, 2 of 4 floors in the Svc Building at the Highlands Campus and 2 of 4 floors in the A Wing at the Highlands Campus. This deficient condition could result in a delay to contain smoke or fire to a floor.

Findings:

During a facility tour with staff, the vertical openings in the facility were observed.

Highland Campus - Building H
1. On 4/4/12, at 11:42 a.m., on the 1st floor, 2 of 2 doors to the Conveyor Room were equipped with self-closing devices. Door 1 was held in the open position and was obstructed from closing by a clear tubing that was tied to the door handle and to a nearby shelf. Door 2 was obstructed from latching due to the latching barrel that was taped down in the retracted position by clear tape. The vertical conveyor shaft spanned 10 of 10 floors in the building.



29626


NFPA 101, Life Safety Code, 2000 Edition
19.3.1.2 A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position.

During a tour of the facility with staff members, the vertical openings in the facility were observed.

Highland Campus - E Wing
1. On 4/3/2012, at 11:31 a.m., on the 3rd Floor in the West Stairwell, a penetration was in the wall by the door. The penetration measured approximately 1-inch and it had a black cable (connecting to an antenna) running through the hole.

Highlands Campus - Service Building
1. On 4/3/2012, at 4:15 p.m., on the 2nd Floor by the loading dock area, the stairwell door had its door knob removed.
2. On 4/4/2012, at 9:38 a.m., on the 3rd Floor along the egress pathway leading into the H-Building breeze way, there were two penetrations on the ground by Classroom-C that created a vertical opening. The penetrations measured approximately 1-inch each with visible light coming up from the docking area.
3. On 4/4/2012, at 9:58 a.m., on the 3rd Floor in the Plumber's Room, there was a penetration on the wall that leads into a vertical shaft. The penetration measured approximately 2 x 4-inches.

Highlands Campus - A Wing
1. On 4/4/2012, at 9:28 a.m., on the 3rd Floor in the East Stairwell by the Service Building, the stairwell door did not self-close.
2. On 4/4/2012, at 11:17 a.m., on the 2nd Floor in the West Stairwell by the Department of Medicine, there was a penetration on the wall that measured approximately 1-inch.

Highlands Campus - H Building
1. On 4/4/2012, at 2:20 p.m., on the 3rd Floor in Stairwell 1 H-3 by the Radiologist Coordinator Office, the stairwell door did not positive latch. The door had a latching mechanism installed.

Based on observation, the facility failed to ensure that fire and smoke barrier doors be held open with devices that release upon activation of the fire alarm system and automatically close. This was evidenced by doors that were held open by unapproved methods. This affected 1 of 5 floors in the Svc Building at the Highlands Campus and 2 of 5 floors in the OA Building at the Highlands Campus. This could result in the spread of fire and smoke during a fire, and potentially harm patients, staff, and visitors.

Findings:

During a tour of the facility with Staff-2, the fire and smoke barrier doors were observed.

Highlands Campus - Svc Building
1. On 4/3/2012, at 11:56 a.m., on the 3rd Floor by the Podiatry Office, the stairwell door was held open by a rubber wedge.

Highlands Campus - OA Building
1. On 4/3/2012, at 3:47 p.m., on the Basement Floor between Svc Building and OA Building, 2 of 2 cross corridor fire doors were held open by metal wedges.
2. On 4/4/2012, at 9:51 a.m., on the 3rd Floor by the Pathfinders Program Office, 1 of 2 cross corridor doors was held open by a plastic bag that was tide to the door handle.

Based on observation, the facility failed to maintain their exits as evidenced by not posting directional signs to or at the nearest exits. This affected 1 of 10 floors in Building H at the Highlands Campus, 1 of 4 floors in E Wing at the Highlands Campus, 1 of 4 floors in the OA Building at the Highlands Campus, and 1 of 4 floors in the OA Building at the Highlands Campus. This condition could result in a delayed evacuation in the event of an emergency.

Findings:

During a facility tour with staff, the exit directional signs in the facility were observed.

Highland Campus - Building H
1. On 4/4/12, at 11:04 a.m., on the 4th floor, the Admitting/Financial Counseling Office was observed. The office area was missing approximately 2 exit directional signs leading toward 2 exit doors from that area. The way to exit the office area was not readily apparent from all interior locations.


29626


NFPA 101, Life Safety Code, 2000 Edition
7.7.3 The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

Highland Campus - E Wing
1. On 4/3/2012, at 11:32 a.m., on the 4th Floor West Stairwell, there was no exit sign placed by the stairwell door and no directional sign for occupants evacuating from the Service Building. The exit was not readily apparent.

Highland Campus - OA Building
1. On 4/3/2012, at 2:19 p.m., on the 1st Floor in the South-West section of the building, there was no directional sign in the exit discharge area that would direct evacuees to the public way. Two of two available discharge pathways were not readily apparent.

Highland Campus - B Wing
1. On 4/4/2012, at 10:04 a.m., on the 4th Floor West Stairwell, there was no exit sign placed by the stairwell door. The exit was not readily apparent.
2. On 4/4/2012, at 10:53 a.m., on the Basement Floor, there was no exit sign and no directional sign placed towards exits from the carpenter's shop. The exit was not readily apparent.

Based on observation and interview, the facility failed to maintain fire doors as evidenced by fire doors that did not fully close and latch, and by fire doors that were obstructed. These deficient conditions affected 2 of 10 floors in Building H at the Highlands Campus and could result in the spread of smoke in the event of a fire.

NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings
During a tour of the facility with staff, the smoke barriers and facility fire doors were observed:
Highlands Campus - Building H
1. On 4/05/12, at 2:44 p.m., on the 3rd floor by the elevator lobby FDR#3-03, released upon activation of the fire alarm system but failed to fully close and positively latch.
2. . On 4/05/12, at 2:46 p.m., on the 3rd floor by stairwell 2 FDR#3-01, released upon activation of the fire alarm system but failed to fully close and positively latch.


27893


Highland Campus - Building H
1. On 4/3/12, at 3:15 p.m., on the 7th floor, the smoke barrier door near Room 7219 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to close. The door was obstructed from closing due to the door leaf dragging on the floor. The door was pushed to the closed position and the door failed to latch. The door was missing latching hardware. There was no visible fire rating tag on the door edges.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by hazardous area doors that were obstructed from closing or latching and hazardous area doors that were not equipped with self-closing or automatic closing devices. This affected 2 of 10 floors in Building H at the Highlands Campus and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff, the hazardous areas in the facility were observed.

Highlands Campus - Building H
1. On 4/3/12, at 11:50 a.m., on the 9th floor, the corridor door to the Dirty Utility Room across from Room 9207 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to the latching barrel stuck in the retracted position.
2. On 4/4/12, at 10:55 a.m., on the 4th floor, the Supply Room in the Specialty Care (H-4) Clinic was observed to be greater than 50 square feet in area. The room contained paper products, 2 oxygen E cylinders, and other combustible items. The corridor door to the room was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.
3. On 4/4/12, at 10:58 a.m., on the 4th floor, the Dirty Utility Room in the Specialty Care (H-4) Clinic was observed. The corridor door to the room was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.

Based on observation, the facility failed to protect their gift shops. This was evidenced by one gift shop door that was obstructed from closing. This affected 1 of 10 floors in Building H at the Highlands Campus and could result in a delay to contain smoke or fire to the gift shop.

Findings:

During a facility tour with staff, the gift shops were observed.

Highland Campus - Building H
1. On 4/4/12, at 10:39 a.m., on the 4th floor, the corridor door to the Gift Shop was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a door wedge positioned under the door leaf. The self-closing device on the door was equipped with a hold-open device. The hold-open device was not functioning.

Based on observation, the facility failed to maintain their stairways. This was evidenced by one door to a stairway that was obstructed from latching. This affected 1 stairway door in Building H at the Highlands Campus and could result in a delay to prevent the passage of smoke or fire into the stairway.

Findings:

During a facility tour with staff, the stairway doors were observed.

Highlands Campus - Building H
1. On 4/4/12, at 11:37 a.m., on the 1st floor, the corridor door to Stairway 2 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to misalignment of the latching hardware.

Based on observation, the facility failed to maintain stairs in accordance with NFPA 101. This was evidenced by obstructed egress. This affected 2 of 2 floors in the following areas: the OA Building, and A-Wing. This had the potential for delaying egress for patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
7.2.2 Stairs.
7.2.2.1 General. Stairs used as a component in the means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of this subsection.

7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

During a tour of the facility with Staff-2 from 4/3/2012 through 4/6/2012, the stairwells and their egress were observed.

Highlands Campus - OA Building
1. On 4/3/2012, at 2:02 p.m., between the 1st and 2nd Floor in the stairway landing, three windows were stored along the means of egress.
2. On 4/3/2012, at 2:08 p.m., on the 2nd Floor in the West Stairwell by the Internal Medicine Residency Program, two recycle bins obstructed the access to the stairwell. The first bin had a 64 gallon capacity and the second bin had a 96 gallon capacity.

Highlands Campus - A Wing
1. On 4/4/2012, at 11:16 a.m., on the 2nd Floor in the West Stairwell by the Department of Medicine, there was a housekeeping bin that was stored along the means of egress.

2. On 4/4/2012, at 11:20 a.m., on the 3rd Floor in the West Stairwell, there was a trash can that was stored along the means of egress.

Based on interview and observation, the facility failed to maintain their emergency exits, as evidenced exit discharge areas that were obstructed. this deficient condition affected three of six floors in Building H at the Highlands Campus and could result in a delay of egress in the event of an emergency evacuation.

NFPA 101 Life Safety Code, 2000 edition
4.5.3 Means of Egress.
4.5.3.2 Unobstructed Egress. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. No lock or fastening shall be permitted that prevents free escape from the inside of any building other than in health care occupancies and detention and correctional occupancies where staff are continually on duty and effective provisions are made to remove occupants in case of fire or other emergency. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.
7.1.3.2.3* An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2.2 There shall be no obstructions by railings, barriers, or gates that divide the open space into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment.



Findings:

During a tour of the facility with staff members, the emergency exits were observed.
Highlands Campus - Building K
1. On 4/03/12, at 1:57 p.m., on the 6th floor by rest room H6121, a Breast Feeding Education Center had been set up along the corridor to the emergency exit. The door at the end of the hallway was designated with an illuminated Exit sign. Staff confirmed that the door is used as part of the emergency egress route.
2. On 4/03/12, at 2:40 p.m., on the 5th floor by exit door # 5058, two operating room machines were blocking the passage through the exit door. Staff stated that the machines are not usually stored in that area.
3. On 4/05/12, at 11:14 a.m., on the 4th floor in the Emergency Department, a triage area with a gurney, table and rolling privacy curtains had been set up in front of a door designated with an illuminated Exit sign. The triage area minimized the passage way from 8 feet to approximately 3 feet. The privacy curtains blocked the visibility of the illuminated exit sign. Staff confirmed that the triage area is always set up in that area.

3. At 10:17 a.m., the panic hardware on the exit access doors by Resident room 39 and Resident Room 40, was obstructed by pink curtains hanging from the exit doors, and completely covered the panic hardware. The panic hardware or push bar was obstructed by the window length curtain.

Based on observation, the facility failed to maintain illumination throughout means of egress as evidenced by lighting units that failed to illuminate. This condition affected 3 of 4 floors in the E Wing at the Highlands Campus and 1 of 4 floors in the Svc Building at the Highlands Campus. This could result in injury to patients, visitors, and staff during an evacuation.

Findings:

During a tour of the facility with Staff-2, the egress lighting units were observed.

Highlands Campus - E Wing
1. On 4/3/2012, at 11:30 a.m., on the 3rd Floor in the West Stairwell, there was no illumination in the stairwell from the 2nd Floor to the 4th Floor.

Highlands Campus - Service Building
1. On 4/3/2012, at 3:50 p.m., on the Basement Floor in the stairwell by the salvage area, there was no illumination in the stairwell from the Basement Floor to the 1st Floor.

Based on document review and staff interview, the facility failed to to ensure that staff members are instructed in life safety procedures and devices as evidenced by not conducting four fire drills in Building K . This deficient condition affected six of six floors and could result in the lack of staff knowledge in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2 Procedure in Case of Fire.
19.7.2.1* For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined
in the fire safety plan.

Findings

During document with staff members, the fire drill records were observed.
Highlands campus - Building K
1. On 4/04/12, at 2:30 p.m., the fire drill records for Building H and Building K were observed. of 12 fire drills performed in the past 12 months, only one fire drill was activated in Building K. During staff interview, staff stated that staff in Building K report back with response sheets that state the alarm was heard, doors closed and that an announcement was heard.

Based on document review, and staff interview, the facility failed to maintain the fire alarm system as evidenced by chimes that were not audile, by strobes that did not function, by obstructed pull stations and by batteries for the Fire Alarm Control Panels that were not dated. These deficient practices affected 2 of 10 floors in Building H at the Highlands Campus, 1 of 4 floors in E-Wing, 1 of 4 floors in B-Wing, 1 of 4 floors in the OA Building at Highlands Campus, 1 of 1 floor in the John George Pavilion at the Fairmont Campus and 1 of 2 floors in Building H at the Fairmont Campus. These conditions could result in failure of the fire alarm system to alert staff and occupants of a fire.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.
9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system:
(1) Release of hold-open devices for doors or other opening protectives
(2) Stairwell or elevator shaft pressurization
(3) Smoke management or smoke control systems
(4) Emergency lighting control
(5) Unlocking of doors
19.3.4.4 Emergency Control. Operation of any activating device in the required fire alarm system shall be arranged to accomplish automatically any control functions to be performed by that device. (See 9.6.5.)

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.2.1 Location and Spacing
Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.
7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
Table 7-2.2 - 5. Batteries - General Tests - b. Battery Replacement Batteries shall be replaced in accordance with the recommendations of the alarm equipment manufacturer or when the recharged battery voltage or current falls below the manufacturer's recommendations.
Table 7-3.2 - 6. Batteries - Fire Alarm Systems - d. Sealed Lead-Acid Type 1. Charger Test (Replace battery every 4 years)

Findings

During fire alarm testing with staff members, the fire alarm devices were observed.
Highlands Campus - Building H
1. On 4/05/12, at 2:02 p.m., on the 6th floor, the chime/strobe combo # 6-1 did not function during fire alarm testing. There was no light or audible sound.
2. On 4/05/12, at 3:10 p.m., on the 1st floor, outside of the old operating rooms, there were three chime/strobe combo devices that failed to function during testing. The strobes did work but there was no audible sound. Staff stated that there have never been audibles heard in the area.
3. On 4/05/12, at 3:05 p.m., on the 1st floor, the chime/strobe combo # 1-5 did not function during fire alarm testing. The strobe did function but the audible failed to function.
4. On 4/05/12, at 3:06 p.m., on the 1st floor, the chime/strobe combo # 1-26 did not function during fire alarm testing. The strobe did function but the audible failed to function.
5. On 4/05/12, at 3:07 p.m., on the 1st floor, the chime/strobe combo # 1-29 did not function during fire alarm testing. The strobe did function but the audible failed to function.
6. On 4/05/12, at 3:07 p.m., on the 1st floor, the chime/strobe combo # 1-30 did not function during fire alarm testing. The strobe did function but the audible failed to function.
7. On 4/05/12, at 3:08 p.m., on the 1st floor, the chime/strobe combo # 1-31 did not function during fire alarm testing. The strobe did function but the audible failed to function.


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Findings:

During a facility tour with staff, the fire alarm system and components were observed.

Fairmont Campus - Building H
1. On 4/5/12, at 9:48 a.m., on the 1st floor, the fire alarm chime near Room 152A failed to emit an audible sound when the fire alarm system was tested.



29626

During a tour of the facility with Staff-2, the fire alarm devices were observed.

Highlands Campus - OA Building
1. On 4/3/2012, at 2:09 p.m., on the 2nd Floor in the West Stairwell by the Internal Medicine Residency Program, the manual fire alarm pull station was obstructed by two recycle bins. The first bin had a 64 gallon capacity and the second bin had a 96 gallon capacity.

Highlands Campus - H Building
1. On 4/5/2012, at 3:09 p.m., on the 1st Floor in the old surgical suite, no audible alarm notification was heard throughout the entire suite upon activating the Inspector's Test Valve.

Highland Campus - E Wing
1. On 4/5/2012, at 3:30 p.m., on the 2nd Floor in the Dental Service Unit, a chime failed to sound an alarm by Room 9 and the Dark Room DK2 when the manual pull station was activated.

Highland Campus - B Wing
1. On 4/5/2012, at 3:54 p.m., on the 2nd Floor in the Outpatient Psychiatric Unit, the Fire Control Panel (FCP) had a flashing troubled light with the silent button depressed. Also, the 12-Volt battery was not dated and Staff-3 did not know when the battery had been replaced. There was no evidence provided to show that the battery was within the manufacture's recommended lifespan or voltage.

John George Psychiatric Pavilion
1. On 4/5/2012, at 11:04 a.m., on the 1st Floor by the ambulance entrance, the main Fire Control Panel (FCP) had four batteries with one dated 7/29/2001. Engineer-2 and Staff-3 did not know when the batteries had been replaced. There was no evidence provided to show that the batteries were within the manufacture's recommended lifespan or voltage.
2. On 4/5/2012, at 11:42 a.m., on the 1st Floor in the East section of D-Unit, two locked gates in the patio failed to unlock upon activating the Inspector's Test Valve (sprinkler system water flow test). At 11:51 a.m., the smoke detector by D-16 was activated with canned smoke and the two locked gates in the patio failed to release. At 12:15 p.m., the pull station by the patio was activated and the two gates failed to unlock. Interim Life Safety Measures were initiated by staff at 1:24 p.m.


30514

Highland Campus - Building H
1. On 4/5/12, at 2:06 p.m., on the 7th floor by Room 6219, a table and chair was obstructing the manual pull station.

2. On 4/5/12, at 3:07 p.m., on the 1st floor in the old surgery area, three out of three strobe/horn combos had visual alarms, but no audible alarms.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by sprinkler head escutcheons that had dropped of the ceiling surface or had shifted off to one side and by sprinkler heads that had less than the required 18" clearance. This deficient condition affected two of six floors in Building K at the Highlands Campus and could result in the passage of smoke from one smoke compartment to another.

NFPA 13, Installation of Sprinkler System, 1999 Edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1: Where other standards specify greater minimums, they shall be followed.
Exception No. 2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.


Findings

During a tour of the facility with staff members, the sprinkler heads were observed.
Highlands Campus - Building K
1. On 4/03/12, at 12:00 p.m., on the 6th floor in room 6063, there was less than the required 18 inch clearance between the sprinkler head and the items on the top shelf.
2. On 4/03/12, at 12:06 p.m., on the 6th floor in room K6A across from room 6054, the sprinkler head escutcheon was missing and exposed a two inch penetration in the ceiling.

Based on observation and document review, the facility failed to maintain the portable fire extinguishers as evidenced by a fire extinguisher being past due for the annual service, and by a fire extinguisher that was had not been checked monthly in over four months. This deficient condition affected one of six floors in Building H at the Highlands Campus and could result in the failure of the fire extinguisher in the event of a fire.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
4-3.2 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 (1998 Edition) 4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Findings

During a tour of the facility with staff members, the fire extinguishers were observed.
Highlands Campus - Building K
1. On 4/03/12/12, at 11:19 a.m., on the 8th floor, the fire extinguisher (#CCBFE041) by the sprinkler riser had not been checked monthly since 11/2011.
2. On 4/03/12, at 11:20 a.m., on the 8th floor in the Elevator Room, the fire extinguisher (#CCBFE040) had not been checked monthly since 11/2011.

Based on observation, the facility failed to maintain their heating, ventilating, and air conditioning system. This was evidenced by the facility's use of household items that are not listed or approved for heating, ventilating, and air conditioning systems. This affected 1 of 10 floors in Building H at the Highlands Campus and could result in a malfunctioning heating, ventilating, and air conditioning system.

Findings:

During a facility tour with staff, the heating, ventilating, and air conditioning system was observed.

Highlands Campus - Building H
1. On 4/4/12, at 9:49 a.m., on the 5th floor, the Medication Room near Room 5410 was observed. An air distribution unit was observed attached to a ceiling vent with a cardboard box and duct tape. The cardboard box and duct tape were not listed or approved for that purpose.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices in accordance with 2000 edition NFPA 101, 1999 edition NFPA 99, and 1999 edition NFPA 70. This was evidenced by unapproved portable heaters in non-sleeping staff areas of the facility that did not have proper clearance from combustible materials in accordance with the manufacturer's labeled instructions and portable space heaters that were not verified to not exceed 212 degrees Fahrenheit. This affected 3 of 10 floors in Building H at the Highlands Campus and could result in the ignition of fire.

NFPA 99, 1999 edition
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator 's, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

NFPA 70, 1999 edition
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a facility tour with staff, electrical equipment was inspected throughout the facility.

Highlands Campus - Building H
1. On 4/3/12, at 4:18 p.m., on the 6th floor, a portable space heater was observed in Staff Office 6418. The portable space heater had a coil style heating element. The portable space heater was located on top of a table in that room and did not have three feet of clearance from furnishings or combustibles.
2. On 4/4/12, at 9:54 a.m., on the 5th floor, a portable space heater was observed in the Nurse Manager's Office near Room 5412. The portable space heater had a coil style heating element. The portable space heater was plugged into a surge protected multi-outlet extension cord and not directly to a dedicated electrical receptacle. The portable space heater was located on top of a cardboard box under a desk in that room. The portable space heater did not have three feet of clearance from furnishings or combustibles. Engineer 3 was interviewed at that time. Engineer 3 could not confirm that the portable space heater would not exceed 212 degrees Fahrenheit. Engineer 3 indicated that it was not a facility approved portable space heater.
3. On 4/4/12, at 10:15 a.m., on the 4th floor, a portable space heater was observed in Staff Office 4153. The portable space heater had a coil style heating element. Engineer 3 was interviewed at that time. Engineer 3 could not confirm that the portable space heater would not exceed 212 degrees Fahrenheit. Engineer 3 indicated that it was not a facility approved portable space heater.
4. On 4/4/12, at 10:46 a.m., on the 4th floor, a portable space heater was observed in the Social Workers Office located near the Main Entrance. The portable space heater had a coil style heating element. The portable space heater was located on top of a table in that room and did not have three feet of clearance from furnishings or combustibles. Engineer 3 was interviewed at that time. Engineer 3 could not confirm that the portable space heater would not exceed 212 degrees Fahrenheit.

Based on observation, the facility failed to maintain the storage of oxygen cylinders. This deficient condition was evidenced by an oxygen cylinder that was left free standing and by light switches that were less than 5 ft. off the floor. these conditions affected 2 of 10 floors in Building H at the Highlands Campus, 1 of 4 floors in the Svc Building at the Highlands Campus and 1 of 2 floors in Building H at the Fairmont campus and could result in the acceleration of a fire.

NFPA 101 Life Safety Code, 2000 edition
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99,
Standard for Health Care Facilities.


27893

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.
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.

Findings:

During a facility tour with staff, the medical gas cylinder storage locations were observed.

Highland Campus - Building H
1. On 4/3/12, at 2:22 p.m., on the 8th floor, 1 oxygen E cylinder was observed to be free standing and unsecured in Room 8207.
2. On 4/3/12, at 3:54 p.m., on the 6th floor, the Oxygen Gas Cylinder Storage Room near Room 6105 was observed. A light switch located in that room was mounted on the wall approximately 4 feet from the center of the switch to the floor.

Fairmont Campus - Building H
1. On 4/4/12, at 4:26 p.m., on the 2nd floor, the Oxygen Gas Cylinder Storage Room 219 was observed. A light switch located in that room was mounted on the wall approximately 4 feet from the center of the switch to the floor.


29626


Highlands Campus - Svc Building
1. On 4/3/2012, at 4:18 p.m., on the 2nd Floor by the Receiving Management Loading Dock, there was an argon gas cylinder that measured approximately 39-cubic feet in the empty gas storage room that was standing upright and unsecured from falling.

Based on observation, the facility failed to maintain their anesthetizing locations. This was evidenced by 2 anesthetizing locations that were not equipped with battery-powered emergency lighting units. This affected 1 of 10 floors in Building H at the Highland Campus and could result in delayed visibility during a procedure in the event of a power failure in conjunction with an emergency generator delay or malfunction.

NFPA 99, 1999 edition
3-3.2.1.2(a)5 Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electric Code, Section 700-12(e).

Findings:

During a facility tour with staff, the anesthetizing locations in the facility were observed.

Highlands Campus - Building H
1. On 4/3/12, at 11:36 a.m., on the 9th floor, 2 of 2 Labor and Deliver Operating Rooms were not equipped with battery-powered emergency lighting units.

Based on observation and interview, the facility failed to maintain their the Emergency Power System (EPS) in accordance with NFPA 110 as evidenced by no battery-powered emergency lighting found by the generator. This condition affected the John George Psychiatric Pavilion at the Fairmont Campus and could result in the inability to troubleshoot a failure of the generator during the loss of power.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition.
5-3 Lighting.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Findings:

During a tour of the facility with Hospital Staff, the generator was observed.

Fairmont Campus - John George Psychiatric Pavilion
1. On 4/6/2012, at 9:38 a.m., the area where the generator was located did not have battery-powered emergency lighting unit. The Engineer-2 confirmed that there was no battery-powered lighting unit in the area.

Based on observation, the facility failed to maintain their electrical wiring and equipment, as evidenced by a power strip that was plugged into another power strip, and by motorized items plugged into a power strip. This deficient condition affected one of six floors and could result in the ignition of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4)Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection\
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b)& 305-4 c)
400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.


Findings:

During a tour of the facility with staff members, the use of power strips was observed.
Highlands Campus - Building K
1. On 4/03/12, at 3:26 p.m., on the 3rd floor room 3054, a power strip was plugged into another power strip instead of directly into the wall outlet.
2. On 4/03/12, at 3:27 p.m., on the 3rd floor room 3055, a small refrigerator and a microwave were plugged into a power strip instead of directly into the wall outlet.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of 5 alcohol based hand rub dispensers over or adjacent to ignition sources. This affected 2 of 10 floors in the Highland Campus Building H, 1 of 2 floors in the Fairmont Campus Building H, and 1 floor in the Fairmont Campus John George Building. This could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff, the alcohol based hand rub dispensers in the facility were observed.

Highland Campus - Building H
1. On 4/3/12, at 3:50 p.m., on the 6th floor, an alcohol based hand rub dispenser in Staff Office 6101 was mounted on the wall approximately 2 inches to the upper right of an electrical receptacle. The hand rub was 62 percent ethyl alcohol by volume.
2. On 4/4/12, at 10:07 a.m., on the 5th floor, an alcohol based hand rub dispenser in the corridor near Room 5211 was mounted on the wall approximately 3 feet above an electrical receptacle. The hand rub was 85 percent ethyl alcohol by volume.

Fairmont Campus - Building H
1. On 4/4/12, at 4:16 p.m., on the 2nd floor, an alcohol based hand rub dispenser near the Nurse Station was mounted on the wall approximately 3.5 feet above an electrical receptacle. The hand rub was 70 percent ethyl alcohol by volume.
2. On 4/4/12, at 4:35 p.m., on the 2nd floor, an alcohol based hand rub dispenser in Room 235 was mounted on the wall approximately 8 inches above a light switch. The hand rub was 70 percent ethyl alcohol by volume.

Fairmont Campus - John George Building
1. On 4/5/12, at 10:52 a.m., on the 1st floor, an alcohol based hand rub dispenser in the Unit C Conference was mounted on the wall approximately 3 feet above an electrical receptacle. The hand rub was 70 percent ethyl alcohol by volume.