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Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected smoke compartments on four of four floors in the main hospital. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff, from 6/6/11 to 6/9/11, the walls and ceilings were observed in the main hospital.

6/6/11 - Third Floor
At 1:56 p.m., there were five approximately 1/4 inch penetrations in the left wall of the 3 South Med Room. There were four, less than 1/8 inch penetrations, in the same wall. The penetrations were near the electrical panel.
At 1:58 p.m., there was an approximately 1/2 inch penetration in the ceiling tile in Room 3S32.
At 2:15 p.m., there were two approximately 1/8 inch penetrations in the front wall of the Director of Renal Services office. There was an approximately 1 inch penetration in the left wall.
At 2:20 p.m., there were five, less than 1/8 inch penetrations, in the wall of the biohazard room on 3N.
At 2:35 p.m., there were two approximately 1/8 inch penetrations in the maintenance closet in 3C (3rd floor center).
At 2:45 p.m., there was an approximately 1/8 x 1 1/2 inch penetration at the top of the electrical cover plate in the left wall of the waiting room on 3W. There was an approximately 1/4 inch penetration behind the waiting room door.
At 2:46 p.m., there were two approximately 1/4 inch penetrations in the front wall of the Ultra Sound Procedure Room 1. The penetrations were opposite the folding door.
At 3:15 p.m., there were five, less than 1/8 inch penetrations, in the back left wall , near a telemetry rack, on 3W. There were six approximately 1/8 inch penetrations in the right wall, behind the door, in the storage room on 3W.
At 3:20 p.m., there were four approximately 1/4 inch penetrations in the back wall of the central Telemetry Room.
At 4:02 p.m., there was an approximately 1 1/2 x 1 1/2 inch square penetration in the right wall, near the floor, in the 3E utility closet (elevator lobby area).

6/7/11 - First Floor
At 11:55 a.m., there was an approximately 3 1/4 x 1 1/2 inch penetration behind the door, in the central supply room, in Zone 3 ED (emergency department).

6/8/11 - First Floor
At 10:04 a.m., there were nine approximately 1/8 inch penetrations in the front wall of the ED, fast track area, housekeeping closet. There were five approximately 1/8 - 1/4 inch penetrations in the left wall and 15 approximately 1/8 - 1/4 inch penetrations in the back wall.
At 10:12 a.m., there was an approximately 1/2 inch penetration in the ceiling tile at the entrance to Nuclear Med. There were two damaged tiles above the doorway.
At 10:18 a.m., the plastic construction wall was left open in the old CT Room. There was an approximately 12 x 12 inch penetration in the ceiling where the access hatch was missing.

During an interview, Engineering Staff 2 reported the construction project for remodeling the room had not yet started. He reported the plastic should not have been opened.

At 10:23 a.m., there were two approximately 1/8 inch penetrations and an approximately 1/4 inch penetration around a pipe, in the back wall of the CT equipment closet.

During interviews throughout the survey, Engineering Staff 1 and 2 confirmed the penetrations.


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6/6/11 - Fourth Floor
At 2:12 p.m., there was an approximately 10 by 21 inch penetration around the reverse osmosis plumbing, in the wall of Room 408, 4C. This is the storage room for renal dialysis.

6/8/11- Second Floor
At 9:46 a.m., there was a 1 1/4 inch penetration through an empty pipe sleeve in the ceiling of the housekeeping closet, in the lobby area for 2 East.

First Floor
At 11:34 a.m., there was an approximately 3/4 inch penetration, on one side of a blue cable, in a ceiling tile, in the Pharmacy.
At 1:49 p.m., there was an approximately 1 inch penetration around a ceiling recessed sprinkler, in the surgery storage room, above the tissue freezer.

6/9/11 - First Floor
At 9:03 a.m., there was an approximately 1 by 2 inch triangular shaped penetration, around the network hub wire bundle, in the Pharmacy ceiling.
At 9:07 a.m., there were six approximately 1/2 inch penetrations, in the ceiling around conduits, above an electrical panel located in Pharmacy.

First Floor.
At 9:03 a.m., there was an approximately 2 inch penetration, around a wire, inside of a pipe sleeve in the corridor wall above the ceiling tiles. There was an approximately 1 1/2 x 1 inch penetration at the bottom of a pipe sleeve and an approximately 1/4 - 1/2 inch penetration inside the pipe sleeve, around a blue wire. The penetrations were located in the wall above the east, Women's Staff Only bathroom.

At 9:15 a.m., there was an approximately 1/4 -1/2 inch penetration around data cables, inside a 3/4 inch pipe sleeve. The penetration was above the ceiling, in the wall across from the Patient Access Director's office.







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Based on observation, the facility failed to maintain the integrity of the corridor construction. This was evidenced by penetrations in the corridor walls above the ceiling. This affected smoke compartments on two of four floors. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the hospital tour with staff, from 6/6/11 - 6/9/11, penetrations were observed in corridor areas of the facility.

6/6/11 - Fourth Floor
At 1:42 p.m., there was a penetration in a the corridor wall just above the ceiling, in the Mineral King building. The penetration went into a re-purposed laundry chute on the fourth floor, at 4 C. There were four chilled water lines running into the chute. The chute had been converted into a utility chase and had been closed off at the floor and ceiling.

6/8/11
At 2:58 p.m., there was an approximately 10 by 8 inch oval shaped penetration in the corridor above the ceiling. This was located to the right of the door for the surgery scheduler in the surgery hallway.

6/9/11
At 9:29 a.m., there was an approximately 10 by 10 inch opening above the double door at 1031A, in the sterile hallway next to the ambulatory surgery center.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected smoke compartments on three of four floors and the basement, and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with staff, from 6/6/11 to 6/9/11, the facility corridor doors were observed.

6/6/11 - First Floor
At 11:20 a.m., the door to the gift shop was equipped with kick type hardware. The door was obstructed from closing. Each day of the survey, the door was held open when the gift shop was open for business.

Third Floor
At 4:26 p.m., the door 3E24, self closed but failed to latch. The door is at the Nurses' Station in Broderick Pavilion.
At 4:30 p.m., the library door, 3E65, was equipped with a self-closing device. The door closed but failed to latch.

6/7/11 - First Floor
At 11:38 a.m., two doors in the ED area were equipped with kick type hardware. The doors were obstructed from closing.
At 12:10 p.m., the door to the gift shop was obstructed from closing by kick type hardware.

6/8/11
At 10:07 a.m., the corridor door, to radiology was equipped with a self-closing device. The door closed but failed to latch.
At 11:06 a.m., the door to the gift shop was obstructed from closing by kick type hardware.

6/9/11 - Basement
At 9:31 a.m., the self closing door to the lab biohazard area, closed but failed to latch.


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6/7/11 - Second Floor
At 3:49 p.m., the NICU, Neonatal Intensive Care Unit, north side entrance corridor door closed but did not latch.

6/8/11 - First Floor
At 11:06 a.m., the Endoscopy entry door 1W5 did not close completely upon release from a fully open position. The door remained open approximately one inch during two attempts.
At 11:15 a.m., one side of the double doors, 1W20B, did not latch when closed. This was the door closest to the stairwell.

Based on observation, interview and record review, the facility failed to maintain the integrity of smoke barrier walls, as evidenced by penetrations around wires, ducts and pipe sleeves. This affected smoke compartments on two of four floors in the Mineral King building and two of six floors in Acequia, and could result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During the facility tour with staff, from 6/6/11 - 6/9/11, the smoke barrier walls were observed.

6/6/11 - Third Floor
At 3:25 p.m., there was an approximately 1/2 inch penetration around black cables in the center of the smoke barrier wall at 3W, across from 3W02. There was an approximately 2 1/2 x 1 inch, oval shaped, penetration, an approximately 1/2 inch penetration around a pipe sleeve and an approximately 1/2 - 3/4 inch penetration on the far right side of the wall.

6/7/11 - First Floor
At 11:56 a.m., the smoke barrier wall in the ED Zone 1 to Zone 2 was observed. There was an approximately 1/2 inch penetration around communication wire, inside of a pipe sleeve, on the left side of the wall.
There was an approximately 1/4 - 1/2 inch penetration around a pipe sleeve on the far left area of the wall.

6/8/11 - First Floor Acequia
At 9:55 a.m., the smoke barrier from ED Zone 3 to Acequia was observed. There was an approximately 1/2 inch penetration around a wire, inside of a pipe sleeve, at ED34.
At 11:33 a.m., there were three approximately 1/8 - 1/4 inch penetrations in the left wall of the smoke barrier at Elevators 1 and 2. There were three approximately 1/4 inch penetrations in the back wall above the housekeeping closet.

6/9/11 - Third Floor Acequia
There were square cut outs around the main air ducts, going through the smoke barrier walls, in this area. Insulation was placed around the ducts, on one side of the wall.

At 12:05 p.m., there was an approximately 1/2 x 1 1/2 inch penetration, around the air duct, at the corners of the cut out.
At 12:20 p.m., there was an approximately 1/2 - 1 inch penetration, at the top left corner of the cut out, around the air duct, in the smoke barrier at A5-020. There was an approximately 1/2 - 3/4 inch penetration along the right side of the cut out, viewed from the opposite side of the smoke barrier. There was an approximately 1/8 inch penetration along the bottom of the cut out.
At 2:04 p.m., there was an approximately 5 x 5 inch triangular penetration at the top corners of the air duct, in the smoke barrier at CCU, 3197. There was an approximately 1 1/2 x 1 1/2 inch triangular penetration at the bottom corners of the cut out.
At 2:12 p.m., there was an approximately 1 inch penetration around the square cut out, for the air duct in the smoke barrier 3147, CVIC.

During an interview at 2:25 p.m., Engineering Staff 2 reported the air ducts were installed in accordance with the manufacturer's specifications. Information was requested for the specifications for the duct installation. A faxed report was received from the facility on 6/20/11. There was no information on the report to indicate that the ducts should not be sealed on both sides of the smoke barrier wall.


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6/6/09 - Fourth Floor
At 1:38 p.m., there was an approximately 1 by 2 inch penetration around cables to the left side of a two hour fire rated wall between the corridor and the vestibule for Elevators 6 & 7, 4C. At 1:39 p.m., there was a 1 penetration around two 3/4" armored cables in the smoke barrier wall above the doors between the corridor and elevator vestibule.

At 1:42 p.m., there was an approximately 4 x 18 inch penetration in the wall just above the ceiling, into a re-purposed laundry chute on the fourth floor, 4 Center area. There were four chilled water lines running into the chute. The chute had been converted into a utility chase and had been closed off at the floor and ceiling.

At 1:52 p.m., there was an approximately 1 inch penetration around unsealed cables inside a 1 1/2 inch pipe sleeve. This was located in the smoke barrier wall above the entry doors to the 4N Pod.

Based on observation, the facility failed to ensure that smoke barrier doors are capable to resist the passage of smoke. This was evidenced by doors that failed to latch after closing. This affected smoke compartments on three of six floors in the Acequia Wing, and one of four floors in the Mineral King Building. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with staff on 6/7/11, the smoke barrier doors were observed in the Acequia Wing.

At 1:50 p.m., Smoke Barrier Doors 4149, at the 4T entrance, released from the magnetic hold-open device upon activation of the fire alarm. The right door closed but failed to latch.

At 1:54 p.m., Smoke Barrier Doors 4150, at the nurses' station, closed. The right door failed to latch.

At 2:12 p.m., Smoke Barrier Door A5-020, closed after activation of the fire alarm. The right door failed to latch.


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6/7/11 - Fourth Floor Acequia Wing
At 1:58 p.m., the smoke barrier door 4181 nearest to the nurse station did not close completely or latch. The door remained open approximately 1/2 inch when released from the open position.

Third Floor
At 2:23 p.m., the smoke barrier door 3135, next to room 3165, failed to latch upon closing.

6/8/11 - First Floor
At 11:06 a.m., the Endoscopy Entrance Door at 1WS did not close completely and latch. The door remained open approximately one inch when released from the full open position.

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self closing doors. This was evidenced by hazardous areas with penetrations, and by doors that failed to self close and latch. This affected smoke compartments on two of four floors, the penthouse and the basement. This could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour with staff, from 6/6/11 to 6/9/11, hazardous areas in the facility were observed. Hazardous areas are combustible storage rooms/spaces greater than 50 square feet, boiler and heater rooms, mechanical rooms, repair shops, and trash and soiled linen collection rooms.

On 6/6/11 - Penthouse area
At 12:03 p.m., there was an approximately 2 inch round penetration in the exterior wall of the elevator room.
At 12:04 p.m., there was an approximately 1/4 inch penetration around two pipes in the front wall of the elevator room.

Third Floor
At 1:47 p.m., there were three approximately 1/8 inch penetrations in the Biohazard Room on 3S. The room contained soiled linen and trash bins.
At 4:30 p.m., there was an approximately 1/2 x 1 inch damaged area, on the wall behind the door, in the Biohazard/Soiled Utility Room on 3E.

6/8/11 - Kitchen
The kitchen dry storage room contained combustible cardboard boxes and paper packages of supplies. The room is greater than 50 square feet and is open to the kitchen. The entire kitchen and dietary area is considered one hazardous area and is protected by self-closing doors and one hour rated construction.

At 11:50 a.m., there were eight approximately 1/8 - 1/4 inch penetrations in the back wall of the Food Services Business Office.
At 11:51 a.m., there was an approximately 1/8 inch penetration around a conduit in the front wall of the soda storage room.
At 11:52 a.m., there were eight less than 1/8 inch penetrations in the left wall of room W132.
At 11:55 a.m., there was an approximately 1 x 3/4 inch penetration in the wall behind the door, in the kitchen exit to the back corridor.

At 11:58 a.m., the self-closing double doors closed but failed to latch, in the exit from the kitchen into the corridor.

At 3:23 p.m., there was an approximately 5 x 6 inch penetration around pipe sleeves, in the corridor separation wall, above the ceiling tiles, above the kitchen double doors. There was an approximately 1/4 - 1/2 inch penetration around a wrapped pipe to the right side of the doors.
At 3:28 p.m., there was an approximately 2 x 2 inch square penetration in the left corridor wall, accessed above the ceiling tiles, from inside W132. There was an approximately 3 1/2 x 2 inch penetration around a valve handle, and an approximately 1 inch penetration on the left side of a pipe sleeve in the center area of the wall. There was an approximately 1 inch penetration on the left side of the air duct on the right side of the wall.

6/9/11 - Basement
At 9:25 a.m., there was an approximately 1/4 inch penetration in the wall of the elevator room, where a fire extinguisher had been mounted.

Based on observation, the facility failed to ensure emergency lighting is provided in accordance with NFPA 101. This was evidenced by the failure of emergency lights during testing. This affected one of four floors and one stairwell. This could result in a possible delay in evacuation in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code.
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 11/2 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 the facility tour with staff on 6/6/11 and 6/8/11, emergency lights were observed in the facility.

6/6/11 - Third Floor Stairs
At 1:30 p.m., one emergency light in the 3rd floor stairway, Center, was not illuminated.

6/8/22 - First Floor
At 10:40 a.m., the "older" bull frog type emergency light was tested in the Nuclear Medicine corridor area. The light failed to light when the test button was depressed.


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At 11:31 a.m., there was an emergency battery back-up light that failed to operate after the test switch was activated. This was mounted to the ceiling, in the corridor outside of Central Logistics.

Based on observation, record review, and interview, the facility failed to maintain the complete fire alarm system. This was evidenced by alarm devices that failed, by incomplete documentation of annual testing, and by no dates on fire alarm panel batteries. This affected multiple smoke compartments in the hospital and could result in a failure of the alarm system or a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code 2000 Edition
19.3.4.3 Occupant Notification
Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

Maintaining and Testing
4.6.12.1 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 continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

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.

NFPA 72, National Fire Alarm Code, 1999 Edition.
Table 7-3.2 requires annual testing of building systems connected to the fire supervising station.

Table 7-3.2
6. Batteries d. Sealed-Lead Acid Type 1. Charger Test (Replace battery every 4 years.)

Findings:

During the facility tour on 6/7/11 and 6/8/11, the fire alarm system was observed and tested. Records for fire alarm testing were reviewed on 6/7/11.

6/7/11 - Acequia
At 2:12 p.m., the combination audible/visible annunciator 3-014 on the 3rd floor was observed. The chime failed to alarm after activation of a smoke detector.
At 2:15 p.m., the combination audible/visible annunciator 3-015, chimed once and then stopped, after activation of a smoke detector.
At 2:16 p.m., the combination audible/visible annunciator 3-010, chimed once and then stopped, after activation of a smoke detector.

6/8/11 - Second Floor
At 2:25 p.m., the combination audible/visible annunciator at W220, in ICU, failed to flash after activation of a smoke detector.

First Floor
At 2:57 p.m., the combination audible/visible annunciator 1-029, failed to chime after activation of a smoke detector in Zone 2 ED.

6/9/11 - Basement
At 10:15 a.m., there was no date on the batteries in the fire alarm system sub panel. During an interview, Staff 2 confirmed there was no visible date.


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On 6/8/11 at 3:24 p.m., one audio visual notification device failed to chime during testing of the fire alarm system. This device was located along the west wall, near the back door of sterile processing.

During record review a complete record for annual fire alarm testing was requested.

On 6/8/11 there was no complete list of all fire alarm devices provided on the annual testing report "Fire Safety System Inspection and Test Report." There were no records of fire alarm panel battery replacement dates indicated on the report. The dates installed were not indicated on batteries in the fire alarm panels. The report contained testing results for quarterly testing in April and May 2010. The report did not indicate that all devices were testing during the last year.

During an interview on 6/8/11, Engineering Staff 2 reported there were no other records for alarm testing that indicated all devices were tested.

Based on observation and interview, the facility failed to ensure maintenance, inspection and testing of smoke detectors was conducted in accordance with the manufacturers' specifications and NFPA 72. This was evidenced by no documentation for testing and replacement for single station smoke detectors, incomplete records for annual testing of all smoke detectors, and by one missing smoke detector. This affected three of four floors and two of two smoke compartments on each floor, of the Mineral King Building.

NFPA 101, Life Safety Code 2000 Edition
Maintaining and Testing
4.6.12.1 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 continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 edition
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

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 13. Initiating Devices (g) Smoke Detectors - 2. The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.


8-3.5 Unless otherwise recommended by the manufacturer, smoke alarms installed in accordance with Chapters 18, 19, or 21 of NFPA 101, Life Safety Code, shall be replaced when they fail to respond to tests conducted in accordance with 8-3.4 but shall not remain in service longer than 10 years from the date of installation.


Findings:

During the facility tour, record review, and interview with facility staff, from 6/6/11 through 6/9/11, smoke detectors were observed and testing records were requested.

6/6/11 - Third Floor Mineral King Building
At 1:52 p.m., the smoke detector was missing from Room 3S26. Wires were hanging from the ceiling where the detector had been mounted.

During record review on 6/7/11, records were requested for smoke detector testing and sensitivity testing.
At 8:43 a.m., records indicated that smoke detectors were tested in April and May of 2010. There were no records that indicated that all smoke detectors were tested during the last year.

During an interview, on 6/8/11, Engineering Staff 2 reported that the detectors in the Acequia Wing are self calibrating for sensitivity. A report was provided for sensitivity testing for the Mineral King Building. The report "Fire Alarm Inspection Report 07/2008" was a report for the third quarter of 2008.
The report indicated smoke detector sensitivity testing was performed in January 2008. No other records were provided for previous years or for the current year. There was no indication that the detectors were sensitivity tested the first year, the third year and every five years thereafter.

During an interview on 6/9/11, at 8:03 a.m., Engineering Staff 2 reported there are single station smoke detectors in every room of the pods, on 2 North, 3 North, 3 South, 4 North, and 4 South. He reported there were no records for testing the single station smoke detectors located in the pods. He stated the detectors were not tested. The facility could not provide any information for the dates the single station smoke detectors were installed, tested, or replaced according to the manufacturer's recommendation.

Based on observation, the facility failed to ensure that at least a local alarm will sound when the sprinkler system valves are closed. This was evidenced by no alarm or trouble signal received at the panel in PBX, or by the monitoring company, during testing of 1 of 19 tamper alarms. The tamper valve alarm indicates the water has been shut off for the sprinkler system. This affected one of four floors and could result in a failure of the sprinkler system if the water were shut off.

Findings:

During the facility tour and alarm testing with facility staff on 6/8/11, the tamper alarm was tested for the west side expansion area. At 4:50 p.m., there was no no audible alarm or trouble signal received at PBX when the valve was closed three revolutions.

During record review on 6/9/11, the reports for fire alarm test signals, received by the monitoring company on 6/7 and 6/8/11, were requested. Two reports were provided.

During record review on 6/15/11, the report "Alarm Log History (External)," from the monitoring company, was reviewed. There was no indication a signal was received by the monitoring company during the time that the tamper valve was closed at 4:50 p.m.

Based on observation, and record review, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by missing or displaced escutcheon rings, and by incomplete documents for quarterly testing of the sprinkler system for two of four quarters. There were no records for quarterly inspection of the dry pipe system in the Acequia Wing. This affected the entire hospital and could result in a delay in extinguishing a fire.

Escutcheon rings (ER) are part of the sprinkler assembly that function to cover the penetration around the sprinkler pipe.

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

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.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
9-5.1 Inspection and Testing of Sprinkler Pressure Reducing Control Valves. Sprinkler pressure reducing control valves shall be inspected and tested as described in 9-5.1.1 and 9-5.1.2.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

Findings:

During a facility tour with staff from 6/6/11 - 6/9/11, the sprinkler system was observed.

6/6/11 - Third Floor
At 1:35 p.m., there was an approximately 1/8 - 1/4 inch gap on one side of the escutcheon ring (ER), near the column, in the 3rd Floor elevator lobby area.
At 3:15 p.m., there was an approximately 1/8 - 1/4 inch gap between the ER and the ceiling, in the 3W02 Bathroom.

6/8/11 - First Floor
At 10:01 a.m., there was a sprinkler cap missing, in the IT closet, near the emergency department (ED) fast track area.

6/9/11
At 10:50 a.m., there was a sprinkler cap missing, outside of the IT Room, on the exterior of the building.
At 11:05 a.m., two ERs were missing in the ambulance bay outside of the ED.


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During record review on 6/8/11, the sprinkler system inspection records were requested. At 9:30 a.m., there were no complete quarterly fire sprinkler testing records for the second and third quarters of 2010. The records failed to indicate the number of waterflow valves and tamper alarms tested each quarter. Records indicated there are 45 tamper alarms and 28 waterflow (ITV) valves. There was no record that confirmed all tamper alarms and ITV (inspector's test valves) were tested quarterly as required.

6/8/11 - Basement
At 9:59 a.m., a pre-action valve for a dry pipe system was observed in the basement of the new addition. During record review no records were provided for testing of this system.

At 10:37 a.m., there was a recessed sprinkler cap that was dropped approximately 1/4 inch, in the ceiling, in the 2E step down nursery storage room.

At 11:25 a.m., there were 4 recessed sprinkler caps that were dropped approximately 1/2 inch from the ceiling, in the recovery area.

At 11:51 a.m., there was a recessed sprinkler cap that had dropped approximately 3/8 inch from the ceiling, in the IT office in the surgery support area.

Based on observation, the facility failed to ensure fire extinguishers are provided and maintained per NFPA 10. This was evidenced by fire extinguishers that were unsecured or missing monthly checks. This affected smoke compartments on one of four floors and the basement. This could result in a delay in extinguishing a fire.

NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturers's instructions.

4.3.1 *Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected, manually or by electronic monitoring, at more frequent intervals when circumstances require.

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

Findings:

During the facility tour with staff on 6/6/11 and 6/9/11, fire extinguishers were observed on the third floor and basement area.

6/6/11 - Third Floor Mineral King Building
At 2:05 p.m., the tag on the fire extinguisher, in the IT phone room, was missing monthly checks for January 2011 through May 2011.

At 2:23 p.m., the fire extinguisher tag indicated there was no monthly check for March 2011, for the extinguisher in the 3 North charting station.

6/9/11 - Basement
At 9:25 a.m., a fire extinguisher was sitting on the floor in the elevator room. A penetration in the wall indicated where the extinguisher was previously mounted.

At 9:28 a.m., a fire extinguisher was sitting on the floor in the AV Room. The extinguisher was missing monthly checks for April and May 2011.

Based on observation, the facility failed to ensure that a capacity of 32 gallons of soiled linen or trash collection receptacles was not exceeded within any 64 square foot area. This was evidenced by multiple soiled linen receptacles placed side by side in the corridor. This affected one of four floors and could result in an increased risk of fire.

Findings:

During the facility tour with facility staff on 6/6/11, soiled linen and trash receptacles were observed on the third floor.

3 South
At 1:44 p.m., there were two approximately 32 gallon receptacles (bins) placed side by side, in the area outside of 3S4. There were two approximately 32 gallon bins, side by side, in the area outside of 3S13.

At 1:45 p.m., there were two approximately 32 gallon bins, side by side, in the area outside of 3S19.

At 1:50 p.m., there were four approximately 32 gallon bins, in the back corridor area on 3 South. Two bins were side by side. Approximately five feet away the other two bins were placed in the corridor, side by side.

At 1:58 p.m., there were two approximately 32 gallon bins, side by side, in the area outside of 3S35.

3 North
At 2:17 p.m., there were two approximately 32 gallon bins, side by side, in the area outside of 3N7. There were two approximately 32 gallon bins, side by side, in the area outside of 3N33 and 3N27.

At 2:22 p.m., there were two approximately 32 gallon bins, side by side, in the area outside of 3N21.

At 2:27 p.m., there were two approximately 32 gallon bins, side by side, in the area outside of 3N9.

Based on record review and staff interview, the hospital failed to ensure anesthetizing locations were maintained at a minimum of 35% relative humidity. This was evidenced by humidity logs that indicated humidity less than 35 % in 3 of 3 months during the first quarter of 2011. This could result in fire and injury or death affecting patients in 2 of 10 OR (Operating Room) Suites in the hospital.

Findings:

During record review on 6/8/11, the humidity logs for anesthetizing locations were provided. The first quarter of 2011 was reviewed.

At 8:32 a.m., the main hospital binder for Surgery Humidity Report 2011 included the Temperature/Humidity Reports for Surgery OR Suites 1 to 10.

At 9 a.m., the January 2011 records indicated both OR 9 and 10 were below the minimum 35% relative humidity 6 of 31 days.

At 9:15 a.m., the February 2011 records indicated that OR 9 was below 35% relative humidity for 27 of 28 days.

At 9:33 a.m., the March 2011 records indicated OR 9 was below 35% relative humidity for 19 of 31 days.

At 9:35 a.m., there was no documentation provided that verified a process was in place for correcting out of range humidity readings in the OR Suites.

At 9:36 a.m., there were no records available for the anesthetizing locations in the new hospital addition.

During an interview on 6/7/11 at 4:45 p.m., Engineering Staff 2 stated, the reports are printed and filed in the humidity log binder. He stated he was unsure if they were reviewed. He was asked if there were any records of repairs for the out of range humidity readings. He stated there were no records available regarding repairs related to out of range humidity readings.

Based on observation, the facility failed to ensure no smoking signs are posted in areas where oxygen is used or stored. This was evidenced by one oxygen storage area with no signs on two of two exposed sides. This could result in an increased risk of smoking and potential risk of fire in this area.

Findings:

During the facility tour on 6/9/11, the exterior areas of the facility were observed. The respiratory oxygen storage area is located in a brick enclosure adjacent to the trash compactor.

At 11:24 a.m., the respiratory oxygen storage area failed to have no smoking signs on two sides that were exposed to public view.

Based on observation and interview, the facility failed to maintain their electrical wiring in accordance with NFPA 70 and NFPA 99. This was evidenced by the use of surge protectors, outlet boxes, and extension cords, as permanent wiring, and by obstructions in front of electrical panels. This affected smoke compartments on four of four floors. This could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

110-26
(a)Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(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 inches (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.

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

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

400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(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.
(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 99 Health Care Facilities, 1999 Edition
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patients care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During the facility tour with staff from 6/6/11 to 6/9/11, the electrical wiring was observed.

6/6/11 - Third Floor
At 1:56 p.m., electrical panel 3EB2 was obstructed by stacked IV solution bins, on wheels, placed against the panel door. The panel is located in the 3rd floor med room.
At 1:58 p.m., there was a sharps container placed in front of electrical panel 3B3. The door could not be opened.

3 West
At 2:40 p.m., a refrigerator was plugged into a six-plug surge protector in the Pharmacy Services Office.
At 2:50 p.m., a refrigerator was plugged into a six-plug surge protector in the Respiratory Director's Office.
At 3:55 p.m., a refrigerator was plugged into a six-plug surge protector in the Maternal Child office area.

6/7/11 - Emergency Department
At 11:31 a.m., a refrigerator was plugged into a six-plug surge protector in the ED med room.

6/8/11 - First Floor
At 9:59 a.m., a refrigerator was plugged into a six-plug surge protector in the ED assistant manager's office.

At 10:58 a.m., there was approximately 20 feet of plastic wrapped conduit, laying on the floor, connecting two outlet boxes to a junction box on the floor. The conduit, outlet boxes and junction box, were unsecured and located under a counter in the "old" admissions reception area.

During an interview at 11 a.m., Engineering Staff 2 reported the counters were no longer used for processing admissions and the outlets were no longer in use. He stated he was unsure why the outlets were not hardwired or if they were installed by an electrician.

At 11:05 a.m., there were four plastic cases of soda stacked in front of the electrical panel 1EE, in the Ambrosia Cafe. The panel door could not be opened.

At 11:12 a.m., an extension cord connected fans and a CD player to the wall outlet.

At 12:02 p.m., tray carts and dish carts were placed against electrical panels K-1, K-2, and K-3, in the kitchen dishwashing area. The panel doors could not be opened without moving the carts.

6/9/11 - Basement
At 10:20 a.m., there was a refrigerator and a microwave plugged into a six-plug surge protector in the basement staff lounge.


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6/6/11 - Fourth Floor
At 2:18 p.m., there was a patient bed plugged into a surge protector/ extension cord in Room 4N (North) 1.

At 2:19 p.m., there was a patient bed plugged into a surge protector in Room 4N 3.

At 2:27 p.m., there were four infusion pumps set-up for patient use and plugged into one surge protector, in the 4C (Center) dialysis infusion area.

At 2:49 p.m., there were four Pyxis medication dispensers plugged into a surge protector, plugged into another surge protector that was plugged into an electrical wall outlet in the 4S (South) medication room.

Second Floor
At 3:10 p.m., there was a missing cover plate on the ceiling outlet for the Television/Nurse Call light cable in patient room 2N 7.

At 3:52 p.m., there were six medical devices plugged into a surge protector at NICU (Nursery Intensive Care Unit) Bed 1.

At 3:54 p.m., there were four medical devices plugged into a surge protector at NICU Bed 2.

At 4:02 p.m., there was a refrigerator and a computer plugged into an extension cord in Room 2548.

At 4:06 p.m., there were two coffee makers plugged into a surge protector in the NICU staff break room.

6/7/11 - Second Floor
At 11:36 a.m., there was a micro-wave and toaster plugged into a surge protector in the 2 West ICU staff lounge.

At 11:42 a.m., there were 2 Pyxis medication dispensers plugged into a surge protector in the 2 West ICU medication room.

At 2:46 p.m., there was a blanket warmer plugged into a surge protector in the sterile storage room.

At 3:13 p.m., there was an anesthesia station plugged into an extension cord, in the ZEEGO Cath Lab #6.

6/8/11
At 10:37 a.m., there was a Pyxis medication dispenser plugged into a surge protector at the 2 East Nurse Station in Labor and Delivery.

At 10:46 a.m., there was an electrical power cord run through a ceiling tile to an electrical wall outlet in the Nurse Manager's office. This was connected to equipment located above the ceiling.

First Floor
At 3:37 p.m., there was an anesthesia station plugged into a portable, four outlet box, connected to the wall outlet by a heavy duty attachment cord, in OR 7. The outlet box was placed on the floor.

At 3:45 p.m., there was an anesthesia station plugged into a portable, four outlet box, connected to the wall outlet by a heavy duty attachment cord, in OR 14. The outlet box was placed on the floor.


At 3:53 p.m., there was an anesthesia station plugged into a portable, four outlet box, connected to the wall outlet by a heavy duty attachment cord, in OR 9. The outlet box was placed on the floor.

At 4:20 p.m., there was a full size copy machine plugged into a surge protector at the PACU (Post Anesthesia Care Unit) main entrance.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected smoke compartments on four of four floors in the main hospital. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff, from 6/6/11 to 6/9/11, the walls and ceilings were observed in the main hospital.

6/6/11 - Third Floor
At 1:56 p.m., there were five approximately 1/4 inch penetrations in the left wall of the 3 South Med Room. There were four, less than 1/8 inch penetrations, in the same wall. The penetrations were near the electrical panel.
At 1:58 p.m., there was an approximately 1/2 inch penetration in the ceiling tile in Room 3S32.
At 2:15 p.m., there were two approximately 1/8 inch penetrations in the front wall of the Director of Renal Services office. There was an approximately 1 inch penetration in the left wall.
At 2:20 p.m., there were five, less than 1/8 inch penetrations, in the wall of the biohazard room on 3N.
At 2:35 p.m., there were two approximately 1/8 inch penetrations in the maintenance closet in 3C (3rd floor center).
At 2:45 p.m., there was an approximately 1/8 x 1 1/2 inch penetration at the top of the electrical cover plate in the left wall of the waiting room on 3W. There was an approximately 1/4 inch penetration behind the waiting room door.
At 2:46 p.m., there were two approximately 1/4 inch penetrations in the front wall of the Ultra Sound Procedure Room 1. The penetrations were opposite the folding door.
At 3:15 p.m., there were five, less than 1/8 inch penetrations, in the back left wall , near a telemetry rack, on 3W. There were six approximately 1/8 inch penetrations in the right wall, behind the door, in the storage room on 3W.
At 3:20 p.m., there were four approximately 1/4 inch penetrations in the back wall of the central Telemetry Room.
At 4:02 p.m., there was an approximately 1 1/2 x 1 1/2 inch square penetration in the right wall, near the floor, in the 3E utility closet (elevator lobby area).

6/7/11 - First Floor
At 11:55 a.m., there was an approximately 3 1/4 x 1 1/2 inch penetration behind the door, in the central supply room, in Zone 3 ED (emergency department).

6/8/11 - First Floor
At 10:04 a.m., there were nine approximately 1/8 inch penetrations in the front wall of the ED, fast track area, housekeeping closet. There were five approximately 1/8 - 1/4 inch penetrations in the left wall and 15 approximately 1/8 - 1/4 inch penetrations in the back wall.
At 10:12 a.m., there was an approximately 1/2 inch penetration in the ceiling tile at the entrance to Nuclear Med. There were two damaged tiles above the doorway.
At 10:18 a.m., the plastic construction wall was left open in the old CT Room. There was an approximately 12 x 12 inch penetration in the ceiling where the access hatch was missing.

During an interview, Engineering Staff 2 reported the construction project for remodeling the room had not yet started. He reported the plastic should not have been opened.

At 10:23 a.m., there were two approximately 1/8 inch penetrations and an approximately 1/4 inch penetration around a pipe, in the back wall of the CT equipment closet.

During interviews throughout the survey, Engineering Staff 1 and 2 confirmed the penetrations.


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6/6/11 - Fourth Floor
At 2:12 p.m., there was an approximately 10 by 21 inch penetration around the reverse osmosis plumbing, in the wall of Room 408, 4C. This is the storage room for renal dialysis.

6/8/11- Second Floor
At 9:46 a.m., there was a 1 1/4 inch penetration through an empty pipe sleeve in the ceiling of the housekeeping closet, in the lobby area for 2 East.

First Floor
At 11:34 a.m., there was an approximately 3/4 inch penetration, on one side of a blue cable, in a ceiling tile, in the Pharmacy.
At 1:49 p.m., there was an approximately 1 inch penetration around a ceiling recessed sprinkler, in the surgery storage room, above the tissue freezer.

6/9/11 - First Floor
At 9:03 a.m., there was an approximately 1 by 2 inch triangular shaped penetration, around the network hub wire bundle, in the Pharmacy ceiling.
At 9:07 a.m., there were six approximately 1/2 inch penetrations, in the ceiling around conduits, above an electrical panel located in Pharmacy.

First Floor.
At 9:03 a.m., there was an approximately 2 inch penetration, around a wire, inside of a pipe sleeve in the corridor wall above the ceiling tiles. There was an approximately 1 1/2 x 1 inch penetration at the bottom of a pipe sleeve and an approximately 1/4 - 1/2 inch penetration inside the pipe sleeve, around a blue wire. The penetrations were located in the wall above the east, Women's Staff Only bathroom.

At 9:15 a.m., there was an approximately 1/4 -1/2 inch penetration around data cables, inside a 3/4 inch pipe sleeve. The penetration was above the ceiling, in the wall across from the Patient Access Director's office.







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Based on observation, the facility failed to maintain the integrity of the corridor construction. This was evidenced by penetrations in the corridor walls above the ceiling. This affected smoke compartments on two of four floors. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the hospital tour with staff, from 6/6/11 - 6/9/11, penetrations were observed in corridor areas of the facility.

6/6/11 - Fourth Floor
At 1:42 p.m., there was a penetration in a the corridor wall just above the ceiling, in the Mineral King building. The penetration went into a re-purposed laundry chute on the fourth floor, at 4 C. There were four chilled water lines running into the chute. The chute had been converted into a utility chase and had been closed off at the floor and ceiling.

6/8/11
At 2:58 p.m., there was an approximately 10 by 8 inch oval shaped penetration in the corridor above the ceiling. This was located to the right of the door for the surgery scheduler in the surgery hallway.

6/9/11
At 9:29 a.m., there was an approximately 10 by 10 inch opening above the double door at 1031A, in the sterile hallway next to the ambulatory surgery center.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected smoke compartments on three of four floors and the basement, and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with staff, from 6/6/11 to 6/9/11, the facility corridor doors were observed.

6/6/11 - First Floor
At 11:20 a.m., the door to the gift shop was equipped with kick type hardware. The door was obstructed from closing. Each day of the survey, the door was held open when the gift shop was open for business.

Third Floor
At 4:26 p.m., the door 3E24, self closed but failed to latch. The door is at the Nurses' Station in Broderick Pavilion.
At 4:30 p.m., the library door, 3E65, was equipped with a self-closing device. The door closed but failed to latch.

6/7/11 - First Floor
At 11:38 a.m., two doors in the ED area were equipped with kick type hardware. The doors were obstructed from closing.
At 12:10 p.m., the door to the gift shop was obstructed from closing by kick type hardware.

6/8/11
At 10:07 a.m., the corridor door, to radiology was equipped with a self-closing device. The door closed but failed to latch.
At 11:06 a.m., the door to the gift shop was obstructed from closing by kick type hardware.

6/9/11 - Basement
At 9:31 a.m., the self closing door to the lab biohazard area, closed but failed to latch.


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6/7/11 - Second Floor
At 3:49 p.m., the NICU, Neonatal Intensive Care Unit, north side entrance corridor door closed but did not latch.

6/8/11 - First Floor
At 11:06 a.m., the Endoscopy entry door 1W5 did not close completely upon release from a fully open position. The door remained open approximately one inch during two attempts.
At 11:15 a.m., one side of the double doors, 1W20B, did not latch when closed. This was the door closest to the stairwell.

Based on observation, interview and record review, the facility failed to maintain the integrity of smoke barrier walls, as evidenced by penetrations around wires, ducts and pipe sleeves. This affected smoke compartments on two of four floors in the Mineral King building and two of six floors in Acequia, and could result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During the facility tour with staff, from 6/6/11 - 6/9/11, the smoke barrier walls were observed.

6/6/11 - Third Floor
At 3:25 p.m., there was an approximately 1/2 inch penetration around black cables in the center of the smoke barrier wall at 3W, across from 3W02. There was an approximately 2 1/2 x 1 inch, oval shaped, penetration, an approximately 1/2 inch penetration around a pipe sleeve and an approximately 1/2 - 3/4 inch penetration on the far right side of the wall.

6/7/11 - First Floor
At 11:56 a.m., the smoke barrier wall in the ED Zone 1 to Zone 2 was observed. There was an approximately 1/2 inch penetration around communication wire, inside of a pipe sleeve, on the left side of the wall.
There was an approximately 1/4 - 1/2 inch penetration around a pipe sleeve on the far left area of the wall.

6/8/11 - First Floor Acequia
At 9:55 a.m., the smoke barrier from ED Zone 3 to Acequia was observed. There was an approximately 1/2 inch penetration around a wire, inside of a pipe sleeve, at ED34.
At 11:33 a.m., there were three approximately 1/8 - 1/4 inch penetrations in the left wall of the smoke barrier at Elevators 1 and 2. There were three approximately 1/4 inch penetrations in the back wall above the housekeeping closet.

6/9/11 - Third Floor Acequia
There were square cut outs around the main air ducts, going through the smoke barrier walls, in this area. Insulation was placed around the ducts, on one side of the wall.

At 12:05 p.m., there was an approximately 1/2 x 1 1/2 inch penetration, around the air duct, at the corners of the cut out.
At 12:20 p.m., there was an approximately 1/2 - 1 inch penetration, at the top left corner of the cut out, around the air duct, in the smoke barrier at A5-020. There was an approximately 1/2 - 3/4 inch penetration along the right side of the cut out, viewed from the opposite side of the smoke barrier. There was an approximately 1/8 inch penetration along the bottom of the cut out.
At 2:04 p.m., there was an approximately 5 x 5 inch triangular penetration at the top corners of the air duct, in the smoke barrier at CCU, 3197. There was an approximately 1 1/2 x 1 1/2 inch triangular penetration at the bottom corners of the cut out.
At 2:12 p.m., there was an approximately 1 inch penetration around the square cut out, for the air duct in the smoke barrier 3147, CVIC.

During an interview at 2:25 p.m., Engineering Staff 2 reported the air ducts were installed in accordance with the manufacturer's specifications. Information was requested for the specifications for the duct installation. A faxed report was received from the facility on 6/20/11. There was no information on the report to indicate that the ducts should not be sealed on both sides of the smoke barrier wall.


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6/6/09 - Fourth Floor
At 1:38 p.m., there was an approximately 1 by 2 inch penetration around cables to the left side of a two hour fire rated wall between the corridor and the vestibule for Elevators 6 & 7, 4C. At 1:39 p.m., there was a 1 penetration around two 3/4" armored cables in the smoke barrier wall above the doors between the corridor and elevator vestibule.

At 1:42 p.m., there was an approximately 4 x 18 inch penetration in the wall just above the ceiling, into a re-purposed laundry chute on the fourth floor, 4 Center area. There were four chilled water lines running into the chute. The chute had been converted into a utility chase and had been closed off at the floor and ceiling.

At 1:52 p.m., there was an approximately 1 inch penetration around unsealed cables inside a 1 1/2 inch pipe sleeve. This was located in the smoke barrier wall above the entry doors to the 4N Pod.

Based on observation, the facility failed to ensure that smoke barrier doors are capable to resist the passage of smoke. This was evidenced by doors that failed to latch after closing. This affected smoke compartments on three of six floors in the Acequia Wing, and one of four floors in the Mineral King Building. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with staff on 6/7/11, the smoke barrier doors were observed in the Acequia Wing.

At 1:50 p.m., Smoke Barrier Doors 4149, at the 4T entrance, released from the magnetic hold-open device upon activation of the fire alarm. The right door closed but failed to latch.

At 1:54 p.m., Smoke Barrier Doors 4150, at the nurses' station, closed. The right door failed to latch.

At 2:12 p.m., Smoke Barrier Door A5-020, closed after activation of the fire alarm. The right door failed to latch.


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6/7/11 - Fourth Floor Acequia Wing
At 1:58 p.m., the smoke barrier door 4181 nearest to the nurse station did not close completely or latch. The door remained open approximately 1/2 inch when released from the open position.

Third Floor
At 2:23 p.m., the smoke barrier door 3135, next to room 3165, failed to latch upon closing.

6/8/11 - First Floor
At 11:06 a.m., the Endoscopy Entrance Door at 1WS did not close completely and latch. The door remained open approximately one inch when released from the full open position.

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self closing doors. This was evidenced by hazardous areas with penetrations, and by doors that failed to self close and latch. This affected smoke compartments on two of four floors, the penthouse and the basement. This could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour with staff, from 6/6/11 to 6/9/11, hazardous areas in the facility were observed. Hazardous areas are combustible storage rooms/spaces greater than 50 square feet, boiler and heater rooms, mechanical rooms, repair shops, and trash and soiled linen collection rooms.

On 6/6/11 - Penthouse area
At 12:03 p.m., there was an approximately 2 inch round penetration in the exterior wall of the elevator room.
At 12:04 p.m., there was an approximately 1/4 inch penetration around two pipes in the front wall of the elevator room.

Third Floor
At 1:47 p.m., there were three approximately 1/8 inch penetrations in the Biohazard Room on 3S. The room contained soiled linen and trash bins.
At 4:30 p.m., there was an approximately 1/2 x 1 inch damaged area, on the wall behind the door, in the Biohazard/Soiled Utility Room on 3E.

6/8/11 - Kitchen
The kitchen dry storage room contained combustible cardboard boxes and paper packages of supplies. The room is greater than 50 square feet and is open to the kitchen. The entire kitchen and dietary area is considered one hazardous area and is protected by self-closing doors and one hour rated construction.

At 11:50 a.m., there were eight approximately 1/8 - 1/4 inch penetrations in the back wall of the Food Services Business Office.
At 11:51 a.m., there was an approximately 1/8 inch penetration around a conduit in the front wall of the soda storage room.
At 11:52 a.m., there were eight less than 1/8 inch penetrations in the left wall of room W132.
At 11:55 a.m., there was an approximately 1 x 3/4 inch penetration in the wall behind the door, in the kitchen exit to the back corridor.

At 11:58 a.m., the self-closing double doors closed but failed to latch, in the exit from the kitchen into the corridor.

At 3:23 p.m., there was an approximately 5 x 6 inch penetration around pipe sleeves, in the corridor separation wall, above the ceiling tiles, above the kitchen double doors. There was an approximately 1/4 - 1/2 inch penetration around a wrapped pipe to the right side of the doors.
At 3:28 p.m., there was an approximately 2 x 2 inch square penetration in the left corridor wall, accessed above the ceiling tiles, from inside W132. There was an approximately 3 1/2 x 2 inch penetration around a valve handle, and an approximately 1 inch penetration on the left side of a pipe sleeve in the center area of the wall. There was an approximately 1 inch penetration on the left side of the air duct on the right side of the wall.

6/9/11 - Basement
At 9:25 a.m., there was an approximately 1/4 inch penetration in the wall of the elevator room, where a fire extinguisher had been mounted.

Based on observation, the facility failed to ensure emergency lighting is provided in accordance with NFPA 101. This was evidenced by the failure of emergency lights during testing. This affected one of four floors and one stairwell. This could result in a possible delay in evacuation in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code.
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 11/2 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 the facility tour with staff on 6/6/11 and 6/8/11, emergency lights were observed in the facility.

6/6/11 - Third Floor Stairs
At 1:30 p.m., one emergency light in the 3rd floor stairway, Center, was not illuminated.

6/8/22 - First Floor
At 10:40 a.m., the "older" bull frog type emergency light was tested in the Nuclear Medicine corridor area. The light failed to light when the test button was depressed.


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At 11:31 a.m., there was an emergency battery back-up light that failed to operate after the test switch was activated. This was mounted to the ceiling, in the corridor outside of Central Logistics.

Based on observation, record review, and interview, the facility failed to maintain the complete fire alarm system. This was evidenced by alarm devices that failed, by incomplete documentation of annual testing, and by no dates on fire alarm panel batteries. This affected multiple smoke compartments in the hospital and could result in a failure of the alarm system or a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code 2000 Edition
19.3.4.3 Occupant Notification
Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

Maintaining and Testing
4.6.12.1 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 continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

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.

NFPA 72, National Fire Alarm Code, 1999 Edition.
Table 7-3.2 requires annual testing of building systems connected to the fire supervising station.

Table 7-3.2
6. Batteries d. Sealed-Lead Acid Type 1. Charger Test (Replace battery every 4 years.)

Findings:

During the facility tour on 6/7/11 and 6/8/11, the fire alarm system was observed and tested. Records for fire alarm testing were reviewed on 6/7/11.

6/7/11 - Acequia
At 2:12 p.m., the combination audible/visible annunciator 3-014 on the 3rd floor was observed. The chime failed to alarm after activation of a smoke detector.
At 2:15 p.m., the combination audible/visible annunciator 3-015, chimed once and then stopped, after activation of a smoke detector.
At 2:16 p.m., the combination audible/visible annunciator 3-010, chimed once and then stopped, after activation of a smoke detector.

6/8/11 - Second Floor
At 2:25 p.m., the combination audible/visible annunciator at W220, in ICU, failed to flash after activation of a smoke detector.

First Floor
At 2:57 p.m., the combination audible/visible annunciator 1-029, failed to chime after activation of a smoke detector in Zone 2 ED.

6/9/11 - Basement
At 10:15 a.m., there was no date on the batteries in the fire alarm system sub panel. During an interview, Staff 2 confirmed there was no visible date.


29752

On 6/8/11 at 3:24 p.m., one audio visual notification device failed to chime during testing of the fire alarm system. This device was located along the west wall, near the back door of sterile processing.

During record review a complete record for annual fire alarm testing was requested.

On 6/8/11 there was no complete list of all fire alarm devices provided on the annual testing report "Fire Safety System Inspection and Test Report." There were no records of fire alarm panel battery replacement dates indicated on the report. The dates installed were not indicated on batteries in the fire alarm panels. The report contained testing results for quarterly testing in April and May 2010. The report did not indicate that all devices were testing during the last year.

During an interview on 6/8/11, Engineering Staff 2 reported there were no other records for alarm testing that indicated all devices were tested.

Based on observation and interview, the facility failed to ensure maintenance, inspection and testing of smoke detectors was conducted in accordance with the manufacturers' specifications and NFPA 72. This was evidenced by no documentation for testing and replacement for single station smoke detectors, incomplete records for annual testing of all smoke detectors, and by one missing smoke detector. This affected three of four floors and two of two smoke compartments on each floor, of the Mineral King Building.

NFPA 101, Life Safety Code 2000 Edition
Maintaining and Testing
4.6.12.1 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 continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 edition
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

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 13. Initiating Devices (g) Smoke Detectors - 2. The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.


8-3.5 Unless otherwise recommended by the manufacturer, smoke alarms installed in accordance with Chapters 18, 19, or 21 of NFPA 101, Life Safety Code, shall be replaced when they fail to respond to tests conducted in accordance with 8-3.4 but shall not remain in service longer than 10 years from the date of installation.


Findings:

During the facility tour, record review, and interview with facility staff, from 6/6/11 through 6/9/11, smoke detectors were observed and testing records were requested.

6/6/11 - Third Floor Mineral King Building
At 1:52 p.m., the smoke detector was missing from Room 3S26. Wires were hanging from the ceiling where the detector had been mounted.

During record review on 6/7/11, records were requested for smoke detector testing and sensitivity testing.
At 8:43 a.m., records indicated that smoke detectors were tested in April and May of 2010. There were no records that indicated that all smoke detectors were tested during the last year.

During an interview, on 6/8/11, Engineering Staff 2 reported that the detectors in the Acequia Wing are self calibrating for sensitivity. A report was provided for sensitivity testing for the Mineral King Building. The report "Fire Alarm Inspection Report 07/2008" was a report for the third quarter of 2008.
The report indicated smoke detector sensitivity testing was performed in January 2008. No other records were provided for previous years or for the current year. There was no indication that the detectors were sensitivity tested the first year, the third year and every five years thereafter.

During an interview on 6/9/11, at 8:03 a.m., Engineering Staff 2 reported there are single station smoke detectors in every room of the pods, on 2 North, 3 North, 3 South, 4 North, and 4 South. He reported there were no records for testing the single station smoke detectors located in the pods. He stated the detectors were not tested. The facility could not provide any information for the dates the single station smoke detectors were installed, tested, or replaced according to the manufacturer's recommendation.

Based on observation, the facility failed to ensure that at least a local alarm will sound when the sprinkler system valves are closed. This was evidenced by no alarm or trouble signal received at the panel in PBX, or by the monitoring company, during testing of 1 of 19 tamper alarms. The tamper valve alarm indicates the water has been shut off for the sprinkler system. This affected one of four floors and could result in a failure of the sprinkler system if the water were shut off.

Findings:

During the facility tour and alarm testing with facility staff on 6/8/11, the tamper alarm was tested for the west side expansion area. At 4:50 p.m., there was no no audible alarm or trouble signal received at PBX when the valve was closed three revolutions.

During record review on 6/9/11, the reports for fire alarm test signals, received by the monitoring company on 6/7 and 6/8/11, were requested. Two reports were provided.

During record review on 6/15/11, the report "Alarm Log History (External)," from the monitoring company, was reviewed. There was no indication a signal was received by the monitoring company during the time that the tamper valve was closed at 4:50 p.m.

Based on observation, and record review, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by missing or displaced escutcheon rings, and by incomplete documents for quarterly testing of the sprinkler system for two of four quarters. There were no records for quarterly inspection of the dry pipe system in the Acequia Wing. This affected the entire hospital and could result in a delay in extinguishing a fire.

Escutcheon rings (ER) are part of the sprinkler assembly that function to cover the penetration around the sprinkler pipe.

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

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.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
9-5.1 Inspection and Testing of Sprinkler Pressure Reducing Control Valves. Sprinkler pressure reducing control valves shall be inspected and tested as described in 9-5.1.1 and 9-5.1.2.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

Findings:

During a facility tour with staff from 6/6/11 - 6/9/11, the sprinkler system was observed.

6/6/11 - Third Floor
At 1:35 p.m., there was an approximately 1/8 - 1/4 inch gap on one side of the escutcheon ring (ER), near the column, in the 3rd Floor elevator lobby area.
At 3:15 p.m., there was an approximately 1/8 - 1/4 inch gap between the ER and the ceiling, in the 3W02 Bathroom.

6/8/11 - First Floor
At 10:01 a.m., there was a sprinkler cap missing, in the IT closet, near the emergency department (ED) fast track area.

6/9/11
At 10:50 a.m., there was a sprinkler cap missing, outside of the IT Room, on the exterior of the building.
At 11:05 a.m., two ERs were missing in the ambulance bay outside of the ED.


29752

During record review on 6/8/11, the sprinkler system inspection records were requested. At 9:30 a.m., there were no complete quarterly fire sprinkler testing records for the second and third quarters of 2010. The records failed to indicate the number of waterflow valves and tamper alarms tested each quarter. Records indicated there are 45 tamper alarms and 28 waterflow (ITV) valves. There was no record that confirmed all tamper alarms and ITV (inspector's test valves) were tested quarterly as required.

6/8/11 - Basement
At 9:59 a.m., a pre-action valve for a dry pipe system was observed in the basement of the new addition. During record review no records were provided for testing of this system.

At 10:37 a.m., there was a recessed sprinkler cap that was dropped approximately 1/4 inch, in the ceiling, in the 2E step down nursery storage room.

At 11:25 a.m., there were 4 recessed sprinkler caps that were dropped approximately 1/2 inch from the ceiling, in the recovery area.

At 11:51 a.m., there was a recessed sprinkler cap that had dropped approximately 3/8 inch from the ceiling, in the IT office in the surgery support area.

Based on observation, the facility failed to ensure fire extinguishers are provided and maintained per NFPA 10. This was evidenced by fire extinguishers that were unsecured or missing monthly checks. This affected smoke compartments on one of four floors and the basement. This could result in a delay in extinguishing a fire.

NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturers's instructions.

4.3.1 *Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected, manually or by electronic monitoring, at more frequent intervals when circumstances require.

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

Findings:

During the facility tour with staff on 6/6/11 and 6/9/11, fire extinguishers were observed on the third floor and basement area.

6/6/11 - Third Floor Mineral King Building
At 2:05 p.m., the tag on the fire extinguisher, in the IT phone room, was missing monthly checks for January 2011 through May 2011.

At 2:23 p.m., the fire extinguisher tag indicated there was no monthly check for March 2011, for the extinguisher in the 3 North charting station.

6/9/11 - Basement
At 9:25 a.m., a fire extinguisher was sitting on the floor in the elevator room. A penetration in the wall indicated where the extinguisher was previously mounted.

At 9:28 a.m., a fire extinguisher was sitting on the floor in the AV Room. The extinguisher was missing monthly checks for April and May 2011.

Based on observation, the facility failed to ensure that a capacity of 32 gallons of soiled linen or trash collection receptacles was not exceeded within any 64 square foot area. This was evidenced by multiple soiled linen receptacles placed side by side in the corridor. This affected one of four floors and could result in an increased risk of fire.

Findings:

During the facility tour with facility staff on 6/6/11, soiled linen and trash receptacles were observed on the third floor.

3 South
At 1:44 p.m., there were two approximately 32 gallon receptacles (bins) placed side by side, in the area outside of 3S4. There were two approximately 32 gallon bins, side by side, in the area outside of 3S13.

At 1:45 p.m., there were two approximately 32 gallon bins, side by side, in the area outside of 3S19.

At 1:50 p.m., there were four approximately 32 gallon bins, in the back corridor area on 3 South. Two bins were side by side. Approximately five feet away the other two bins were placed in the corridor, side by side.

At 1:58 p.m., there were two approximately 32 gallon bins, side by side, in the area outside of 3S35.

3 North
At 2:17 p.m., there were two approximately 32 gallon bins, side by side, in the area outside of 3N7. There were two approximately 32 gallon bins, side by side, in the area outside of 3N33 and 3N27.

At 2:22 p.m., there were two approximately 32 gallon bins, side by side, in the area outside of 3N21.

At 2:27 p.m., there were two approximately 32 gallon bins, side by side, in the area outside of 3N9.

Based on record review and staff interview, the hospital failed to ensure anesthetizing locations were maintained at a minimum of 35% relative humidity. This was evidenced by humidity logs that indicated humidity less than 35 % in 3 of 3 months during the first quarter of 2011. This could result in fire and injury or death affecting patients in 2 of 10 OR (Operating Room) Suites in the hospital.

Findings:

During record review on 6/8/11, the humidity logs for anesthetizing locations were provided. The first quarter of 2011 was reviewed.

At 8:32 a.m., the main hospital binder for Surgery Humidity Report 2011 included the Temperature/Humidity Reports for Surgery OR Suites 1 to 10.

At 9 a.m., the January 2011 records indicated both OR 9 and 10 were below the minimum 35% relative humidity 6 of 31 days.

At 9:15 a.m., the February 2011 records indicated that OR 9 was below 35% relative humidity for 27 of 28 days.

At 9:33 a.m., the March 2011 records indicated OR 9 was below 35% relative humidity for 19 of 31 days.

At 9:35 a.m., there was no documentation provided that verified a process was in place for correcting out of range humidity readings in the OR Suites.

At 9:36 a.m., there were no records available for the anesthetizing locations in the new hospital addition.

During an interview on 6/7/11 at 4:45 p.m., Engineering Staff 2 stated, the reports are printed and filed in the humidity log binder. He stated he was unsure if they were reviewed. He was asked if there were any records of repairs for the out of range humidity readings. He stated there were no records available regarding repairs related to out of range humidity readings.

Based on observation, the facility failed to ensure no smoking signs are posted in areas where oxygen is used or stored. This was evidenced by one oxygen storage area with no signs on two of two exposed sides. This could result in an increased risk of smoking and potential risk of fire in this area.

Findings:

During the facility tour on 6/9/11, the exterior areas of the facility were observed. The respiratory oxygen storage area is located in a brick enclosure adjacent to the trash compactor.

At 11:24 a.m., the respiratory oxygen storage area failed to have no smoking signs on two sides that were exposed to public view.

Based on observation and interview, the facility failed to maintain their electrical wiring in accordance with NFPA 70 and NFPA 99. This was evidenced by the use of surge protectors, outlet boxes, and extension cords, as permanent wiring, and by obstructions in front of electrical panels. This affected smoke compartments on four of four floors. This could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

110-26
(a)Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(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 inches (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.

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

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

400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(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.
(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 99 Health Care Facilities, 1999 Edition
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patients care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During the facility tour with staff from 6/6/11 to 6/9/11, the electrical wiring was observed.

6/6/11 - Third Floor
At 1:56 p.m., electrical panel 3EB2 was obstructed by stacked IV solution bins, on wheels, placed against the panel door. The panel is located in the 3rd floor med room.
At 1:58 p.m., there was a sharps container placed in front of electrical panel 3B3. The door could not be opened.

3 West
At 2:40 p.m., a refrigerator was plugged into a six-plug surge protector in the Pharmacy Services Office.
At 2:50 p.m., a refrigerator was plugged into a six-plug surge protector in the Respiratory Director's Office.
At 3:55 p.m., a refrigerator was plugged into a six-plug surge protector in the Maternal Child office area.

6/7/11 - Emergency Department
At 11:31 a.m., a refrigerator was plugged into a six-plug surge protector in the ED med room.

6/8/11 - First Floor
At 9:59 a.m., a refrigerator was plugged into a six-plug surge protector in the ED assistant manager's office.

At 10:58 a.m., there was approximately 20 feet of plastic wrapped conduit, laying on the floor, connecting two outlet boxes to a junction box on the floor. The conduit, outlet boxes and junction box, were unsecured and located under a counter in the "old" admissions reception area.

During an interview at 11 a.m., Engineering Staff 2 reported the counters were no longer used for processing admissions and the outlets were no longer in use. He stated he was unsure why the outlets were not hardwired or if they were installed by an electrician.

At 11:05 a.m., there were four plastic cases of soda stacked in front of the electrical panel 1EE, in the Ambrosia Cafe. The panel door could not be opened.

At 11:12 a.m., an extension cord connected fans and a CD player to the wall outlet.

At 12:02 p.m., tray carts and dish carts were placed against electrical panels K-1, K-2, and K-3, in the kitchen dishwashing area. The panel doors could not be opened without moving the carts.

6/9/11 - Basement
At 10:20 a.m., there was a refrigerator and a microwave plugged into a six-plug surge protector in the basement staff lounge.


29752


6/6/11 - Fourth Floor
At 2:18 p.m., there was a patient bed plugged into a surge protector/ extension cord in Room 4N (North) 1.

At 2:19 p.m., there was a patient bed plugged into a surge protector in Room 4N 3.

At 2:27 p.m., there were four infusion pumps set-up for patient use and plugged into one surge protector, in the 4C (Center) dialysis infusion area.

At 2:49 p.m., there were four Pyxis medication dispensers plugged into a surge protector, plugged into another surge protector that was plugged into an electrical wall outlet in the 4S (South) medication room.

Second Floor
At 3:10 p.m., there was a missing cover plate on the ceiling outlet for the Television/Nurse Call light cable in patient room 2N 7.

At 3:52 p.m., there were six medical devices plugged into a surge protector at NICU (Nursery Intensive Care Unit) Bed 1.

At 3:54 p.m., there were four medical devices plugged into a surge protector at NICU Bed 2.

At 4:02 p.m., there was a refrigerator and a computer plugged into an extension cord in Room 2548.

At 4:06 p.m., there were two coffee makers plugged into a surge protector in the NICU staff break room.

6/7/11 - Second Floor
At 11:36 a.m., there was a micro-wave and toaster plugged into a surge protector in the 2 West ICU staff lounge.

At 11:42 a.m., there were 2 Pyxis medication dispensers plugged into a surge protector in the 2 West ICU medication room.

At 2:46 p.m., there was a blanket warmer plugged into a surge protector in the sterile storage room.

At 3:13 p.m., there was an anesthesia station plugged into an extension cord, in the ZEEGO Cath Lab #6.

6/8/11
At 10:37 a.m., there was a Pyxis medication dispenser plugged into a surge protector at the 2 East Nurse Station in Labor and Delivery.

At 10:46 a.m., there was an electrical power cord run through a ceiling tile to an electrical wall outlet in the Nurse Manager's office. This was connected to equipment located above the ceiling.

First Floor
At 3:37 p.m., there was an anesthesia station plugged into a portable, four outlet box, connected to the wall outlet by a heavy duty attachment cord, in OR 7. The outlet box was placed on the floor.

At 3:45 p.m., there was an anesthesia station plugged into a portable, four outlet box, connected to the wall outlet by a heavy duty attachment cord, in OR 14. The outlet box was placed on the floor.


At 3:53 p.m., there was an anesthesia station plugged into a portable, four outlet box, connected to the wall outlet by a heavy duty attachment cord, in OR 9. The outlet box was placed on the floor.

At 4:20 p.m., there was a full size copy machine plugged into a surge protector at the PACU (Post Anesthesia Care Unit) main entrance.