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Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This could result in the spread of smoke or fire from one smoke compartment to another, and increase the risk of injury due to smoke and fire. This affected 1 of 5 floors in the Main Hospital, and 1 of 4 floors in the Professional Office Building.

Findings:

During a tour of the facility with Staff I and Staff II on September 24, 2012, through September 27, 2012, the walls and ceilings were observed.

Main Hospital
September 24, 2012

At 9:20 a.m., there was an approximately 1 1/2 inch penetration around purple communication wires in the ceiling of the Gift Shop storage closet.




29626


LLUMC Outpatient Services Building
September 26, 2012

1. At 10:08 a.m., the wall to the Hyperbaric Chamber Room, located in Suite 410 on the 4th Floor, had four approximately 3 inch diameter penetrations. The penetrations were located behind four Class B chambers, and were around copper pipes used for oxygen.

2. At 10:30 a.m., the corridor wall to Suite 410 on the 4th Floor, had five penetrations above the drop-down ceiling by the exit door from the Hyperbaric Chamber Room. The first penetration measured approximately 2 inches, and was located around a copper pipe. The second penetration measured approximately 1 inch, and was located around purple cables. The last three penetrations measured approximately 1/2 inch each, and were located around electrical conduits.

3. At 10:41 a.m., the corridor wall to Suite 410 on the 4th Floor, had a penetration above the drop-down ceiling by the entrance into the suite. The penetration measured approximately 1 inch.

4. At 10:47 a.m., the wall that separated Suite 410 from other tenants on the 4th Floor, had nine penetration above the drop-down ceiling in the Hyperbaric Chamber Room. The penetrations ranged from approximately 1/2 inch to 3 inches, and were located around pipes, cables, conduits, and beams.

Based on observation, the facility failed to maintain the corridor doors. This was evidenced by doors that were obstructed from closing, and by doors that failed to latch. This affected 3 of 5 floors in the Main Hospital, and could result in the spread of smoke or fire in the event of a fire.

Findings:

During a tour of the facility with the Director of Facilities on September 24, 2012, through September 25, 2012, the doors were observed.

Main Hospital/ Pharmacy
September 25,2012

At 9:07 a.m., two unoccupied offices had wooden door stops holding open doors that were equipped with self closing devices.

Main Hospital/ CATH Lab
September 25,2012

At 10:20 a.m., the latching mechanism on the door to Room 22106 failed to latch whenn the door handle was pushed, or the door was pulled closed

Main Hospital/3rd Floor
September 25, 2012

At 1:45 p.m. the door to Patient Room 3004 failed to positive latch when closed.

Based on observation, the facility failed to install exit signs on or by doors designated as exits. This was evidenced by no exit signs posted on exit doors in the Operating Room's Sterile Processing Area. This could result in a delay in evacuation, and affected 1 of 5 floors in the Main Hospital.

Findings:

During a tour of the facility with the Lead Facility Technician on September 24, 2012, through September 27, 2012, the exits and exit signs were observed.

Main Hospital
September 25, 2012

At 3:00 p.m., there were no exit signs posted over or near the exit doors in the Operating Room's Sterile Processing Area, located on the 2nd Floor. The room measured 1,635 square feet, and had 3 of 5 doors that exited into corridors.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls in accordance with NFPA 101. This was evidenced by penetrations in smoke barrier walls. This could result in the spread of smoke or fire from one smoke compartment to another, and increase the risk of injury to the patients due to smoke and fire. This affected 2 of 5 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
8.3.2 Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Findings:

During a tour of the facility with Staff I and Staff II on September 24, 2012, through September 26, 2012, the smoke barrier walls were observed.

Main Hospital
September 25, 2012

At 12:08 p.m., there was an approximately 1 1/2 inch penetration around a green wire in the smoke barrier wall adjacent to Room 13028.


29626

Main Hospital
September 25, 2012

At 10:30 a.m., the smoke barrier wall in the attic space above fire door
# 22034, located by the entrance into the Operating Room on the 2nd Floor, had a penetration that measured approximately 1/2 inch with white cables running through it.

Based on observation, the facility failed to maintain the Gift Shop in accordance with NFPA 101. This was evidenced by a door to the storage room in the Gift Shop that was obstructed from closing. This could result in the spread of smoke or fire in the event of a fire, and affected 1 of 5 floors in the Main Hospital.

Findings:


During a tour of the facility with Staff I on September 25, 2012, the gift shop fire rated doors were observed.

Main Hospital

At 9:20 a.m., the door to the storage room of the Gift Shop was propped open with a rubber door stop.

Based on staff interview, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by a staff member who did not know how to respond to a fire. This could result in staff members not being familiar with their roles and responsibilities in the event of a fire, and affected the main hospital building.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During a tour of the facility with the Lead Facility Technician on September 24, 2012, through September 27, 2012, facility staff was interviewed to determine their knowledge of their fire emergency procedures and usage of life safety equipment.

Main Hospital
September 26, 2012

At 2:31 p.m., Clinical Staff was asked how they would respond to a fire. The staff member stated that they would remove any patients directly involved with the fire, but staff was unable to describe how to transmit a fire alarm signal, confine or contain a fire, and evacuate as described in the facility's fire/disaster plan. When asked how long they had been working at the hospital, and if they had received training, staff stated that they had been working there for approximately 1 year, and had not completed the online course on fire safety.

Based on observation and record review, the facility failed to maintain their fire suppression system in accordance with NFPA 101, and NFPA 25. This was evidenced by no monthly inspection records for the fire suppression system in the Computer Room. This could result in the failure of the supression system in the event of a fire, and affected 1 of 5 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
9.7.3 Other Automatic Extinguishing Equipment.
9.7.3.1 In any occupancy where the character of the potential fuel for fire is such that extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as water mist, carbon dioxide, dry chemical, foam, Halon 1301, water spray, or a standard extinguishing system of another type, that system shall be permitted to be installed in lieu of an automatic sprinkler system. Such systems shall be installed, inspected, and maintained in accordance with appropriate NFPA standards.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
9-4.3.1.1 Gauges shall be inspected weekly. The gauge on the supply side of the preaction or deluge valve shall indicate that the normal supply water pressure is being maintained.
Exception No. 1: The gauge monitoring the preaction system supervisory air pressure, if provided, shall be inspected monthly to verify that it indicates that normal pressure is being maintained.
Exception No. 2: The gauge monitoring the detection system pressure, if provided, shall be tested monthly to verify that it indicates that normal pressure is being maintained.

9-4.3.1.2 The preaction or deluge valve shall be externally inspected monthly to verify the following:
(a) The valve is free from physical damage.
(b) All trim valves are in the appropriate open or closed position.
(c) There is no leakage from the valve seat.
(d) Electrical components are in service.

Findings:

During a tour of the facility with the Lead Facility Technician on September 24, 2012, through September 27, 2012, the fire suppression systems were observed, and documents were requested.

Main Hospital
September 25, 2012

At 9:43 a.m., the fire suppression system in the Computer Room #14007, located on the 1st Floor, was observed to have a pressure gauge installed. The Lead Facility Technician stated that the system was a pre-action type system. When asked for the monthly inspection records, the Lead Facility Technician stated that monthly inspections had not been done since the system was installed approximately 2 years ago. The only inspection record available for the system was the annual inspection that was done in September, 2012.

Based on observation, the facility failed to maintain there fire extinguishers in accordance with NFPA 10. This was evidenced a fire extinguisher that was stored unsecured. This could result in damage to the fire extinguisher, and affected 1 of 5 floors in the Main Hospital.

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 manufacturer ' s instructions.

Findings:

During a tour of the facility with the Director of Facilities on September 25, 2012, the fire extinguishers were observed.

Main Hospital

At 9:40 a.m., there was a fire extinguisher stored unsecured on the floor in Elevator Room 13024.

Based on observation, the facility failed to maintain their fire dampers in accordance with NFPA 90A. This was evidenced by the failure of an LED light that indicated damper function. This affected 1 of 5 floors of the Main Hospital, and had the potential the allow the spread of smoke from compartment to compartment in the event of a fire.

NFPA 90A,5-3 Controls and Operating Systems.
5-3.1* Controls relating to fan shutdown and automatic damper operation shall be tested for compliance with the requirements of this standard.
5-3.2 Acceptance tests of fire protection devices in air-conditioning
and ventilating systems shall, as far as practicable, be performed under normal operating conditions. Some portions of control or alarm systems are permitted to have standby power or other emergency modes of operation. The tests shall be performed to determine that the system operates under these conditions as well as normal conditions.
5.4.5.4.2 requires smoke dampers be tested in accordance with UL 555S "Standard for Safety Smoke Dampers."

Findings:

During a tour of the facility with the Director of Facilities on September 25, 2012, the damper indicator lights were observed.

Main Hospital

At 3:00 p.m., the damper function light in Closet 2145 failed to illuminate a green light to indicate it was functioning.

Based on observation, the facility failed to maintain their medical gas cylinders in accordance with NFPA 99. This was evidenced by oxygen cylinders that were not stored individually secured. This could result in damage to an oxygen cylinder, and affected 1 of 5 floors in the Main Hospital.

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

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.1. Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a tour of the facility with the Lead Facility Technician on September 24, 2012, through September 27, 2012, the medical gas storage was observed.

Main Hospital
September 25, 2012

At 11:56 a.m., the Medical Gas Storage Area, located on the Loading Dock, had 2 H-Type oxygen cylinders that were not stored individually secured. The cylinders measured approximately 251 cubic feet each.

Based on observation, the facility failed to maintain their heliport in accordance with NFPA 101, and NFPA 418. This was evidenced by cigarette butts observed on the ground within a 50 foot radius of the heliport landing pad, and no "No Smoking" signs displayed. This could result in an increased risk of fire, and affected the Main Hospital.

NFPA 101, 2000 Edition
18-3.2.7
Buildings housing health care occupancies as indicated in 18.1.1.1.2 that have rooftop heliports shall be protected in accordance with NFPA 418, Standard for Heliports.

NFPA 418, Standard for Heliports, 1995 Edition
2-5 No Smoking. No smoking shall be permitted within 50 ft (15.2 m) of the landing pad edge. No smoking signs shall be erected at access/egress points to the heliport.

Findings:

During a tour of the facility with the Lead Facility Technician on September 24, 2012, through September 27, 2012, the heliport was observed.

Main Hospital
September 25, 2012

At 12:01 p.m., there were cigarette butts observed on the ground within approximately 10 feet to 20 feet from the landing pad. There were no signs that read "NO SMOKING", or signs with the international symbol for no smoking, displayed at the access/egress points to the heliport.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This could result in the spread of smoke or fire from one smoke compartment to another, and increase the risk of injury due to smoke and fire. This affected 1 of 5 floors in the Main Hospital, and 1 of 4 floors in the Professional Office Building.

Findings:

During a tour of the facility with Staff I and Staff II on September 24, 2012, through September 27, 2012, the walls and ceilings were observed.

Main Hospital
September 24, 2012

At 9:20 a.m., there was an approximately 1 1/2 inch penetration around purple communication wires in the ceiling of the Gift Shop storage closet.




29626


LLUMC Outpatient Services Building
September 26, 2012

1. At 10:08 a.m., the wall to the Hyperbaric Chamber Room, located in Suite 410 on the 4th Floor, had four approximately 3 inch diameter penetrations. The penetrations were located behind four Class B chambers, and were around copper pipes used for oxygen.

2. At 10:30 a.m., the corridor wall to Suite 410 on the 4th Floor, had five penetrations above the drop-down ceiling by the exit door from the Hyperbaric Chamber Room. The first penetration measured approximately 2 inches, and was located around a copper pipe. The second penetration measured approximately 1 inch, and was located around purple cables. The last three penetrations measured approximately 1/2 inch each, and were located around electrical conduits.

3. At 10:41 a.m., the corridor wall to Suite 410 on the 4th Floor, had a penetration above the drop-down ceiling by the entrance into the suite. The penetration measured approximately 1 inch.

4. At 10:47 a.m., the wall that separated Suite 410 from other tenants on the 4th Floor, had nine penetration above the drop-down ceiling in the Hyperbaric Chamber Room. The penetrations ranged from approximately 1/2 inch to 3 inches, and were located around pipes, cables, conduits, and beams.

Based on observation, the facility failed to maintain the corridor doors. This was evidenced by doors that were obstructed from closing, and by doors that failed to latch. This affected 3 of 5 floors in the Main Hospital, and could result in the spread of smoke or fire in the event of a fire.

Findings:

During a tour of the facility with the Director of Facilities on September 24, 2012, through September 25, 2012, the doors were observed.

Main Hospital/ Pharmacy
September 25,2012

At 9:07 a.m., two unoccupied offices had wooden door stops holding open doors that were equipped with self closing devices.

Main Hospital/ CATH Lab
September 25,2012

At 10:20 a.m., the latching mechanism on the door to Room 22106 failed to latch whenn the door handle was pushed, or the door was pulled closed

Main Hospital/3rd Floor
September 25, 2012

At 1:45 p.m. the door to Patient Room 3004 failed to positive latch when closed.

Based on observation, the facility failed to install exit signs on or by doors designated as exits. This was evidenced by no exit signs posted on exit doors in the Operating Room's Sterile Processing Area. This could result in a delay in evacuation, and affected 1 of 5 floors in the Main Hospital.

Findings:

During a tour of the facility with the Lead Facility Technician on September 24, 2012, through September 27, 2012, the exits and exit signs were observed.

Main Hospital
September 25, 2012

At 3:00 p.m., there were no exit signs posted over or near the exit doors in the Operating Room's Sterile Processing Area, located on the 2nd Floor. The room measured 1,635 square feet, and had 3 of 5 doors that exited into corridors.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls in accordance with NFPA 101. This was evidenced by penetrations in smoke barrier walls. This could result in the spread of smoke or fire from one smoke compartment to another, and increase the risk of injury to the patients due to smoke and fire. This affected 2 of 5 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
8.3.2 Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Findings:

During a tour of the facility with Staff I and Staff II on September 24, 2012, through September 26, 2012, the smoke barrier walls were observed.

Main Hospital
September 25, 2012

At 12:08 p.m., there was an approximately 1 1/2 inch penetration around a green wire in the smoke barrier wall adjacent to Room 13028.


29626

Main Hospital
September 25, 2012

At 10:30 a.m., the smoke barrier wall in the attic space above fire door
# 22034, located by the entrance into the Operating Room on the 2nd Floor, had a penetration that measured approximately 1/2 inch with white cables running through it.

Based on observation, the facility failed to maintain the Gift Shop in accordance with NFPA 101. This was evidenced by a door to the storage room in the Gift Shop that was obstructed from closing. This could result in the spread of smoke or fire in the event of a fire, and affected 1 of 5 floors in the Main Hospital.

Findings:


During a tour of the facility with Staff I on September 25, 2012, the gift shop fire rated doors were observed.

Main Hospital

At 9:20 a.m., the door to the storage room of the Gift Shop was propped open with a rubber door stop.

Based on staff interview, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by a staff member who did not know how to respond to a fire. This could result in staff members not being familiar with their roles and responsibilities in the event of a fire, and affected the main hospital building.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During a tour of the facility with the Lead Facility Technician on September 24, 2012, through September 27, 2012, facility staff was interviewed to determine their knowledge of their fire emergency procedures and usage of life safety equipment.

Main Hospital
September 26, 2012

At 2:31 p.m., Clinical Staff was asked how they would respond to a fire. The staff member stated that they would remove any patients directly involved with the fire, but staff was unable to describe how to transmit a fire alarm signal, confine or contain a fire, and evacuate as described in the facility's fire/disaster plan. When asked how long they had been working at the hospital, and if they had received training, staff stated that they had been working there for approximately 1 year, and had not completed the online course on fire safety.

Based on observation and record review, the facility failed to maintain their fire suppression system in accordance with NFPA 101, and NFPA 25. This was evidenced by no monthly inspection records for the fire suppression system in the Computer Room. This could result in the failure of the supression system in the event of a fire, and affected 1 of 5 floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
9.7.3 Other Automatic Extinguishing Equipment.
9.7.3.1 In any occupancy where the character of the potential fuel for fire is such that extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as water mist, carbon dioxide, dry chemical, foam, Halon 1301, water spray, or a standard extinguishing system of another type, that system shall be permitted to be installed in lieu of an automatic sprinkler system. Such systems shall be installed, inspected, and maintained in accordance with appropriate NFPA standards.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
9-4.3.1.1 Gauges shall be inspected weekly. The gauge on the supply side of the preaction or deluge valve shall indicate that the normal supply water pressure is being maintained.
Exception No. 1: The gauge monitoring the preaction system supervisory air pressure, if provided, shall be inspected monthly to verify that it indicates that normal pressure is being maintained.
Exception No. 2: The gauge monitoring the detection system pressure, if provided, shall be tested monthly to verify that it indicates that normal pressure is being maintained.

9-4.3.1.2 The preaction or deluge valve shall be externally inspected monthly to verify the following:
(a) The valve is free from physical damage.
(b) All trim valves are in the appropriate open or closed position.
(c) There is no leakage from the valve seat.
(d) Electrical components are in service.

Findings:

During a tour of the facility with the Lead Facility Technician on September 24, 2012, through September 27, 2012, the fire suppression systems were observed, and documents were requested.

Main Hospital
September 25, 2012

At 9:43 a.m., the fire suppression system in the Computer Room #14007, located on the 1st Floor, was observed to have a pressure gauge installed. The Lead Facility Technician stated that the system was a pre-action type system. When asked for the monthly inspection records, the Lead Facility Technician stated that monthly inspections had not been done since the system was installed approximately 2 years ago. The only inspection record available for the system was the annual inspection that was done in September, 2012.

Based on observation, the facility failed to maintain there fire extinguishers in accordance with NFPA 10. This was evidenced a fire extinguisher that was stored unsecured. This could result in damage to the fire extinguisher, and affected 1 of 5 floors in the Main Hospital.

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 manufacturer ' s instructions.

Findings:

During a tour of the facility with the Director of Facilities on September 25, 2012, the fire extinguishers were observed.

Main Hospital

At 9:40 a.m., there was a fire extinguisher stored unsecured on the floor in Elevator Room 13024.

Based on observation, the facility failed to maintain their fire dampers in accordance with NFPA 90A. This was evidenced by the failure of an LED light that indicated damper function. This affected 1 of 5 floors of the Main Hospital, and had the potential the allow the spread of smoke from compartment to compartment in the event of a fire.

NFPA 90A,5-3 Controls and Operating Systems.
5-3.1* Controls relating to fan shutdown and automatic damper operation shall be tested for compliance with the requirements of this standard.
5-3.2 Acceptance tests of fire protection devices in air-conditioning
and ventilating systems shall, as far as practicable, be performed under normal operating conditions. Some portions of control or alarm systems are permitted to have standby power or other emergency modes of operation. The tests shall be performed to determine that the system operates under these conditions as well as normal conditions.
5.4.5.4.2 requires smoke dampers be tested in accordance with UL 555S "Standard for Safety Smoke Dampers."

Findings:

During a tour of the facility with the Director of Facilities on September 25, 2012, the damper indicator lights were observed.

Main Hospital

At 3:00 p.m., the damper function light in Closet 2145 failed to illuminate a green light to indicate it was functioning.

Based on observation, the facility failed to maintain their medical gas cylinders in accordance with NFPA 99. This was evidenced by oxygen cylinders that were not stored individually secured. This could result in damage to an oxygen cylinder, and affected 1 of 5 floors in the Main Hospital.

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

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.1. Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a tour of the facility with the Lead Facility Technician on September 24, 2012, through September 27, 2012, the medical gas storage was observed.

Main Hospital
September 25, 2012

At 11:56 a.m., the Medical Gas Storage Area, located on the Loading Dock, had 2 H-Type oxygen cylinders that were not stored individually secured. The cylinders measured approximately 251 cubic feet each.

Based on observation, the facility failed to maintain their heliport in accordance with NFPA 101, and NFPA 418. This was evidenced by cigarette butts observed on the ground within a 50 foot radius of the heliport landing pad, and no "No Smoking" signs displayed. This could result in an increased risk of fire, and affected the Main Hospital.

NFPA 101, 2000 Edition
18-3.2.7
Buildings housing health care occupancies as indicated in 18.1.1.1.2 that have rooftop heliports shall be protected in accordance with NFPA 418, Standard for Heliports.

NFPA 418, Standard for Heliports, 1995 Edition
2-5 No Smoking. No smoking shall be permitted within 50 ft (15.2 m) of the landing pad edge. No smoking signs shall be erected at access/egress points to the heliport.

Findings:

During a tour of the facility with the Lead Facility Technician on September 24, 2012, through September 27, 2012, the heliport was observed.

Main Hospital
September 25, 2012

At 12:01 p.m., there were cigarette butts observed on the ground within approximately 10 feet to 20 feet from the landing pad. There were no signs that read "NO SMOKING", or signs with the international symbol for no smoking, displayed at the access/egress points to the heliport.