HospitalInspections.org

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that patient's doors protecting corridors on the third and fourth floor do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1. During the tour for life safety from fire, patient's sleeping room doors were tested on 10/31/12 from 2:00 pm till 4:00 pm and on 11/2/12 from 9:00 am till 12:00 noon with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was found that the following patient's rooms do not have the capability of latching when the doors are in the closed position, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire:

a. Patient's rooms on the third and fourth floors: #325, #330, #405, #406, #415 and #420 (all patient sleeping room doors shall be verified for compliance).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that the facility failed to provide readily visible illuminated "exit" signs where the exit or way to reach the exit is not readily apparent to its occupants such as the main sorting area of the medical record department as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.10.1.2.

Findings include:

There is the need of an illuminated exit sign to ensure the path of travel in the event of an emergency near the main sorting area of the medical record department as observed with the facility's Engineer (employee #1) on 10/31/12 at 10:10 am.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that smoke barriers on the second, third and fourth floors are not provided to form at least two smoke compartments for every sleeping room floor of more than 30 patients as required by the 2000 edition of the Life Safety Code of the NFPA Sections 19.3.7.1 and 19.3.7.2.

Findings include:

During the tour for life safety from fire, patient's sleeping rooms on the second and third floors were observed on 11/2/12 from 10:00 am till 11:30 am and it was found that the smoke barriers on the second and third floors do not provide at least two smoke compartments for each sleeping room floor of over 30 patients. There are a total of 43 patient's beds per floor. The nursing station is constructed in a manner that creates an opening in the smoke barrier (nursing counter creates an opening between the two hallways) and smoke at one side of the smoke barrier will enter the other side of the smoke barrier.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided at the medication preparation room of the emergency room, in the internal staircase (#1, #2, #3), outside exits, generator rooms and hallways, an emergency lamps on the second floor did not illuminate when tested and no evidence was found that the facility is testing the emergency lamps on a monthly (off-site emergency room at "Cidra") and annual (main hospital) basis as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour from 10/30/12 through 11/2/12 from 9:00 am till 4:00 pm in the following areas:
a. At the three internal exit staircases (newly constructed-staircases #1, #2 and #3) from the top floor (fourth floor) through the first floor to ensure visibility at night if power is lost and an emergency evacuation is needed.
b. At all outside locations where the inside of the facility's exits leads to the outside of the building such as the emergency room's exits to the outside.
c. At the Medication preparation room of the Emergency room.
d. Within the covered structures where the two electrical generators are located.
e. In the hallway near the sterile supply department and in front of mechanical room #1.
f. In the waiting room of the off-site emergency room in "Cidra".
g. In the hallway near the Decontamination room of the off-site emergency room in "Cidra".
h. In the hallway in front of the operating suites in the restricted area.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

2. Documentation about tests to emergency lighting reviewed on 11/2/12 at 11:00 am with the facility's Engineer (employee #1) provided evidence that the facility is not performing the annual 90 minute tests. Tests are performed on a monthly basis for approximately 20 to 25 minutes but no evidence was found of the 90 minute annual tests.
a. Also, documentation of monthly emergency light tests from the off-site emergency room in "Cidra" is performed for 15 seconds and not 30 seconds as required.

3. The emergency battery operated lamp (EBOL) in the following area was tested and did not illuminate as observed on 11/2/12 at 11:00 am:
a. The EBOL on the second floor near patient's room #216.

Based on observations and interview made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that smoke detectors are available at all required areas such as mechanical room of the general maintenance department, hallway of the laboratory department, dirty linen room on the third floor, machine room that serves elevators #3 and #4, fire alarm documentation about sensitivity tests was not found, smoke detectors were found close to air conditioner vents, no automatic annunciation for the off-site emergency room of "Aguas Buenas" and some smoke detectors did not work as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. The smoke detector located in the Medical Record department near the main sorting area was observed on 10/31/12 at 10:00 am with the facility's within three feet of the air conditioner vent. Air blown in air conditioner vents can affect the effectiveness of the smoke detector to detect smoke in the event of a fire.

2. The smoke detector in mechanical room #1 was visited on 10/31/12 at 11:50 am with the facility's Engineer (employee #1) and provided evidence that it had a rubber glove wrapped over it. The facility's Engineer (employee #1) stated on 10/31/12 at 11:50 am that the glove was probably placed there by construction personnel working in this room.

3. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) from 10/30/12 through 11/2/12 from 9:00 am till 4:00 pm:
a. In the mechanical room of the general maintenance department.
b. In the hallway of the laboratory department.
c. In the dirty linen room on the third floor.
d. In the machine room that serves elevators #3 and #4.

4. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 11/2/12 at 1:05 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), however no evidence was found of the following:
a. Smoke detector sensitivity tests and readings.

5. Some of the smoke detectors at the off-site emergency room at "Cidra" were not blinking as determined on 11/1/12 at 1:00 pm with the facility's Engineer (employee #1). The entire system was verified on 11/1/12 at 5:00 pm and placed in working order, however the facility must ensure that periodic maintenance is performed when the system is in trouble mode.

6. The fire alarm system of off-site emergency room in "Aguas Buenas" lacks annunciation to an approved central station as reviewed on 11/2/12 at 2:00 pm. The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that portable fire extinguisher are maintained related to updated inspections, are visible and accessible at all required areas and are mounted at the appropriate heights as states in the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. During observations made of the hospital with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) on 10/31/12 at 9:45 am, the fire extinguisher located at the back door of the general storage area was found without the facility's monthly inspections.

2. During the observational tour of the laboratory department of the hospital with the facility's (Engineer #1) and Physical Plant Manager (employee #2) on 10/31/12 at 2:00 pm, it was found that fire extinguisher #53 which weighs less than 40 pounds was placed higher than five feet in height (measured from the top part of the fire extinguishers handle). According with NFPA 10, section 1.5.10, fire extinguishers weighing less than 40 pounds shall be installed so that the top part of the fire extinguisher is not more than five feet in height. The facility must lower the fire extinguisher and verify all other extinguishers to ensure that they are lower than five feet so that they can be accessible to all persons if needed.

3. The fire extinguisher located on the fourth floor near patient's room #420 was found mounted to the side of a column on 10/31/12 at 3:30 pm with the facility's (Engineer #1) and Physical Plant Manager (employee #2). However a sign is needed in order for persons to identify where it is because the column does not allow it to be seen from one side of the hallway.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to monitor means of egress at the back exit of the general storage department, hallway near the janitor's service department, in the exit staircase of the laboratory department and at the exit door in the back of the Nuclear Medicine department to ensure that they are maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. The back exit door of the general storage department was found on 10/31/12 at 9:45 am with the facility's Engineer (employee #1) and provided evidence that there are two tables with chairs located in front of this door. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

2. In the hallway of the facility in front of general maintenance department (Janitor Services) on 10/31/12 at 8:45 am, four large bins were found with dirty linen limiting the space of the hallway to within two feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

3. During the observational tour of the laboratory department of the hospital with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) on 10/31/12 at 2:00 pm, it was found that the emergency staircase located at this department has a large garbage container with a broom and dust pan in it. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

4. During the observational tour of the Nuclear Medicine department on 11/2/12 at 9:30 am, it was found that the back emergency exit door has two latches (latches are not permitted on these exit doors) and a push pad. Once the door was opened the path of travel was blocked by old equipment left in this area and the cement walk way was covered in leaves and dirt. Also, at the end of this cement path are steps instead of a ramp which will not allow a smooth transition away from the building in the event of an evacuation. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and interview, it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.5.5.

Findings include:

During the observational tour of the facility the dirty linen storage room located on the third floor on 11/2/12 at 10:15 am with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that personnel are using this closet to place dirty linen, it had two large hampers full of dirty linen and did not have an air extractor. The facility's Engineer (employee #1) stated during an interview on 11/2/12 at 10:20 am that this closet is used as a holding area until personnel make their rounds and remove them from the closet. This closet did not have a smoke detectors connected to the fire alarm panel. The construction of closets for this purpose must be verified to ensure one hour fire rating (with 3/4 hour fire-rated doors) with positive latching and door closers and containers can not exceed 32 gallons within any 64 square foot area.

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and interview, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to standpipe maintenance, oxygen storage and transporting, evacuation plans are needed at the new construction and the existing plans need to be revised, the use of hand sanitizer in the kitchen and rubbing alcohol in the operating suites, copper and metal tubing were making contact, use of multi-plugs, no documentation of seamise connection, use of regular garbage containers and no documentation of the large oxygen container system alarm.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 10/30/12 through 11/2/12 from 9:00 am till 4:00 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) type H and Type E oxygen tanks were found in areas that do not meet minimum requirements:
a. Two type H oxygen cylinders were found in a material storage room near the observation cubicles used to give patients oxygen therapy and Intravenous solutions of the emergency room. (These tanks are used as spare tanks for patients receiving respiratory therapy).
b. Two type H oxygen cylinders were found in the dirty utility room of the off-site emergency room in "Cidra".
c. Four type E oxygen cylinders were found in the respiratory therapy department.

2. Standpipes (fire hoses) were observed during the life safety observational tour with the facility's Engineer (employee #1) and maintenance documentation was reviewed on 11/2/12 at 1:45 pm and the following was determined:
a. No evidence was found of standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).

3. Evacuation plans located throughout the hospital (both new construction and existing construction) were reviewed from 10/30/12 through 11/2/12 from 9:00 am through 3:00 pm with the facility's Engineer (employee #1) and provided evidence that some areas of the new construction do not have evacuation plans and the evacuation plans of the existing construction are not actualized related to fire extinguisher placement and new exist routes for some areas.

4. The general storage area was visited on 10/31/12 at 9:30 am with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and provided evidence that there is a mechanical utility room. This room was found with copper and metal tubing secured to the ceiling, however at one point the copper tubing was touching the metal tubing. When copper and metal make direct contact they begin to oxidizes affecting the integrity of the tubing which can lead to a hazardous event.

5. The general storage area was visited on 10/31/12 at 9:30 am with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and provided evidence that there is a small office used by personnel. However this room was also found with a toaster, microwave and coffee maker and on the day of the visit the general storage area smelled of burnt toast. The use of these devices shall be inspected by the physical plant department and Safety Officer and the placement of such devices shall be determined by the engineering department, common working spaces such as offices are not designed for such devices.

6. The sterile supply department used by the operating department to clean and sterilize equipment was visited on 10/31/12 at 11:20 am with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and it was found that two multi-plugs devices were used in this area, however multi-plugs are not recommended for hospital use.

7. The general maintenance department used by maintenance personnel to place supplies and receive and store clean linen was visited on 10/31/12 at 1:30 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and it was found that a multi-plug device was used in this area, however multi-plugs are not recommended for hospital use.

8. The diet department was visited on 10/31/12 at 12:10 pm with the facility's Engineer (employee #1) and two bottles with hand sanitizer were found near the hand sinks. Due to the volatile nature of the hand sanitizer it can not be in an area with open flames such as the kitchen.

9. During the observational tour of the facility and the two off-site emergency rooms in "Cidra" and "Aguas Buena" from 10/30/12 through 11/2/12 from 9:00 am till 4:00 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was found that the facility has regular trash containers that do not have lids (located throughout the hospital). The Physical Plant Manager (employee #2) turned over some of these trash containers to verify for the UL (Underwriter's Laboratory) label but they did not have it. The facility failed to ensure that equipment used in the facility have appropriate labels to certify that they are safe to use. If one of these garbage containers catches fire, the smoke that it produces is toxic and can inhibit proper evacuation.

10. The operating suites were visited on 11/1/12 at 3:30 pm with the facility's Physical Plant Manager (employee #2) and it was found that operating suites contained bottles of rubbing alcohol. Due to the volatile nature of the alcohol another product should be considered in its place.

11. The X-ray department was visited on 11/2/12 at 11:00 am with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2). A patient was waiting in front of an X-ray room in a wheel chair alone waiting to have an X-ray performed. On the back of his wheel chair back rest was a type E oxygen cylinder hanging from its regulator control valve. The patient was observed alone for approximately five minutes until the Engineer (employee #1) found the escort who left the patient in this position and explained the safety risk that he left the patient in related to the oxygen cylinder hanging from the back of the wheel chair. Employee #4 stated on 11/2/12 at 11:05 am that he understood and would not do it again. The facility must ensure that all personnel are re-trained and educated in the proper handling and transporting of highly flammable and explosive gases.

12. Documentation of seamise connections to be used by the fire department was verified on 11/2/12 at 1:40 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), however no evidence was found of this connection inspection on a quarterly basis to verify visibility and accessibility, coupling and that the swivels are not damaged and rotate smoothly.

13. The facility has a large oxygen tank that supplies oxygen to the hospital located at the back of the hospital as observed on 10/30/12 at 3:20 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2). The facility was requested evidence of periodic master alarm panel testing related to the audible and visual signals (high/low alarms for +/- 20% operating pressure), however the Engineer (employee #1) stated on 11/2/12 at 1:30 pm that the system is working properly and so are the alarms, however she does not have documentation of tests performed to verify the alarms' status.

Based on the review of written documents during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that personnel perform the monthly 30 minute load test of the electrical generators and monthly transfer switch tests as required by the NFPA 99, section 3.4.4.1.

Findings include:

1. The facility lacks written evidence that the electrical generators (#1 and #2) are tested under load condition for 30 minutes on a monthly basis as reviewed on 11/2/12 at 1:45 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2). The facility has two large electrical generators, however documentation reviewed could not support that the generators run with load for 30 minutes from June 2012 through September 2012 (the 30 minutes shall not include start up or cool down time).

2. The facility lacks written evidence that the electrical generators' transfer switches are tested on a monthly basis as reviewed on 11/2/12 at 1:50 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) from June 2012 through September 2012.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that patient's doors protecting corridors on the third and fourth floor do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1. During the tour for life safety from fire, patient's sleeping room doors were tested on 10/31/12 from 2:00 pm till 4:00 pm and on 11/2/12 from 9:00 am till 12:00 noon with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was found that the following patient's rooms do not have the capability of latching when the doors are in the closed position, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire:

a. Patient's rooms on the third and fourth floors: #325, #330, #405, #406, #415 and #420 (all patient sleeping room doors shall be verified for compliance).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that the facility failed to provide readily visible illuminated "exit" signs where the exit or way to reach the exit is not readily apparent to its occupants such as the main sorting area of the medical record department as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.10.1.2.

Findings include:

There is the need of an illuminated exit sign to ensure the path of travel in the event of an emergency near the main sorting area of the medical record department as observed with the facility's Engineer (employee #1) on 10/31/12 at 10:10 am.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that smoke barriers on the second, third and fourth floors are not provided to form at least two smoke compartments for every sleeping room floor of more than 30 patients as required by the 2000 edition of the Life Safety Code of the NFPA Sections 19.3.7.1 and 19.3.7.2.

Findings include:

During the tour for life safety from fire, patient's sleeping rooms on the second and third floors were observed on 11/2/12 from 10:00 am till 11:30 am and it was found that the smoke barriers on the second and third floors do not provide at least two smoke compartments for each sleeping room floor of over 30 patients. There are a total of 43 patient's beds per floor. The nursing station is constructed in a manner that creates an opening in the smoke barrier (nursing counter creates an opening between the two hallways) and smoke at one side of the smoke barrier will enter the other side of the smoke barrier.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided at the medication preparation room of the emergency room, in the internal staircase (#1, #2, #3), outside exits, generator rooms and hallways, an emergency lamps on the second floor did not illuminate when tested and no evidence was found that the facility is testing the emergency lamps on a monthly (off-site emergency room at "Cidra") and annual (main hospital) basis as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour from 10/30/12 through 11/2/12 from 9:00 am till 4:00 pm in the following areas:
a. At the three internal exit staircases (newly constructed-staircases #1, #2 and #3) from the top floor (fourth floor) through the first floor to ensure visibility at night if power is lost and an emergency evacuation is needed.
b. At all outside locations where the inside of the facility's exits leads to the outside of the building such as the emergency room's exits to the outside.
c. At the Medication preparation room of the Emergency room.
d. Within the covered structures where the two electrical generators are located.
e. In the hallway near the sterile supply department and in front of mechanical room #1.
f. In the waiting room of the off-site emergency room in "Cidra".
g. In the hallway near the Decontamination room of the off-site emergency room in "Cidra".
h. In the hallway in front of the operating suites in the restricted area.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

2. Documentation about tests to emergency lighting reviewed on 11/2/12 at 11:00 am with the facility's Engineer (employee #1) provided evidence that the facility is not performing the annual 90 minute tests. Tests are performed on a monthly basis for approximately 20 to 25 minutes but no evidence was found of the 90 minute annual tests.
a. Also, documentation of monthly emergency light tests from the off-site emergency room in "Cidra" is performed for 15 seconds and not 30 seconds as required.

3. The emergency battery operated lamp (EBOL) in the following area was tested and did not illuminate as observed on 11/2/12 at 11:00 am:
a. The EBOL on the second floor near patient's room #216.

Based on observations and interview made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that smoke detectors are available at all required areas such as mechanical room of the general maintenance department, hallway of the laboratory department, dirty linen room on the third floor, machine room that serves elevators #3 and #4, fire alarm documentation about sensitivity tests was not found, smoke detectors were found close to air conditioner vents, no automatic annunciation for the off-site emergency room of "Aguas Buenas" and some smoke detectors did not work as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. The smoke detector located in the Medical Record department near the main sorting area was observed on 10/31/12 at 10:00 am with the facility's within three feet of the air conditioner vent. Air blown in air conditioner vents can affect the effectiveness of the smoke detector to detect smoke in the event of a fire.

2. The smoke detector in mechanical room #1 was visited on 10/31/12 at 11:50 am with the facility's Engineer (employee #1) and provided evidence that it had a rubber glove wrapped over it. The facility's Engineer (employee #1) stated on 10/31/12 at 11:50 am that the glove was probably placed there by construction personnel working in this room.

3. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) from 10/30/12 through 11/2/12 from 9:00 am till 4:00 pm:
a. In the mechanical room of the general maintenance department.
b. In the hallway of the laboratory department.
c. In the dirty linen room on the third floor.
d. In the machine room that serves elevators #3 and #4.

4. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 11/2/12 at 1:05 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), however no evidence was found of the following:
a. Smoke detector sensitivity tests and readings.

5. Some of the smoke detectors at the off-site emergency room at "Cidra" were not blinking as determined on 11/1/12 at 1:00 pm with the facility's Engineer (employee #1). The entire system was verified on 11/1/12 at 5:00 pm and placed in working order, however the facility must ensure that periodic maintenance is performed when the system is in trouble mode.

6. The fire alarm system of off-site emergency room in "Aguas Buenas" lacks annunciation to an approved central station as reviewed on 11/2/12 at 2:00 pm. The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that portable fire extinguisher are maintained related to updated inspections, are visible and accessible at all required areas and are mounted at the appropriate heights as states in the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. During observations made of the hospital with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) on 10/31/12 at 9:45 am, the fire extinguisher located at the back door of the general storage area was found without the facility's monthly inspections.

2. During the observational tour of the laboratory department of the hospital with the facility's (Engineer #1) and Physical Plant Manager (employee #2) on 10/31/12 at 2:00 pm, it was found that fire extinguisher #53 which weighs less than 40 pounds was placed higher than five feet in height (measured from the top part of the fire extinguishers handle). According with NFPA 10, section 1.5.10, fire extinguishers weighing less than 40 pounds shall be installed so that the top part of the fire extinguisher is not more than five feet in height. The facility must lower the fire extinguisher and verify all other extinguishers to ensure that they are lower than five feet so that they can be accessible to all persons if needed.

3. The fire extinguisher located on the fourth floor near patient's room #420 was found mounted to the side of a column on 10/31/12 at 3:30 pm with the facility's (Engineer #1) and Physical Plant Manager (employee #2). However a sign is needed in order for persons to identify where it is because the column does not allow it to be seen from one side of the hallway.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1), it was determined that the facility failed to monitor means of egress at the back exit of the general storage department, hallway near the janitor's service department, in the exit staircase of the laboratory department and at the exit door in the back of the Nuclear Medicine department to ensure that they are maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. The back exit door of the general storage department was found on 10/31/12 at 9:45 am with the facility's Engineer (employee #1) and provided evidence that there are two tables with chairs located in front of this door. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

2. In the hallway of the facility in front of general maintenance department (Janitor Services) on 10/31/12 at 8:45 am, four large bins were found with dirty linen limiting the space of the hallway to within two feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

3. During the observational tour of the laboratory department of the hospital with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) on 10/31/12 at 2:00 pm, it was found that the emergency staircase located at this department has a large garbage container with a broom and dust pan in it. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

4. During the observational tour of the Nuclear Medicine department on 11/2/12 at 9:30 am, it was found that the back emergency exit door has two latches (latches are not permitted on these exit doors) and a push pad. Once the door was opened the path of travel was blocked by old equipment left in this area and the cement walk way was covered in leaves and dirt. Also, at the end of this cement path are steps instead of a ramp which will not allow a smooth transition away from the building in the event of an evacuation. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and interview, it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.5.5.

Findings include:

During the observational tour of the facility the dirty linen storage room located on the third floor on 11/2/12 at 10:15 am with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that personnel are using this closet to place dirty linen, it had two large hampers full of dirty linen and did not have an air extractor. The facility's Engineer (employee #1) stated during an interview on 11/2/12 at 10:20 am that this closet is used as a holding area until personnel make their rounds and remove them from the closet. This closet did not have a smoke detectors connected to the fire alarm panel. The construction of closets for this purpose must be verified to ensure one hour fire rating (with 3/4 hour fire-rated doors) with positive latching and door closers and containers can not exceed 32 gallons within any 64 square foot area.

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and interview, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to standpipe maintenance, oxygen storage and transporting, evacuation plans are needed at the new construction and the existing plans need to be revised, the use of hand sanitizer in the kitchen and rubbing alcohol in the operating suites, copper and metal tubing were making contact, use of multi-plugs, no documentation of seamise connection, use of regular garbage containers and no documentation of the large oxygen container system alarm.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 10/30/12 through 11/2/12 from 9:00 am till 4:00 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) type H and Type E oxygen tanks were found in areas that do not meet minimum requirements:
a. Two type H oxygen cylinders were found in a material storage room near the observation cubicles used to give patients oxygen therapy and Intravenous solutions of the emergency room. (These tanks are used as spare tanks for patients receiving respiratory therapy).
b. Two type H oxygen cylinders were found in the dirty utility room of the off-site emergency room in "Cidra".
c. Four type E oxygen cylinders were found in the respiratory therapy department.

2. Standpipes (fire hoses) were observed during the life safety observational tour with the facility's Engineer (employee #1) and maintenance documentation was reviewed on 11/2/12 at 1:45 pm and the following was determined:
a. No evidence was found of standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).

3. Evacuation plans located throughout the hospital (both new construction and existing construction) were reviewed from 10/30/12 through 11/2/12 from 9:00 am through 3:00 pm with the facility's Engineer (employee #1) and provided evidence that some areas of the new construction do not have evacuation plans and the evacuation plans of the existing construction are not actualized related to fire extinguisher placement and new exist routes for some areas.

4. The general storage area was visited on 10/31/12 at 9:30 am with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and provided evidence that there is a mechanical utility room. This room was found with copper and metal tubing secured to the ceiling, however at one point the copper tubing was touching the metal tubing. When copper and metal make direct contact they begin to oxidizes affecting the integrity of the tubing which can lead to a hazardous event.

5. The general storage area was visited on 10/31/12 at 9:30 am with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and provided evidence that there is a small office used by personnel. However this room was also found with a toaster, microwave and coffee maker and on the day of the visit the general storage area smelled of burnt toast. The use of these devices shall be inspected by the physical plant department and Safety Officer and the placement of such devices shall be determined by the engineering department, common working spaces such as offices are not designed for such devices.

6. The sterile supply department used by the operating department to clean and sterilize equipment was visited on 10/31/12 at 11:20 am with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and it was found that two multi-plugs devices were used in this area, however multi-plugs are not recommended for hospital use.

7. The general maintenance department used by maintenance personnel to place supplies and receive and store clean linen was visited on 10/31/12 at 1:30 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) and it was found that a multi-plug device was used in this area, however multi-plugs are not recommended for hospital use.

8. The diet department was visited on 10/31/12 at 12:10 pm with the facility's Engineer (employee #1) and two bottles with hand sanitizer were found near the hand sinks. Due to the volatile nature of the hand sanitizer it can not be in an area with open flames such as the kitchen.

9. During the observational tour of the facility and the two off-site emergency rooms in "Cidra" and "Aguas Buena" from 10/30/12 through 11/2/12 from 9:00 am till 4:00 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was found that the facility has regular trash containers that do not have lids (located throughout the hospital). The Physical Plant Manager (employee #2) turned over some of these trash containers to verify for the UL (Underwriter's Laboratory) label but they did not have it. The facility failed to ensure that equipment used in the facility have appropriate labels to certify that they are safe to use. If one of these garbage containers catches fire, the smoke that it produces is toxic and can inhibit proper evacuation.

10. The operating suites were visited on 11/1/12 at 3:30 pm with the facility's Physical Plant Manager (employee #2) and it was found that operating suites contained bottles of rubbing alcohol. Due to the volatile nature of the alcohol another product should be considered in its place.

11. The X-ray department was visited on 11/2/12 at 11:00 am with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2). A patient was waiting in front of an X-ray room in a wheel chair alone waiting to have an X-ray performed. On the back of his wheel chair back rest was a type E oxygen cylinder hanging from its regulator control valve. The patient was observed alone for approximately five minutes until the Engineer (employee #1) found the escort who left the patient in this position and explained the safety risk that he left the patient in related to the oxygen cylinder hanging from the back of the wheel chair. Employee #4 stated on 11/2/12 at 11:05 am that he understood and would not do it again. The facility must ensure that all personnel are re-trained and educated in the proper handling and transporting of highly flammable and explosive gases.

12. Documentation of seamise connections to be used by the fire department was verified on 11/2/12 at 1:40 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), however no evidence was found of this connection inspection on a quarterly basis to verify visibility and accessibility, coupling and that the swivels are not damaged and rotate smoothly.

13. The facility has a large oxygen tank that supplies oxygen to the hospital located at the back of the hospital as observed on 10/30/12 at 3:20 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2). The facility was requested evidence of periodic master alarm panel testing related to the audible and visual signals (high/low alarms for +/- 20% operating pressure), however the Engineer (employee #1) stated on 11/2/12 at 1:30 pm that the system is working properly and so are the alarms, however she does not have documentation of tests performed to verify the alarms' status.

Based on the review of written documents during the survey for life safety from fire with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2), it was determined that the facility failed to ensure that personnel perform the monthly 30 minute load test of the electrical generators and monthly transfer switch tests as required by the NFPA 99, section 3.4.4.1.

Findings include:

1. The facility lacks written evidence that the electrical generators (#1 and #2) are tested under load condition for 30 minutes on a monthly basis as reviewed on 11/2/12 at 1:45 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2). The facility has two large electrical generators, however documentation reviewed could not support that the generators run with load for 30 minutes from June 2012 through September 2012 (the 30 minutes shall not include start up or cool down time).

2. The facility lacks written evidence that the electrical generators' transfer switches are tested on a monthly basis as reviewed on 11/2/12 at 1:50 pm with the facility's Engineer (employee #1) and Physical Plant Manager (employee #2) from June 2012 through September 2012.