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Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed ceiling and wall penetrations. This affected three of four floor, and could result in the passage of smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception:* Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in.
(6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.

8.2.1* Construction. Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction
requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided

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

Findings:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the ceilings and walls were observed.

11/18/14 - Third Floor

1. At 3:52 p.m., there were eight wall penetrations in the bathroom of Room 320. Each measured approximately 1/4 inch. When interviewed, Staff 3 stated that the penetrations were from a toilet tissue holder that was removed.

11/19/14 - Second Floor

2. At 11:07 a.m., there was an approximately 3/4 inch by 1 1/2 inch penetration in the wall in the storage room by the nursing station located in the Pre Anesthesia Surgery Area.

11/19/14 - First Floor

3. At 2:19 p.m., there was an approximately 1/2 inch penetration around a metal conduit in the Dirty Linen Room.

4. At 2:37 p.m., there was an approximately 10 1/2 inch by 11 inch penetration in the wall in the Occupational Health Office. When interviewed, Staff 3 stated that the open area was used as a pass through window.

5. At 2:38 p.m., there was an approximately 1 1/2 inch by 3/4 inch penetration around a sprinkler pipe and a conduit in the Clean Linen Room near Room 169.

6. At 3:17 p.m., there was an approximately 1/2 inch by 4 inch penetration in the door frame behind the strike plate in the Pharmacy Storage Room. When interviewed, Staff 3 stated that a new lock/latch device had been recently installed.

7. At 3:28 p.m., there was an approximately 1 inch penetration around telephone wires in the Security Room.

11/20/14 - First Floor

8. At 10:11 a.m., there was an approximately 2 1/2 inch penetration around an air conditioner line and a conduit pipe in the Business Office Storage near Room 1347.


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11/19/14 - Second Floor

9. At 10:10 a.m., in the Substerile Room between OR 5 and OR 6, there were two penetrations in the ceiling above the sterilizer. They each measured approximately four and one-half inches.

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

NFPA 101, Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

Findings:

During a tour of the facility with Engineering Staff from 11/18/14 to 11/20/14, the corridor doors were observed.

11/18/14 - Third Floor

1. At 3:35 p.m., the door to Room 343 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch upon closure. Four attempts were made. When interviewed, Staff 3 stated that the self closure needed adjustments.

11/19/14 - First and Second Floors

2. At 10:01 a.m., the door to Operating Room 3 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch upon closure. When interviewed, Staff 3 stated that a work order had been submitted to have the door repaired.

3. At 10:05 a.m., a bent strike plate obstructed the door from closing in the OR Sterile Room. Four attempts were made.

4. At 11:15 a.m., the door to Room 246 failed to latch. When interviewed, Staff 3 stated that the door needed a new latching device.

5. At 1:33 p.m., a bed obstructed the door from closing in Emergency Room 1. When interviewed, Staff 3 stated that a different bed was in use in the room.

6. At 1:35 p.m., the door to Caution X-Ray Room was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure. When interviewed, Staff 3 stated that the self-closure device needed adjustments.

7. At 1:38 p.m., the door to Exam Room 3 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch.

8. At 3:36 p.m., the door to the Computer Laboratory was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch. Four attempts were made. When interviewed, Staff 3 stated that the arm to the self-closure device was loose and was hitting the top of the door.

9. At 3:40 p.m., the door to Angio Room 3 Storage in Radiology was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch upon closure. When interviewed, Staff 3 stated that the screws in the hinges were loose.

11/20/14 - First Floor and Basement

10. At 9:50 a.m., the door to an office across from Liberty Room 1 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch.

11. At 10:10 a.m., the door to Stork Room near Room 1337 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch. When interviewed, Staff 3 stated that the screws in the hinges were loose.

12. At 11:34 a.m., the door to the Doctors' Dining Room near the cafeteria was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch. Three attempts were made.




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11/18/14 - Third Floor

13. At 3:08 p.m., in Room 3023, the door was obstructed from closing by two chairs.

14. At 3:18 p.m., in the Telemetry Room, the door was held open to its fullest extent and allowed to close. The door failed to latch because of cardboard that was placed within the latching mechanism.

15. At 3:48 p.m., the door to Room 312 was obstructed from closing by the bedside monitor.

16. At 3:49 p.m., the door to Room 313 was obstructed from closing by the bedside monitor.

17. At 3:50 p.m., the door to Room 316 was obstructed from closing by a wheelchair. In addition, there was an approximately one-half-inch gap between the top of the door frame and the top right side of the door.

11/19/14 - First and Second Floors

18. At 10:54 a.m., in the Intensive Care Unit, the door to Room 2038 was obstructed from closing by an overbed tray.

19. At 1:34 p.m., in the Emergency Room Registration Office, the door was held open to its fullest extent and allowed to close. The door failed to latch because surgical tape was on the latching mechanism.

20. At 3:21 p.m., in the Administration Hall, the right side door to the Electrical Room was held open to its fullest extent and allowed to close. The door failed to latch because of a misaligned striker plate.

11/20/14 - First Floor

21. At 10:18 a.m., the door to Room 137 (Respiratory Therapy) was held open to its fullest extent and allowed to close. The door failed to latch.

Based on observation, the facility failed to maintain its fire doors, as evidenced by fire doors that failed to latch when tested. This could result in the passage of smoke and flames in the event of a fire and affected two of four floors and the basement.

Finding:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the fire doors were observed.

11/18/14 - Third Floor

1. At 3:14 p.m., the exit door to the southwest stairwell in the 100 Building was opened to its fullest extent and allowed to close. The exit door failed to latch because of a misaligned striker plate.

11/19/14 - First Floor

2. At 1:50 p.m., the fire doors by Trauma Room 2 failed to latch when manually tested. When interviewed, Staff 3 stated that self-closure devices needed adjustments.

3. At 1:58 p.m., the fire door adjacent to the Emergency Room Director's Office was allowed to close from a fully open position. The fire door failed to latch because of the low closing force of the self-closing mechanism.


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11/20/14 - Basement

4. At 10:50 a.m., the fire doors near Central Sterile were manually tested. The left leaf failed to latch. When interviewed, Staff 3 stated that they would check the closure on the left leaf fire door.

Based on observation, the facility failed to maintain its exit signs as evidenced by exit signs with no directional indicators. This could result in confusion in the event of an emergency and affected two of four floors.

NFPA 101, Life Safety Code, 2000 Edition

7.10.2 Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Findings:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the exit signs were observed.

11/19/14 - First and Second Floors

1. At 10:11 a.m., exit signs near the OR Nurses' Station on the Second Floor did not have directional indicators that designated the path of egress from the area.

2. At 3:15 p.m., the exit sign above the Men's Rest Room near the Administration Office on the First Floor did not have a directional indicator that designated the path of egress from the area.

Based on observation and interview, the facility failed to maintain its automatic sprinkler system. This was evidenced by paint and/or foreign material on sprinkler deflectors, items stored less than 18 inches below a sprinkler deflector, missing escutcheon rings, escutcheon rings that shifted, and escutcheon rings that were not flush with the ceiling surface. This could result in a sprinkler malfunction in the event of a fire and affected three of four floors and the basement.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection System, 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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

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

Findings:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the automatic fire sprinkler system was observed.

11/18/14 - Third Floor

1. At 3:43 p.m., there was paint on the sprinkler deflector at the Nurses' Station near the Medication Room.

2. At 3:46 p.m., the escutcheon ring was not flush to the ceiling and exposed an approximately 1/2 inch penetration in the ceiling in the corridor near Room 311.

11/19/14 - First and Second Floors

3. At 9:50 a.m., there was a missing escutcheon ring in Operating Room 3. Staff 3 stated that they were not aware of the missing escutcheon ring.

4. At 10:38 a.m., a television was approximately eight inches below the sprinkler deflector in Room 9 located in the Post Anesthesia Care Unit.

5. At 2:13 p.m., the escutcheon ring was not flush to the ceiling and exposed an approximately one inch penetration in the ceiling in the corridor near the Marketing Public Relation Office. When interviewed, Staff 3 stated that the wrong escutcheon ring had been used.

6. At 2:30 p.m., a box was stored approximately four inches below the sprinkler deflector in the Clinical Educator's Office closet.

7. At 2:42 p.m., there were three escutcheon rings missing from three sprinkler heads located in the bathroom, shower room, and above the door to the shower room in Room 169.

8. At 2:50 p.m., an escutcheon ring had shifted to one side and exposed an approximately one inch by two inch penetration on the right side in the closet of Room 167.

9. At 2:53 p.m., the escutcheon ring was not flush to the ceiling and exposed an approximately one inch penetration in the ceiling in the bathroom of Room 163.

10. At 2:56 p.m., an escutcheon ring had shifted to one side and exposed an approximately two inch by 3/4 inch penetration on the right side above a sink in Room 161.

11. At 3:28 p.m., there was a missing escutcheon ring in the Security Room.

11/20/14 - First Floor and Basement

12. At 9:54 a.m., there was a missing escutcheon ring in the Infection Control Coordinator's Office.

13. At 9:55 a.m., there was a missing escutcheon ring in the closet of Liberty Room 2.

14. At 9:58 a.m., there was a missing escutcheon ring in the Point of Care Testing Room. When interviewed, Staff 3 stated that he was not aware of the missing escutcheon ring.

15. At 10:25 a.m., there was paint on the sprinkler deflector in the closet near the Case Management Nurses' Desk.

16. At 11:09 a.m., there was a missing escutcheon ring and paint on a sprinkler deflector in the Bed/Equipment Storage Room.


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11/18/14 - Third Floor

17. At 3:40 p.m., in Room 307, the escutcheon plate was missing from the bathroom sprinkler head.

18. At 3:53 p.m., in Room 317, the sprinkler was obstructed by the light fixture canopy.

19. At 3:56 p.m., in Room 318, the sprinkler was obstructed by the light fixture canopy. In addition, the canopy was mounted approximately two inches from the sprinkler.

20. At 3:59 p.m., in Room 319, the sprinkler was obstructed by the light fixture canopy.

21. At 4 p.m., in Room 320, the sprinkler was obstructed by the light fixture canopy. In addition, the canopy was mounted flush against the sprinkler.

11/19/14 - First and Second Floors

22. At 1:32 p.m., in the Security Office, items were stored approximately 10 inches below the sprinkler deflector.

23. At 3:41 p.m., in the Radiology Lab Storage Room, items were stored approximately eight inches below the sprinkler deflector.

24. At 3:44 p.m., in Radiology Dressing Room 3, the escutcheon ring was not flush with the ceiling and exposed an approximately four and one-half inch crescent-shaped penetration.

11/20/14 - First Floor

25. At 10:12 a.m., in the Pastoral Care Office storage closet, the escutcheon plate was missing, there was paint on the fusible link, and items were stored approximately one inch below the sprinkler deflector.

Based on observation and interview, the facility failed to maintain its portable fire extinguishers. This was evidenced by a portable fire extinguisher that was mounted higher than 60 inches above the floor and by a portable fire extinguisher that was obstructed from immediate access. This affected one of four floors and the basement and could result in a delay in access to the fire extinguishers, resulting in the spread of smoke and/or fire.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12 Maintenance 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 10, Standard for Portable Fire Extinguishers, 1998 Edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
3-7 Fire Extinguisher Size and Placement for Class K Fires.
3-7.1 Fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats).
3-7.2 Maximum travel distance shall not exceed 30 ft (9.15 m) from the hazard to the extinguishers.

Findings:

During a tour of the facility with Engineering Staff on 11/19/14 and 11/20/14, the portable fire extinguishers were observed.

11/20/14 - Basement

1. At 11:06 a.m., in the Linen Room, the fire extinguisher was mounted at 69 inches from the floor to the operable handle.

2. At 11:20 a.m., in the Materials Management Receiving Area, a portable fire extinguisher was obstructed from immediate access by a cart placed in front of the fire extinguisher. Staff 3 informed staff in the area and staff removed the cart.



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11/19/14 - Second Floor

3. At 10:10 a.m., in the OR Central Storage Room, the fire extinguisher was mounted approximately 66 inches above the floor.

11/20/14 - Second Floor 200 Building

4. At 11:57 a.m., an unmounted fire extinguisher was observed inside the Cath Lab 1 construction area.

Based on observation, the facility failed to ensure the safe operation of portable space-hearing devices, as evidenced by the presence of a space heater in a confined space. This could result in the increased risk of fire and affected one of four floors.


NFPA 70, National Electrical Code, 1999 Edition
Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of product of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
Finding:

During a tour of the Engineering Staff on 11/18/14 to 11/20/19, portable space heaters were observed.

11/19/14 - First Floor

1. At 2:57 p.m., there was a space heater beneath the Admitting Services desk.

The heater had a labeled warning, stating "warning: risk of fire keep combustible materials, clothing and curtains at least three feet from the front, side, and rear."

2. At 3:02 p.m., there was a space heater at a desk located in the Gift Shop. The heater was not plugged in. There were combustible items in the area. The area measured approximately 25 square feet.

Based on observation, the facility failed to properly store oxygen cylinders, as evidenced by oxygen cylinders stored in a room with the light switch mounted less than five feet above the floor, by combustible materials stored in an oxygen storage room, by empty and full cylinders stored in the same rack, and by rooms designated for oxygen storage without door signs. This could result in the increased risk of an oxygen-driven fire. Storage of empty and full cylinders in the same rack could result in delay and potential harm to patients. These deficient practices affected one of four floors and the basement.

NFPA 99, Health Care Facilities, 1999 Edition

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
4-3.1.1.2(a) 11d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

8-3.1.11.1 Storage Requirements. Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

4-3.5.2.2 Storage of Cylinders and Containers - Level 1.

(b) Nonflammable Gases.

2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly

8-3.1.11 Storage Requirements.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Findings:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the Oxygen Storage Rooms were observed.

11/19/14 - First Floor

1. At 1:50 p.m. on 11/19/14, there was oxygen stored inside the Emergency Room Storage Room. There was no sign on the door that indicated the storage of oxygen in the room.

2. At 3:52 p.m., there were eight E-cylinders stored in the Radiology X-ray 1 Dressing Room. The floor was carpeted, and the room was not one-hour rated. The light switch was located on the left wall at 48 inches above the floor. There was no sign on the door that indicated the storage of oxygen in the room.
.


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11/20/14 - Basement

3. At 10:47 a.m., there were 3 full cylinders and 4 empty cylinders in an empty rack in the Cardiac Rehabilitation Storage/Oxygen Room.

Based on observation, the facility failed to maintain the electrical wiring and equipment as evidenced by the use of surge protectors and extension cords in an unauthorized manner. This could result in the increased risk of fire and affected four of four floors.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
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

400-10. Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

Findings:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the electrical wiring and equipment were observed.

11/18/14 - Third Floor

1. At 3:22 p.m., there were three workstations in the "PCU" Workstation Area. At Workstation 2, a surge protector with computer equipment plugged into it was suspended approximately 18 inches above the floor.

2. At 3:25 p.m. on 11/18/14, a surge protector and an Uninterruptible Power Source (UPS) were observed beneath the workstation facing the west hall. Computer equipment was plugged into the UPS. The call light system and the UPS were plugged into the surge protector.

11/19/14 - First and Second Floors

3. At 10:30 a.m., in the Second Floor Waiting Room, two vending machines and a lamp were plugged into a surge protector located near the window.

4. At 11 a.m., in Room 2024 (Critical Care Educator's Office), there were two surge protectors beneath Desk 1. Computer equipment was plugged into Surge Protector 1. An overhead light and Surge Protector 1 were plugged into Surge Protector 2.

5. At 1:32 p.m., in the Security Office, a microwave oven, refrigerator, laptop, and telephone charger were plugged into a surge protector.

6. At 2:01 p.m., in the Emergency Room Director's Office, two surge protectors were observed. Three walkie-talkie chargers were plugged into Surge Protector 1. Two walkie-talkie chargers and Surge Protector 1 were plugged into Surge Protector 2.

7. At 2:05 p.m., in the Emergency Room Disaster Coordinator's Office, two surge protectors were observed. Computer equipment and a charger were plugged into Surge Protector 1. Computer equipment and Surge Protector 1 were plugged into Surge Protector 2.

8. At 2:11 p.m., in the Medical Director's Office, a personal-size refrigerator and computer equipment were plugged into a surge protector.

9. At 2:19 p.m., in the Public Relations Office, a refrigerator and a microwave oven were plugged into a surge protector.

10. At 4:05 p.m., in the Administration Office, two surge protectors were observed beneath Desk 2. Computer equipment and a telephone charger were plugged into Surge Protector 1. A battery charger and Surge Protector 1 were plugged into Surge Protector 2.

11/20/14 - First Floor

11. At 9:46 a.m., in the Director of Surgical Staffing Office, two surge protectors were observed beneath the desk. Computer equipment and a charger were plugged into Surge Protector 1. A printer, scanner, cell phone charger, and Surge Protector 1 were plugged into Surge Protector 2.

12. At 9:54 a.m., in the Doctors' Lounge Medical Staff Office, two surge protectors were observed beneath Desk 2. Computer equipment was plugged into Surge Protector 1. Computer equipment and Surge Protector 1 were plugged into Surge Protector 2.

13. At 10:20 a.m., in Room 136 (Respiratory Care Office), an extension cord was observed. It was plugged directly into the wall and had no devices connected to it.


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11/18/14 - Third and Fourth Floors

14. At 3:16 p.m., two Hoyer lift chargers were plugged into a surge protector in Storage Room 4026. When interviewed, Staff 3 stated that the room did not have enough wall outlets.

15. At 3:20 p.m., an aquarium and an aquarium lamp were plugged into a surge protector, in the Surgical Waiting Area.

16. At 3:19 p.m., there were two surge protectors in use in the Surge/Bariatrics Director's Office. A microwave was plugged into Surge Protector #1, and a refrigerator was plugged into Surge Protector #2. Staff 3 unplugged the refrigerator from Surge Protector #2 and plugged it into a wall outlet.

17. At 3:39 p.m., a coffee maker and a microwave were plugged into a surge protector in the Breakroom.

11/19/14 - First Floor

18. At 2:29 p.m., there was a missing cable faceplate in closet of Room 162.

19. At 2:50 p.m., a coffee maker was plugged into an extension cord in Room 167.

20. At 3:12 p.m., a coffee maker was plugged into an extension cord in the Pharmacy Room.

21. At 3:17 p.m., a defibrillator, suction machine and an incubator machine were plugged into a surge protector in the Pharmacy Storage Room.

22. At 3:28 p.m., a refrigerator was plugged into a surge protector in the Security Room.

23. At 3:54 p.m., a stereo was plugged into an extension cord in the Gastrointestinal Laboratory.

11/20/14 - First Floor

24. At 9:46 a.m., a training microscope was plugged into a surge protector in the Pathology Room.

25. At 9:54 a.m., an air purifier was plugged into a surge protector in the Infection Control Coordinator's Office.

Based on observation and interview, the facility failed to ensure that their Alcohol Based Hand Rub Dispensers (ABHR) were installed away from ignition sources. This was evidenced by an Alcohol Based Hand Rub Dispenser (ABHR) installed above an ignition source. This affected one of four floors and could result in an electrical fire.

NFPA 101 Life Safety Code, 2000 Edition
18.3.2.7* Alcohol-based Hand-rub Solutions. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.4.3 unless all of the following conditions are met:
(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1.8 m).
(2) The maximum individual dispenser fluid capacity shall be:
(a) 0.3 gallons 91.2 liters) for dispensers in rooms, corridors, and areas open to corridors.
(b) 0.5 gallons (2.0 liters) for dispensers in suites of rooms
(3) The dispensers shall have a minimum horizontal spacing of 4 ft (1.2 m) form each other.
(4) Not more than a aggregate 10 gallons (37.8 liters) of alcohol-based hand rub solution shall be in use in a single smoke compartment outside of a storage cabinet.
(5) Storage of quantities greater than 5 gallons (18.9 liters) in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code.
(6) The dispensers shall not be installed over or directly adjacent to an ignition source.
(7) In locations with carpeted floor coverings, dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments.

Findings:

During a tour of the facility with Engineering Staff on 11/19/14 and 11/20/14, the Alcohol Based Hand Rub Dispensers (ABHR) were observed.

First Floor

1. On 11/19/14 at 4:05 p.m., in the Administration Office, an Alcohol Based Hand Rub dispenser was approximately 2 1/2 feet above an outlet.



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2. At 9:40 a.m., in the Clinical Lab Work Area, an alcohol-based hand sanitizer was mounted 33 inches above an outlet.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed ceiling and wall penetrations. This affected three of four floor, and could result in the passage of smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception:* Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in.
(6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.

8.2.1* Construction. Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction
requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided

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

Findings:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the ceilings and walls were observed.

11/18/14 - Third Floor

1. At 3:52 p.m., there were eight wall penetrations in the bathroom of Room 320. Each measured approximately 1/4 inch. When interviewed, Staff 3 stated that the penetrations were from a toilet tissue holder that was removed.

11/19/14 - Second Floor

2. At 11:07 a.m., there was an approximately 3/4 inch by 1 1/2 inch penetration in the wall in the storage room by the nursing station located in the Pre Anesthesia Surgery Area.

11/19/14 - First Floor

3. At 2:19 p.m., there was an approximately 1/2 inch penetration around a metal conduit in the Dirty Linen Room.

4. At 2:37 p.m., there was an approximately 10 1/2 inch by 11 inch penetration in the wall in the Occupational Health Office. When interviewed, Staff 3 stated that the open area was used as a pass through window.

5. At 2:38 p.m., there was an approximately 1 1/2 inch by 3/4 inch penetration around a sprinkler pipe and a conduit in the Clean Linen Room near Room 169.

6. At 3:17 p.m., there was an approximately 1/2 inch by 4 inch penetration in the door frame behind the strike plate in the Pharmacy Storage Room. When interviewed, Staff 3 stated that a new lock/latch device had been recently installed.

7. At 3:28 p.m., there was an approximately 1 inch penetration around telephone wires in the Security Room.

11/20/14 - First Floor

8. At 10:11 a.m., there was an approximately 2 1/2 inch penetration around an air conditioner line and a conduit pipe in the Business Office Storage near Room 1347.


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11/19/14 - Second Floor

9. At 10:10 a.m., in the Substerile Room between OR 5 and OR 6, there were two penetrations in the ceiling above the sterilizer. They each measured approximately four and one-half inches.

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

NFPA 101, Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

Findings:

During a tour of the facility with Engineering Staff from 11/18/14 to 11/20/14, the corridor doors were observed.

11/18/14 - Third Floor

1. At 3:35 p.m., the door to Room 343 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch upon closure. Four attempts were made. When interviewed, Staff 3 stated that the self closure needed adjustments.

11/19/14 - First and Second Floors

2. At 10:01 a.m., the door to Operating Room 3 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch upon closure. When interviewed, Staff 3 stated that a work order had been submitted to have the door repaired.

3. At 10:05 a.m., a bent strike plate obstructed the door from closing in the OR Sterile Room. Four attempts were made.

4. At 11:15 a.m., the door to Room 246 failed to latch. When interviewed, Staff 3 stated that the door needed a new latching device.

5. At 1:33 p.m., a bed obstructed the door from closing in Emergency Room 1. When interviewed, Staff 3 stated that a different bed was in use in the room.

6. At 1:35 p.m., the door to Caution X-Ray Room was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure. When interviewed, Staff 3 stated that the self-closure device needed adjustments.

7. At 1:38 p.m., the door to Exam Room 3 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch.

8. At 3:36 p.m., the door to the Computer Laboratory was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch. Four attempts were made. When interviewed, Staff 3 stated that the arm to the self-closure device was loose and was hitting the top of the door.

9. At 3:40 p.m., the door to Angio Room 3 Storage in Radiology was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch upon closure. When interviewed, Staff 3 stated that the screws in the hinges were loose.

11/20/14 - First Floor and Basement

10. At 9:50 a.m., the door to an office across from Liberty Room 1 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch.

11. At 10:10 a.m., the door to Stork Room near Room 1337 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch. When interviewed, Staff 3 stated that the screws in the hinges were loose.

12. At 11:34 a.m., the door to the Doctors' Dining Room near the cafeteria was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but it failed to positive latch. Three attempts were made.




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11/18/14 - Third Floor

13. At 3:08 p.m., in Room 3023, the door was obstructed from closing by two chairs.

14. At 3:18 p.m., in the Telemetry Room, the door was held open to its fullest extent and allowed to close. The door failed to latch because of cardboard that was placed within the latching mechanism.

15. At 3:48 p.m., the door to Room 312 was obstructed from closing by the bedside monitor.

16. At 3:49 p.m., the door to Room 313 was obstructed from closing by the bedside monitor.

17. At 3:50 p.m., the door to Room 316 was obstructed from closing by a wheelchair. In addition, there was an approximately one-half-inch gap between the top of the door frame and the top right side of the door.

11/19/14 - First and Second Floors

18. At 10:54 a.m., in the Intensive Care Unit, the door to Room 2038 was obstructed from closing by an overbed tray.

19. At 1:34 p.m., in the Emergency Room Registration Office, the door was held open to its fullest extent and allowed to close. The door failed to latch because surgical tape was on the latching mechanism.

20. At 3:21 p.m., in the Administration Hall, the right side door to the Electrical Room was held open to its fullest extent and allowed to close. The door failed to latch because of a misaligned striker plate.

11/20/14 - First Floor

21. At 10:18 a.m., the door to Room 137 (Respiratory Therapy) was held open to its fullest extent and allowed to close. The door failed to latch.

Based on observation, the facility failed to maintain its fire doors, as evidenced by fire doors that failed to latch when tested. This could result in the passage of smoke and flames in the event of a fire and affected two of four floors and the basement.

Finding:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the fire doors were observed.

11/18/14 - Third Floor

1. At 3:14 p.m., the exit door to the southwest stairwell in the 100 Building was opened to its fullest extent and allowed to close. The exit door failed to latch because of a misaligned striker plate.

11/19/14 - First Floor

2. At 1:50 p.m., the fire doors by Trauma Room 2 failed to latch when manually tested. When interviewed, Staff 3 stated that self-closure devices needed adjustments.

3. At 1:58 p.m., the fire door adjacent to the Emergency Room Director's Office was allowed to close from a fully open position. The fire door failed to latch because of the low closing force of the self-closing mechanism.


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11/20/14 - Basement

4. At 10:50 a.m., the fire doors near Central Sterile were manually tested. The left leaf failed to latch. When interviewed, Staff 3 stated that they would check the closure on the left leaf fire door.

Based on observation, the facility failed to maintain its exit signs as evidenced by exit signs with no directional indicators. This could result in confusion in the event of an emergency and affected two of four floors.

NFPA 101, Life Safety Code, 2000 Edition

7.10.2 Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Findings:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the exit signs were observed.

11/19/14 - First and Second Floors

1. At 10:11 a.m., exit signs near the OR Nurses' Station on the Second Floor did not have directional indicators that designated the path of egress from the area.

2. At 3:15 p.m., the exit sign above the Men's Rest Room near the Administration Office on the First Floor did not have a directional indicator that designated the path of egress from the area.

Based on observation and interview, the facility failed to maintain its automatic sprinkler system. This was evidenced by paint and/or foreign material on sprinkler deflectors, items stored less than 18 inches below a sprinkler deflector, missing escutcheon rings, escutcheon rings that shifted, and escutcheon rings that were not flush with the ceiling surface. This could result in a sprinkler malfunction in the event of a fire and affected three of four floors and the basement.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection System, 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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

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

Findings:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the automatic fire sprinkler system was observed.

11/18/14 - Third Floor

1. At 3:43 p.m., there was paint on the sprinkler deflector at the Nurses' Station near the Medication Room.

2. At 3:46 p.m., the escutcheon ring was not flush to the ceiling and exposed an approximately 1/2 inch penetration in the ceiling in the corridor near Room 311.

11/19/14 - First and Second Floors

3. At 9:50 a.m., there was a missing escutcheon ring in Operating Room 3. Staff 3 stated that they were not aware of the missing escutcheon ring.

4. At 10:38 a.m., a television was approximately eight inches below the sprinkler deflector in Room 9 located in the Post Anesthesia Care Unit.

5. At 2:13 p.m., the escutcheon ring was not flush to the ceiling and exposed an approximately one inch penetration in the ceiling in the corridor near the Marketing Public Relation Office. When interviewed, Staff 3 stated that the wrong escutcheon ring had been used.

6. At 2:30 p.m., a box was stored approximately four inches below the sprinkler deflector in the Clinical Educator's Office closet.

7. At 2:42 p.m., there were three escutcheon rings missing from three sprinkler heads located in the bathroom, shower room, and above the door to the shower room in Room 169.

8. At 2:50 p.m., an escutcheon ring had shifted to one side and exposed an approximately one inch by two inch penetration on the right side in the closet of Room 167.

9. At 2:53 p.m., the escutcheon ring was not flush to the ceiling and exposed an approximately one inch penetration in the ceiling in the bathroom of Room 163.

10. At 2:56 p.m., an escutcheon ring had shifted to one side and exposed an approximately two inch by 3/4 inch penetration on the right side above a sink in Room 161.

11. At 3:28 p.m., there was a missing escutcheon ring in the Security Room.

11/20/14 - First Floor and Basement

12. At 9:54 a.m., there was a missing escutcheon ring in the Infection Control Coordinator's Office.

13. At 9:55 a.m., there was a missing escutcheon ring in the closet of Liberty Room 2.

14. At 9:58 a.m., there was a missing escutcheon ring in the Point of Care Testing Room. When interviewed, Staff 3 stated that he was not aware of the missing escutcheon ring.

15. At 10:25 a.m., there was paint on the sprinkler deflector in the closet near the Case Management Nurses' Desk.

16. At 11:09 a.m., there was a missing escutcheon ring and paint on a sprinkler deflector in the Bed/Equipment Storage Room.


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11/18/14 - Third Floor

17. At 3:40 p.m., in Room 307, the escutcheon plate was missing from the bathroom sprinkler head.

18. At 3:53 p.m., in Room 317, the sprinkler was obstructed by the light fixture canopy.

19. At 3:56 p.m., in Room 318, the sprinkler was obstructed by the light fixture canopy. In addition, the canopy was mounted approximately two inches from the sprinkler.

20. At 3:59 p.m., in Room 319, the sprinkler was obstructed by the light fixture canopy.

21. At 4 p.m., in Room 320, the sprinkler was obstructed by the light fixture canopy. In addition, the canopy was mounted flush against the sprinkler.

11/19/14 - First and Second Floors

22. At 1:32 p.m., in the Security Office, items were stored approximately 10 inches below the sprinkler deflector.

23. At 3:41 p.m., in the Radiology Lab Storage Room, items were stored approximately eight inches below the sprinkler deflector.

24. At 3:44 p.m., in Radiology Dressing Room 3, the escutcheon ring was not flush with the ceiling and exposed an approximately four and one-half inch crescent-shaped penetration.

11/20/14 - First Floor

25. At 10:12 a.m., in the Pastoral Care Office storage closet, the escutcheon plate was missing, there was paint on the fusible link, and items were stored approximately one inch below the sprinkler deflector.

Based on observation and interview, the facility failed to maintain its portable fire extinguishers. This was evidenced by a portable fire extinguisher that was mounted higher than 60 inches above the floor and by a portable fire extinguisher that was obstructed from immediate access. This affected one of four floors and the basement and could result in a delay in access to the fire extinguishers, resulting in the spread of smoke and/or fire.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12 Maintenance 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 10, Standard for Portable Fire Extinguishers, 1998 Edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
3-7 Fire Extinguisher Size and Placement for Class K Fires.
3-7.1 Fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats).
3-7.2 Maximum travel distance shall not exceed 30 ft (9.15 m) from the hazard to the extinguishers.

Findings:

During a tour of the facility with Engineering Staff on 11/19/14 and 11/20/14, the portable fire extinguishers were observed.

11/20/14 - Basement

1. At 11:06 a.m., in the Linen Room, the fire extinguisher was mounted at 69 inches from the floor to the operable handle.

2. At 11:20 a.m., in the Materials Management Receiving Area, a portable fire extinguisher was obstructed from immediate access by a cart placed in front of the fire extinguisher. Staff 3 informed staff in the area and staff removed the cart.



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11/19/14 - Second Floor

3. At 10:10 a.m., in the OR Central Storage Room, the fire extinguisher was mounted approximately 66 inches above the floor.

11/20/14 - Second Floor 200 Building

4. At 11:57 a.m., an unmounted fire extinguisher was observed inside the Cath Lab 1 construction area.

Based on observation, the facility failed to ensure the safe operation of portable space-hearing devices, as evidenced by the presence of a space heater in a confined space. This could result in the increased risk of fire and affected one of four floors.


NFPA 70, National Electrical Code, 1999 Edition
Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of product of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
Finding:

During a tour of the Engineering Staff on 11/18/14 to 11/20/19, portable space heaters were observed.

11/19/14 - First Floor

1. At 2:57 p.m., there was a space heater beneath the Admitting Services desk.

The heater had a labeled warning, stating "warning: risk of fire keep combustible materials, clothing and curtains at least three feet from the front, side, and rear."

2. At 3:02 p.m., there was a space heater at a desk located in the Gift Shop. The heater was not plugged in. There were combustible items in the area. The area measured approximately 25 square feet.

Based on observation, the facility failed to properly store oxygen cylinders, as evidenced by oxygen cylinders stored in a room with the light switch mounted less than five feet above the floor, by combustible materials stored in an oxygen storage room, by empty and full cylinders stored in the same rack, and by rooms designated for oxygen storage without door signs. This could result in the increased risk of an oxygen-driven fire. Storage of empty and full cylinders in the same rack could result in delay and potential harm to patients. These deficient practices affected one of four floors and the basement.

NFPA 99, Health Care Facilities, 1999 Edition

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
4-3.1.1.2(a) 11d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

8-3.1.11.1 Storage Requirements. Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

4-3.5.2.2 Storage of Cylinders and Containers - Level 1.

(b) Nonflammable Gases.

2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly

8-3.1.11 Storage Requirements.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Findings:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the Oxygen Storage Rooms were observed.

11/19/14 - First Floor

1. At 1:50 p.m. on 11/19/14, there was oxygen stored inside the Emergency Room Storage Room. There was no sign on the door that indicated the storage of oxygen in the room.

2. At 3:52 p.m., there were eight E-cylinders stored in the Radiology X-ray 1 Dressing Room. The floor was carpeted, and the room was not one-hour rated. The light switch was located on the left wall at 48 inches above the floor. There was no sign on the door that indicated the storage of oxygen in the room.
.


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11/20/14 - Basement

3. At 10:47 a.m., there were 3 full cylinders and 4 empty cylinders in an empty rack in the Cardiac Rehabilitation Storage/Oxygen Room.

Based on observation, the facility failed to maintain the electrical wiring and equipment as evidenced by the use of surge protectors and extension cords in an unauthorized manner. This could result in the increased risk of fire and affected four of four floors.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
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

400-10. Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

Findings:

During a tour of the facility with Engineering Staff on 11/18/14 to 11/20/14, the electrical wiring and equipment were observed.

11/18/14 - Third Floor

1. At 3:22 p.m., there were three workstations in the "PCU" Workstation Area. At Workstation 2, a surge protector with computer equipment plugged into it was suspended approximately 18 inches above the floor.

2. At 3:25 p.m. on 11/18/14, a surge protector and an Uninterruptible Power Source (UPS) were observed beneath the workstation facing the west hall. Computer equipment was plugged into the UPS. The call light system and the UPS were plugged into the surge protector.

11/19/14 - First and Second Floors

3. At 10:30 a.m., in the Second Floor Waiting Room, two vending machines and a lamp were plugged into a surge protector located near the window.

4. At 11 a.m., in Room 2024 (Critical Care Educator's Office), there were two surge protectors beneath Desk 1. Computer equipment was plugged into Surge Protector 1. An overhead light and Surge Protector 1 were plugged into Surge Protector 2.

5. At 1:32 p.m., in the Security Office, a microwave oven, refrigerator, laptop, and telephone charger were plugged into a surge protector.

6. At 2:01 p.m., in the Emergency Room Director's Office, two surge protectors were observed. Three walkie-talkie chargers were plugged into Surge Protector 1. Two walkie-talkie chargers and Surge Protector 1 were plugged into Surge Protector 2.

7. At 2:05 p.m., in the Emergency Room Disaster Coordinator's Office, two surge protectors were observed. Computer equipment and a charger were plugged into Surge Protector 1. Computer equipment and Surge Protector 1 were plugged into Surge Protector 2.

8. At 2:11 p.m., in the Medical Director's Office, a personal-size refrigerator and computer equipment were plugged into a surge protector.

9. At 2:19 p.m., in the Public Relations Office, a refrigerator and a microwave oven were plugged into a surge protector.

10. At 4:05 p.m., in the Administration Office, two surge protectors were observed beneath Desk 2. Computer equipment and a telephone charger were plugged into Surge Protector 1. A battery charger and Surge Protector 1 were plugged into Surge Protector 2.

11/20/14 - First Floor

11. At 9:46 a.m., in the Director of Surgical Staffing Office, two surge protectors were observed beneath the desk. Computer equipment and a charger were plugged into Surge Protector 1. A printer, scanner, cell phone charger, and Surge Protector 1 were plugged into Surge Protector 2.

12. At 9:54 a.m., in the Doctors' Lounge Medical Staff Office, two surge protectors were observed beneath Desk 2. Computer equipment was plugged into Surge Protector 1. Computer equipment and Surge Protector 1 were plugged into Surge Protector 2.

13. At 10:20 a.m., in Room 136 (Respiratory Care Office), an extension cord was observed. It was plugged directly into the wall and had no devices connected to it.


31201

11/18/14 - Third and Fourth Floors

14. At 3:16 p.m., two Hoyer lift chargers were plugged into a surge protector in Storage Room 4026. When interviewed, Staff 3 stated that the room did not have enough wall outlets.

15. At 3:20 p.m., an aquarium and an aquarium lamp were plugged into a surge protector, in the Surgical Waiting Area.

16. At 3:19 p.m., there were two surge protectors in use in the Surge/Bariatrics Director's Office. A microwave was plugged into Surge Protector #1, and a refrigerator was plugged into Surge Protector #2. Staff 3 unplugged the refrigerator from Surge Protector #2 and plugged it into a wall outlet.

17. At 3:39 p.m., a coffee maker and a microwave were plugged into a surge protector in the Breakroom.

11/19/14 - First Floor

18. At 2:29 p.m., there was a missing cable faceplate in closet of Room 162.

19. At 2:50 p.m., a coffee maker was plugged into an extension cord in Room 167.

20. At 3:12 p.m., a coffee maker was plugged into an extension cord in the Pharmacy Room.

21. At 3:17 p.m., a defibrillator, suction machine and an incubator machine were plugged into a surge protector in the Pharmacy Storage Room.

22. At 3:28 p.m., a refrigerator was plugged into a surge protector in the Security Room.

23. At 3:54 p.m., a stereo was plugged into an extension cord in the Gastrointestinal Laboratory.

11/20/14 - First Floor

24. At 9:46 a.m., a training microscope was plugged into a surge protector in the Pathology Room.

25. At 9:54 a.m., an air purifier was plugged into a surge protector in the Infection Control Coordinator's Office.