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NFPA 101, 19.3.6.1 Corridors shall be separate from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5
Exception 2, In smoke compartments protected throughout by an approved, supervised, automatic sprinkler system in accordance with 19.3.5.3, waiting areas shall be permitted to be open to the corridor, provided that the following criteria are met:
(b), Each area is protected by an electronically supervised automatic smoke detection system in accordance with 19.3.4, or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.

This STANDARD was not met as evidenced by:

Based on observation and staff interview the facility failed to assure that an opening onto one corridor had the required smoke detection device. The affected corridor ran through the nursery and neonatal areas of the hospital.

Findings include:

On 1/5/12 during a tour of the facility, it was observed that the father's waiting area on the third floor, across from "The Baby Place", had the door removed. Facilities staff indicated that the door had been removed for security reasons. The room measured 140 square feet and did not have a smoke detection device.

Based on observation, the facility failed to assure that there were no impediments to the closing of patient room doors. Ten patient room doors could not be closed due to blockage from chart carts, trash cans, soiled linen containers, biohazardous waste containers, and soiled linen receptacles. During a fire, it is important to quickly contain the spread of smoke and flames by closing the door to the room of origin. During the survey, patient census was 232 and the number of licensed beds was 320.

Findings include:

On 1/5/12 during a tour of the facility the following obstructions were found blocking the closure of patient room doors: Rooms 372, 375, 388 soiled lined receptacles; Rooms 378, 381, 393 chart carts; Rooms 380, 390 Rubbermaid trash cans; and Room 384 a biohazard container.

The above findings were acknowledged by the facility's Administrator and the Director of Facilities Management during the exit conference on 1/6/12.

NFPA 25 (2008 ed.), 5.2.1.1 Sprinklers shall be inspected from the floor level annually. 5.2.1.1 Sprinklers shall not show signs of leakage; 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). 5.2.1.1.2 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or in the improper orientation.

NFPA 13 (2010 ed.), 8.3.3.2 Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3.

This STANDARD is not met as evidenced by:

Based on observation, the facility failed to assure that they installed sprinkler heads with similar temperature sensitivity throughout one compartment; and failed to maintain all sprinkler heads in good working condition. These deficient practices could have affected staff and residents in the kitchen and in the Intermediate Care (IMC) Unit. The hospital was licensed for 320 beds and had a census of 232 at the time of the survey.

Findings include:

During a tour of the facility on 1/5/12, it was observed that:

a. In the IMC there were several types of sprinkler heads in use; fusible-link pendent, fusible-link anti-ligature (previous geropsych unit) and one quick response, frangible "red" bulb pendent.
b. In the corridor accessing the NICU, there was one quick response, frangible "red" bulb pendent. All of the other sprinkler heads in the corridor were fusible-link pendents.
c. In the kitchen area there were two, quick response "green" bulb pendents. All of the other sprinkler heads in this compartment were fusible-link pendents.
b. In the kitchen area there was one corroded sprinkler head and escutcheon near the oven.

The above findings were acknowledged by the Director of Facilities Management on 1/5/12 and 1/6/12.

NFPA 10, 1.5.7 Portable fire extinguishers other than wheeled extinguishers shall be installed securely on the hanger, or in the bracket supplied by the extinguisher manufacturer, or in a listed bracket approved for such purpose, or placed in cabinets or wall recesses. Wheeled fire extinguishers shall be located in a designated location.
1.5.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1.5.6.)
1.5.6 Fire extinguishers shall not be obstructed or obscured from view. In large rooms, and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to assure that cabinets for fire extinguishers were structually supportive of five CO2 fire extinguishers in one smoke compartment. One fire extinguisher was stored in a cabinet recessed in a wall in the IMC suite that was not obvious to staff.
Findings include:
On 1/5/12, during a tour of the facility the surveyor entered five cardiac catheter labs, each having a wall-mounted fire extinguisher cabinet containing a ten-pound CO2 extinguisher. The plastic cabinets bowed from the weight of the extinguishers, causing the clear plastic face covers not to fit properly. The extinguishers were not strapped into the cabinets. One extinguisher was seen to wobble when a door was closed.
Also on the same day, one fire extinguisher in a recessed cabinet in the IMC suite was observed not to have a locator sign over it. All other extinguishers in the suite were provided with locator signage.
These conditions were discussed with, and acknowledged by, the Director of Facilities Management.

NFPA 99, Chapter 9 Gas Equipment
9.7.5.2 If stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

This STANDARD was not met, as evidenced by:

Based on observation, the facility failed to assure that full and empty oxygen cylinders were stored separately within the same room.

Findings include:

During a tour of the facility on 1/5/12, oxygen storage racks were observed with both full and empty tanks co-mingled in the surgical Intensive Care Unit (ICU).

These conditions were discussed with and acknowledged by the Director of Facilities Management on 1/5/12 and 1/6/12.

NFPA 101, 19.3.6.1 Corridors shall be separate from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5
Exception 2, In smoke compartments protected throughout by an approved, supervised, automatic sprinkler system in accordance with 19.3.5.3, waiting areas shall be permitted to be open to the corridor, provided that the following criteria are met:
(b), Each area is protected by an electronically supervised automatic smoke detection system in accordance with 19.3.4, or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space.

This STANDARD was not met as evidenced by:

Based on observation and staff interview the facility failed to assure that an opening onto one corridor had the required smoke detection device. The affected corridor ran through the nursery and neonatal areas of the hospital.

Findings include:

On 1/5/12 during a tour of the facility, it was observed that the father's waiting area on the third floor, across from "The Baby Place", had the door removed. Facilities staff indicated that the door had been removed for security reasons. The room measured 140 square feet and did not have a smoke detection device.

Based on observation, the facility failed to assure that there were no impediments to the closing of patient room doors. Ten patient room doors could not be closed due to blockage from chart carts, trash cans, soiled linen containers, biohazardous waste containers, and soiled linen receptacles. During a fire, it is important to quickly contain the spread of smoke and flames by closing the door to the room of origin. During the survey, patient census was 232 and the number of licensed beds was 320.

Findings include:

On 1/5/12 during a tour of the facility the following obstructions were found blocking the closure of patient room doors: Rooms 372, 375, 388 soiled lined receptacles; Rooms 378, 381, 393 chart carts; Rooms 380, 390 Rubbermaid trash cans; and Room 384 a biohazard container.

The above findings were acknowledged by the facility's Administrator and the Director of Facilities Management during the exit conference on 1/6/12.

NFPA 25 (2008 ed.), 5.2.1.1 Sprinklers shall be inspected from the floor level annually. 5.2.1.1 Sprinklers shall not show signs of leakage; 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). 5.2.1.1.2 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or in the improper orientation.

NFPA 13 (2010 ed.), 8.3.3.2 Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3.

This STANDARD is not met as evidenced by:

Based on observation, the facility failed to assure that they installed sprinkler heads with similar temperature sensitivity throughout one compartment; and failed to maintain all sprinkler heads in good working condition. These deficient practices could have affected staff and residents in the kitchen and in the Intermediate Care (IMC) Unit. The hospital was licensed for 320 beds and had a census of 232 at the time of the survey.

Findings include:

During a tour of the facility on 1/5/12, it was observed that:

a. In the IMC there were several types of sprinkler heads in use; fusible-link pendent, fusible-link anti-ligature (previous geropsych unit) and one quick response, frangible "red" bulb pendent.
b. In the corridor accessing the NICU, there was one quick response, frangible "red" bulb pendent. All of the other sprinkler heads in the corridor were fusible-link pendents.
c. In the kitchen area there were two, quick response "green" bulb pendents. All of the other sprinkler heads in this compartment were fusible-link pendents.
b. In the kitchen area there was one corroded sprinkler head and escutcheon near the oven.

The above findings were acknowledged by the Director of Facilities Management on 1/5/12 and 1/6/12.

NFPA 10, 1.5.7 Portable fire extinguishers other than wheeled extinguishers shall be installed securely on the hanger, or in the bracket supplied by the extinguisher manufacturer, or in a listed bracket approved for such purpose, or placed in cabinets or wall recesses. Wheeled fire extinguishers shall be located in a designated location.
1.5.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1.5.6.)
1.5.6 Fire extinguishers shall not be obstructed or obscured from view. In large rooms, and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to assure that cabinets for fire extinguishers were structually supportive of five CO2 fire extinguishers in one smoke compartment. One fire extinguisher was stored in a cabinet recessed in a wall in the IMC suite that was not obvious to staff.
Findings include:
On 1/5/12, during a tour of the facility the surveyor entered five cardiac catheter labs, each having a wall-mounted fire extinguisher cabinet containing a ten-pound CO2 extinguisher. The plastic cabinets bowed from the weight of the extinguishers, causing the clear plastic face covers not to fit properly. The extinguishers were not strapped into the cabinets. One extinguisher was seen to wobble when a door was closed.
Also on the same day, one fire extinguisher in a recessed cabinet in the IMC suite was observed not to have a locator sign over it. All other extinguishers in the suite were provided with locator signage.
These conditions were discussed with, and acknowledged by, the Director of Facilities Management.

NFPA 99, Chapter 9 Gas Equipment
9.7.5.2 If stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

This STANDARD was not met, as evidenced by:

Based on observation, the facility failed to assure that full and empty oxygen cylinders were stored separately within the same room.

Findings include:

During a tour of the facility on 1/5/12, oxygen storage racks were observed with both full and empty tanks co-mingled in the surgical Intensive Care Unit (ICU).

These conditions were discussed with and acknowledged by the Director of Facilities Management on 1/5/12 and 1/6/12.