HospitalInspections.org

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital Engineering Representative, the facility failed to assure the integrity of the corridor. Positive latching hardware was not latching at 1) basement ' s janitor closet door E5003 and 2) second floor ' s inpatient rehab door (middle set of doors for this space).

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital Engineering Representative, the facility failed to assure the integrity of the corridor. Positive latching hardware was not latching at second floor ' s clean linen closet ' s double doors. The door with the astragal blocked the active leaf ' s latching hardware

Based on observation the facility failed to provide adequate exit signage.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there was a missing exit sign at the fire pump controller.

Based on observation the facility failed to provide an adequate smoke barrier.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there was a penetration in a smoke barrier at 3rd Floor, Stair I.

Based on observations during the facility walk through on 7/17/2013 with the CEO, Director of Engineering, Safety Director, operations manager, Project Manager, and Quality Manager, it was noted that a corridor door into Linen Holding room #1.412 (on the first floor) was being held open to the corridor with non rated plastic chairs. this room is classified as a hazardous area. the door is rated as a 1 1/2 hour fire door. Fire doors shall not be held open, unless they are rated automatic self-closing devices.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were the following issues.

1) The following areas had no closures: A) fourth floor Physical Therapy Supply/Linen room, B) OR Equipment Storage, 2.LD.82.008B.

2) The following areas had doors that did not latch on their own: A) 3-A.12.002, B) 3-A.11.007, C) 1.EC.1259, and D) 1-SA.30.003b.

3) The storage room door at the gift shop was propped open with cardboard under the bottom of the door.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital Engineering Representative, the facility failed to maintain a rated door. Basement ' s storage double doors were dented and damaged, reducing its rating.

Based on observation the facility failed to provide adequate stair enclosures.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were the following issues.

1) In the penthouse, the South stair door drags on the floor, did not close on its own, and the latch did not work properly.

2) Stair B on the 2nd floor there was a storage closet under the stair with combustible storage within. This closet must be sealed off and have any sprinkler head removed. An enclosed usable space under a stair is not allowed.

" There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. " NFPA 101, 2000, 7.2.2.5.3.

Based on observations during the facility wakl through on 7/16/and 7/17/ 2013, with the CEO, Director of Engineering, Safety Director, Operations Manager, and Quality manager, it was noted that one of the required exits from the dietary department was patrially blocked by the placement of a housekeeping mop bucket filled wiater, mops, and supplies.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital Engineering Representative, the facility failed to maintain an egress path out the building. Exit door was difficult to open when pushing on the panic hardware. This second floor exterior stair 2B door was marked by an exit sign and is a required exit.

Based on observation the facility failed to provide adequate exiting.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there was an exit access in the Department of Anesthesiology that did not have a minimum of 4 foot clear exit access due to obstructions within the egress.

Based on observation during the facility walkthrough on the morning of 7/17/2013, with the CEO, Director of Engineering, Safety Director, Operations manager, Quality Manager, and Safety Director, it was noted that
(1) the fire alarm control panel (FACP) on the third floor was not powered from the Life Safety Branch of the EES. It was powered from a Critical Branch panel. No identification was affixed to the face of the fire alarm panel identifying the electrical panel and circuit number providing power to the FACP.
(2) A fire alarm booster panel was identified on Life Safety Branch panel "LL4A", circuits #6 and #8. However the face of the fire alarm booster panel identifed the power source as circuits "#18-#19" . Could not verify which information was correct.
(3) Life Safety Branch electrical panels on the fourth and fifth floors had yellow color coded labels. However LS Branch panels on the other floors were identified by red color coded labeling,. Color coding for emergency panels shall be maintained the same throughout this facility.
(4) The fire alarm panels on the fifth floor lacked electrical panel and circuiting information affixed to the face of the fire alarm panels. The Life Safety Branch electrical panel on the fifth floor identified circuits #1, #10, and #12 as power to the fire alarm system .

Based on observation the facility failed to provide an adequate fire alarm system.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there was the following issue. The FACP and the panel supplying power to the FACP were not properly cross referenced.

" A dedicated electrical circuit to the life safety branch of the EES shall be provided. The circuit shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL". - NFPA 72, 1999: 1-5.2.5.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 1999: 1-5.2.5.2.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital ' s Engineering Representative, the FACP panel and subpanels were not labeled as to which electrical panel and breaker supplied the power for the FACP at the first floor electrical room. Also the breaker shall be labeled at the panel that supplies power to the FACP. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker shall be colored red.

Based on observation the facility failed to provide complete fire sprinkler system.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were the following issues.

1. The fire pump and risers did not have the valves labeled in all cases.

2. In chase 2-SA.10.010 there was mortar within the sprinkler head. The head must be replaced.

3. There was a missing escutcheon plate the following locations: A) 1-EF.60.002b, and B) 1-EF.60.002a-b.

4. There was cabling resting on sprinkler piping in multiple locations. It was observed in the following locations: A) Dietary Galley, 2-DT.50.002a-c, B) adjacent to the cross corridor between SC 2.6 and SC 2.7 that was outside of the fire stair at courtyard #2, C) at 2-NT.91.002a-j, D) at 2-TA.92.001, E) 1-EC.73.011, and F) at 1-cc.81.001A-B.

5. The elevator equipment rooms were not sprinkled. The local fire department had requested that the sprinkler system be removed. This creates an unsprinkled building. This problem can be solved by making the elevator equipment rooms 2 hour enclosures. This will involve the following: A) Elevator Equipment Room 5-SA.001 had an unlabeled door and the connected space above, 5-SA.003, also had an unlabeled door. There were also penetrations in the CMU walls in 5-SA.003. B) Elevator Equipment Room 5-SA.004 did not have a labeled door and had ceiling penetrations that were not sealed. C) Elevator Equipment Room 5-SA.005 had an unlabeled door. D) Elevator Equipment Room 5-SA.006 did not have a labeled door. These elevator equipment rooms were also open to the 2 hour elevator shaft, and should have been designed as 2 hour enclosures to begin with.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital ' s Engineering Representative, the facility failed to maintain safety in the kitchen. NFPA 96 states that all deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames from adjacent cooking equipment. This occurred both at the kitchen and server line

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were the following issues.

1) The medical gas room did not have the correct signage. The Signage must read as follows:

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

2) All medical gas bottles must be individually secured. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

3) There were open medical gas outlets in the corridors in the following locations: 1) 2-BC.63.007, 2) 2-BC.61.015, 3) 2-BC.62.010, 4) 2-BC.62.002, and 5) 2-BC.63.001.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital ' s Engineering Representative, the facility failed to provide, at the outdoor emergency generator set location, an electrical receptacle. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. This receptacle must be powered from the electrical Type 1 EES life safety panel board.

Based on a review of the records, and discussions with the Director of Engineering and Safety Director during the facility survey on 7/16/2013, it was noted that electrical receptacles in critical care patient areas were not being tested semi-annually as required by NFPA 99; 7-6.2.1.2. Records indicated that all electrical outlets (both in critical care and general care areas) were being tested on an annual basis only.

Based on observation the facility failed to provide an adequate Essential Electrical System, EES.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were the following issues.

1) The ATS and EES panels were not labeled with the branch that they serve. This was found in the following locations: A) the Penthouse, B) the electrical room on the third floor, C) 1-SA.61.006, D) 1-SA.60.006, E) 1-DT.50.002, F) EES panels in the main part of the Kitchen, G) 5-SA.006, and H) 5-SA.005.

2) There were functions that were not properly segregated into the correct panels. This was found in the following locations: A) The Third Floor Electric Closet had 3LCB1A/12 with the medical gas system that must be in a Life Safety cabinet, B) also in this same closet panel 3LLS required an updated directory, C) panel 1LCB6 had a fire alarm function that must be in a Life Safety cabinet, D) 1-SA.60.006 had a fire alarm in 1LCB that must be in a Life Safety cabinet, and E) 2-SA.20.010 the Life Safety panel had " PD Receptacles " that must be moved.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital ' s Engineering Representative, the facility failed to assure that the essential electrical system was in full compliance. Receptacles (circuits 1 & 15) and a time clock were supplied with power from the life safety branch of the essential electrical system and needs to be moved to either the critical branch panel or another panel board, just not life safety panel board.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Based on observation the facility failed to provide adequate labeling of critical receptacles in critical areas.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that the critical receptacles in critical areas were not permanently marked in the following locations: 1) OR 3, and 2) the ICU all patient rooms.

In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a).

Also, there were open j-boxes in the following locations: 1) above the second floor smoke barrier at courtyard #2, and 2) at smoke barrier adjacent to 1-EC.73.011.

Based on observation the facility failed to provide an acceptable location for an alcohol based hand rub dispenser at some locations.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were alcohol based hand rubs above electrical outlets or switches in the following locations: 1) 4-B.31.008, 2) OR #3, 3) 1.EC.1297, 4) 1.EC.1296, and 5) fourth floor bronchoscopy room.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital Engineering Representative, the facility failed to assure the integrity of the corridor. Positive latching hardware was not latching at 1) basement ' s janitor closet door E5003 and 2) second floor ' s inpatient rehab door (middle set of doors for this space).

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital Engineering Representative, the facility failed to assure the integrity of the corridor. Positive latching hardware was not latching at second floor ' s clean linen closet ' s double doors. The door with the astragal blocked the active leaf ' s latching hardware

Based on observation the facility failed to provide adequate exit signage.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there was a missing exit sign at the fire pump controller.

Based on observation the facility failed to provide an adequate smoke barrier.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there was a penetration in a smoke barrier at 3rd Floor, Stair I.

Based on observations during the facility walk through on 7/17/2013 with the CEO, Director of Engineering, Safety Director, operations manager, Project Manager, and Quality Manager, it was noted that a corridor door into Linen Holding room #1.412 (on the first floor) was being held open to the corridor with non rated plastic chairs. this room is classified as a hazardous area. the door is rated as a 1 1/2 hour fire door. Fire doors shall not be held open, unless they are rated automatic self-closing devices.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were the following issues.

1) The following areas had no closures: A) fourth floor Physical Therapy Supply/Linen room, B) OR Equipment Storage, 2.LD.82.008B.

2) The following areas had doors that did not latch on their own: A) 3-A.12.002, B) 3-A.11.007, C) 1.EC.1259, and D) 1-SA.30.003b.

3) The storage room door at the gift shop was propped open with cardboard under the bottom of the door.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital Engineering Representative, the facility failed to maintain a rated door. Basement ' s storage double doors were dented and damaged, reducing its rating.

Based on observation the facility failed to provide adequate stair enclosures.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were the following issues.

1) In the penthouse, the South stair door drags on the floor, did not close on its own, and the latch did not work properly.

2) Stair B on the 2nd floor there was a storage closet under the stair with combustible storage within. This closet must be sealed off and have any sprinkler head removed. An enclosed usable space under a stair is not allowed.

" There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. " NFPA 101, 2000, 7.2.2.5.3.

Based on observations during the facility wakl through on 7/16/and 7/17/ 2013, with the CEO, Director of Engineering, Safety Director, Operations Manager, and Quality manager, it was noted that one of the required exits from the dietary department was patrially blocked by the placement of a housekeeping mop bucket filled wiater, mops, and supplies.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital Engineering Representative, the facility failed to maintain an egress path out the building. Exit door was difficult to open when pushing on the panic hardware. This second floor exterior stair 2B door was marked by an exit sign and is a required exit.

Based on observation the facility failed to provide adequate exiting.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there was an exit access in the Department of Anesthesiology that did not have a minimum of 4 foot clear exit access due to obstructions within the egress.

Based on observation during the facility walkthrough on the morning of 7/17/2013, with the CEO, Director of Engineering, Safety Director, Operations manager, Quality Manager, and Safety Director, it was noted that
(1) the fire alarm control panel (FACP) on the third floor was not powered from the Life Safety Branch of the EES. It was powered from a Critical Branch panel. No identification was affixed to the face of the fire alarm panel identifying the electrical panel and circuit number providing power to the FACP.
(2) A fire alarm booster panel was identified on Life Safety Branch panel "LL4A", circuits #6 and #8. However the face of the fire alarm booster panel identifed the power source as circuits "#18-#19" . Could not verify which information was correct.
(3) Life Safety Branch electrical panels on the fourth and fifth floors had yellow color coded labels. However LS Branch panels on the other floors were identified by red color coded labeling,. Color coding for emergency panels shall be maintained the same throughout this facility.
(4) The fire alarm panels on the fifth floor lacked electrical panel and circuiting information affixed to the face of the fire alarm panels. The Life Safety Branch electrical panel on the fifth floor identified circuits #1, #10, and #12 as power to the fire alarm system .

Based on observation the facility failed to provide an adequate fire alarm system.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there was the following issue. The FACP and the panel supplying power to the FACP were not properly cross referenced.

" A dedicated electrical circuit to the life safety branch of the EES shall be provided. The circuit shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL". - NFPA 72, 1999: 1-5.2.5.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 1999: 1-5.2.5.2.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital ' s Engineering Representative, the FACP panel and subpanels were not labeled as to which electrical panel and breaker supplied the power for the FACP at the first floor electrical room. Also the breaker shall be labeled at the panel that supplies power to the FACP. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker shall be colored red.

Based on observation the facility failed to provide complete fire sprinkler system.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were the following issues.

1. The fire pump and risers did not have the valves labeled in all cases.

2. In chase 2-SA.10.010 there was mortar within the sprinkler head. The head must be replaced.

3. There was a missing escutcheon plate the following locations: A) 1-EF.60.002b, and B) 1-EF.60.002a-b.

4. There was cabling resting on sprinkler piping in multiple locations. It was observed in the following locations: A) Dietary Galley, 2-DT.50.002a-c, B) adjacent to the cross corridor between SC 2.6 and SC 2.7 that was outside of the fire stair at courtyard #2, C) at 2-NT.91.002a-j, D) at 2-TA.92.001, E) 1-EC.73.011, and F) at 1-cc.81.001A-B.

5. The elevator equipment rooms were not sprinkled. The local fire department had requested that the sprinkler system be removed. This creates an unsprinkled building. This problem can be solved by making the elevator equipment rooms 2 hour enclosures. This will involve the following: A) Elevator Equipment Room 5-SA.001 had an unlabeled door and the connected space above, 5-SA.003, also had an unlabeled door. There were also penetrations in the CMU walls in 5-SA.003. B) Elevator Equipment Room 5-SA.004 did not have a labeled door and had ceiling penetrations that were not sealed. C) Elevator Equipment Room 5-SA.005 had an unlabeled door. D) Elevator Equipment Room 5-SA.006 did not have a labeled door. These elevator equipment rooms were also open to the 2 hour elevator shaft, and should have been designed as 2 hour enclosures to begin with.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital ' s Engineering Representative, the facility failed to maintain safety in the kitchen. NFPA 96 states that all deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames from adjacent cooking equipment. This occurred both at the kitchen and server line

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were the following issues.

1) The medical gas room did not have the correct signage. The Signage must read as follows:

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

2) All medical gas bottles must be individually secured. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

3) There were open medical gas outlets in the corridors in the following locations: 1) 2-BC.63.007, 2) 2-BC.61.015, 3) 2-BC.62.010, 4) 2-BC.62.002, and 5) 2-BC.63.001.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital ' s Engineering Representative, the facility failed to provide, at the outdoor emergency generator set location, an electrical receptacle. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. This receptacle must be powered from the electrical Type 1 EES life safety panel board.

Based on a review of the records, and discussions with the Director of Engineering and Safety Director during the facility survey on 7/16/2013, it was noted that electrical receptacles in critical care patient areas were not being tested semi-annually as required by NFPA 99; 7-6.2.1.2. Records indicated that all electrical outlets (both in critical care and general care areas) were being tested on an annual basis only.

Based on observation the facility failed to provide an adequate Essential Electrical System, EES.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were the following issues.

1) The ATS and EES panels were not labeled with the branch that they serve. This was found in the following locations: A) the Penthouse, B) the electrical room on the third floor, C) 1-SA.61.006, D) 1-SA.60.006, E) 1-DT.50.002, F) EES panels in the main part of the Kitchen, G) 5-SA.006, and H) 5-SA.005.

2) There were functions that were not properly segregated into the correct panels. This was found in the following locations: A) The Third Floor Electric Closet had 3LCB1A/12 with the medical gas system that must be in a Life Safety cabinet, B) also in this same closet panel 3LLS required an updated directory, C) panel 1LCB6 had a fire alarm function that must be in a Life Safety cabinet, D) 1-SA.60.006 had a fire alarm in 1LCB that must be in a Life Safety cabinet, and E) 2-SA.20.010 the Life Safety panel had " PD Receptacles " that must be moved.

Based on observations during the survey walk of the facility on the afternoon of 7-16-2013, with the Hospital ' s Engineering Representative, the facility failed to assure that the essential electrical system was in full compliance. Receptacles (circuits 1 & 15) and a time clock were supplied with power from the life safety branch of the essential electrical system and needs to be moved to either the critical branch panel or another panel board, just not life safety panel board.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Based on observation the facility failed to provide adequate labeling of critical receptacles in critical areas.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that the critical receptacles in critical areas were not permanently marked in the following locations: 1) OR 3, and 2) the ICU all patient rooms.

In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a).

Also, there were open j-boxes in the following locations: 1) above the second floor smoke barrier at courtyard #2, and 2) at smoke barrier adjacent to 1-EC.73.011.

Based on observation the facility failed to provide an acceptable location for an alcohol based hand rub dispenser at some locations.

The inspector observed, while accompanied by the Safety Specialist, the Infection Prevention Coordinator, the PSA, the Tech II, the Senior Project Manager, the Safety Director, a Volunteer with the Facility, and the Engineering Supervisor during the hours of the inspection from 11:45 am to 5:30 pm on 7/16/2013 and 8:30 am to 6:30 pm on 7/17/2013 that there were alcohol based hand rubs above electrical outlets or switches in the following locations: 1) 4-B.31.008, 2) OR #3, 3) 1.EC.1297, 4) 1.EC.1296, and 5) fourth floor bronchoscopy room.