HospitalInspections.org

July 31, 2012 - Heart and Surgical Hospital
At 3:40 p.m., there was an approximately 1/2 inch unsealed penetration around the overhead light and monitoring equipment, in the ceiling of Operating Room 2.

Based on observation, the facility failed to maintain the integrity of the walls and ceiling, as evidenced by two penetration in the ceilings. This affected 1 of 2 smoke compartments in the Pediatric Speciality Team Center and 1 of 3 smoke compartments on the lower level of the Heart and Surgical Hospital. This could result in the spread of smoke and fire and increase the risk of injury to patients and staff in the event of a fire.

Findings:

During the facility tour with Safety Technician on July 30, 2012, and July 31, 2012, the ceilings were observed in two offsite locations.

Pediatric Speciality Team Center
At 4:20 p.m., there were two approximately 1/2 inch penetrations, around 2 conduits, in the ceiling of the Receiving Room.

Based on observation, the facility failed to maintain the integrity of the building construction of corridor walls. This was evidenced by two penetrations in corridor walls, affecting 1 of 6 smoke compartments at the East Campus Hospital. This could result in the spread of fire and smoke, potentially harming patients, visitors, and staff evacuating through the corridors.

Findings:

During a tour of the facility with hospital staff on August 1, 2012, the corridor walls were observed at the East Campus Hospital.

At 2:43 p.m., there were two penetrations in the corridor wall by the entrance to the Operating Rooms. The penetrations were located above the drop down tiled ceiling in the wall shared with the storage rooms. The first penetration measured approximately 1-inch in diameter and was by the anchor cable to the ceiling tile. The second penetration measured approximately 2-inches around electrical conduits.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by corridor doors that failed to close and latch, and by corridor doors that were impeded from closing. This affected 4 of 9 floors in the Medical Center and would allow the spread of smoke and fire to other areas in the building.

Findings:

During a tour of the facility with the Plumber II, Director of Facility Management, Office of Environmental Health and Safety, and Quality Analyst from July 30, 2012, through August 2, 2012, the corridor doors were observed.

July 30, 2012
Medical Center - Seventh floor
At 1:11 p.m., the corridor door to Room 7212 was impeded from closing by a Workstation on Wheels (WOW) that was in the door way.

Medical Center - Fourth floor
At 2:49 p.m., the self-closing corridor door to Room 4835 failed to latch when closed.

July 31, 2012
Medical Center - Fourth floor
At 3:36 p.m., the self-closing corridor door to Room 4770 failed to close and latch.

During an interview at 3:37 p.m., the Environmental Health and Safety Officer stated" the closure arm has been disconnected to the door."

August 1, 2012
Medical Center - Second floor
At 9:19 a.m., the two roll down doors were impeded from closing, at Radiology, near Room 2221. The front door was impeded by a coffee size can placed in the door's path. The side door was impeded by a 4 inch by 5 inch box.

August 1, 2012
Medical Center - Third floor
At 10:24 a.m., the corridor door, to Nursing Station Triage (near Room 3000), was impeded from closing by a refrigerator that was in front of the door.

August 2, 2012
Medical Center - Level A Basement
At 8:35 a.m., the door to Room A-323 in the Emergency Room was impeded from closing by two chairs.

At 8:36 a.m., the Office of Environmental Health and Safety person stated, "I see that the door is blocked."

Based on observation, the facility failed to maintain smoke barrier doors held open by magnetic devices. This was evidenced by doors that failed to release from the magnets when the fire alarm system was activated. This affected 1 of 6 smoke compartments at the East Campus Hospital. This could result in the spread of fire and smoke to other smoke compartments, increasing the risk of harm to the patients, visitors, and staff.

Finding:

During a tour of the facility with the hospital staff on August 1, 2012, the cross-corridor fire doors were observed.

August 1, 2012 - East Campus Hospital

At 1:51 p.m., 1 of 2 cross-corridor doors, located by Room 229, failed to release from the magnet hold open device. The door failed to release and self-close when the fire alarm was activated.
At 1:52 p.m., the fire alarm was activated a second time. The same door failed to release and self-close.

Based on observation and interview, the facility failed to maintain their smoke barrier walls, as evidenced by smoke barrier walls with penetrations. This would allow the spread of smoke and fire to other compartments within the buildings. This affected 2 of 9 floors in the Medical Center, 2 of 6 smoke compartments at the East Campus Hospital, the Outpatient Diabetic Treatment Center, and two of two smoke compartments in the Pediatric Specialty Building.

Findings:

NFPA 101 Life Safety Code, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke 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 smoke barrier, the sleeve shall be solidly set in the smoke 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 smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Plumber II, Director of Facility Management, Officer of Environmental Health and Safety, Safety Technician and Quality Analyst, from July 30, 2012, through August 2, 2012, the smoke barrier walls were observed in the hospital and out buildings.

July 31, 2012
Medical Center - Third floor
At 9:25 a.m., there was an approximate 6 inch by 6 inch unsealed penetration in the smoke barrier wall between the elevator lobby and Room 3400 on the third floor.

At 9:26 a.m., the Director of Facility Management confirmed during an interview, "I agree that the hole is about 6 by 6 inches."

At 9:47 a.m., there was an approximate 5 foot by 3 foot unsealed penetration in the smoke barrier wall near the South entrance to 3800. The drywall was missing on the south side of the entrance.

August 1, 2012
Medical Center - Second floor
At 9:49 a.m., there was an approximately 2 inch by 3 inch unsealed penetration in the smoke barrier wall on the second floor near the entrance to the Surgery Unit.

At 9:50 a.m., the Director of Facility Management confirmed the penetration.

At 10:15 a.m., there was an approximately 3 inch unsealed pipe in the smoke barrier wall near Room 2712 on the second floor.


29566

During a tour of facility with the Safety Technician on July 30, 2012, the smoke barrier walls were observed in the Outpatient Diabetic Treatment Center.

At 3:10 p.m., there was missing sheet rock in the smoke barrier wall in the attic space near Room 3. The open area measured 1 1/2 by 3 feet.


August 1, 2012 - Pediatric Speciality Team Center.

At 2:55 p.m., above Room 17, there was a penetration around a one inch copper pipe in the draft stop barrier.

At 3:05 p.m., there was a one inch penetration in the smoke barrier wall by the restroom.


29626

August 1, 2012 - East Campus Hospital.

At 11:14 a.m., there was an approximately 2 by 1 inch penetration, in the smoke barrier wall by the exit door leading into the Healing Garden. There was red colored caulking material surrounding the penetration in the attic space.

Based on observation and interview, the facility failed to maintain their smoke barrier doors to prevent the spread of smoke and fire. This was evidenced by smoke barrier doors that were equipped with latching hardware, that failed to close and latch. This could allow the spread of smoke and fire to other compartments and cause potential harm to patients. This affected 2 of 9 floors within the Medical Center, 1 of 3 fire doors separating smoke compartments at the 1500 Unit, East Campus Hospital, and 2 of 2 smoke compartments in the Heart and Surgical Hospital.

Findings:

During fire alarm testing with the Plumber II, Director of Facility Management, Office of Environmental Health and Safety staff, and Quality Analyst, on August 1, 2012 and August 2, 2012, the smoke barrier doors were tested and observed.

August 1, 2012
Medical Center - First floor
At 1:24 p.m., the smoke barrier doors (both) failed to latch, after activation of the fire alarm system, near Elevator 1.

At 1:55 p.m., the South smoke barrier door, near Elevators 17 and 18, failed to latch after activation of the fire alarm system.

During an interview, at 1:56 p.m., the Director of Facility Management stated he thought this was an air handling issue.

August 2, 2012
Medical Center - Level B floor
At 10:08 a.m., the smoke barrier door near Room B255 failed to close completely and latch.

At 10:34 a.m., the East smoke barrier door failed to latch after activation of the fire alarm system, near the Nuclear Med Lobby, level B.

At 10:35 a.m., during an interview, the Director of Facility Management stated he thought this was an air handling issue.


29626

August 1, 2012
1500 Unit - East Campus Hospital

At 3:41 p.m., 1 of 2 cross-corridor fire doors, located by Room 1508, failed to fully close and positive latch upon activation of the fire alarm system. The fire alarm was activated a second time at 3:45 p.m. The cross-corridor smoke barrier doors failed to close and positive latch.

During facility alarm testing with Facilities staff on July 31, 2012, the smoke barrier door was observed in the Heart & Surgical Hospital.

At 2:01 p.m., the smoke barrier door by Room 2120 failed to release and close during fire alarm testing.

Based on observation, the facility failed to protect a hazardous area as evidenced by one oxygen storage room door that failed to close and latch. This affected 1 of 2 floors in the Outpatient Surgical Center. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

National Fire Prevention Association 101, Life Safety Code 2000 Edition:
19.3.2.1 Hazardous Areas. Any Hazardous area shall be safe-guarded by a fire barrier having a 1 -hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic closing. Hazardous areas shall include, but shall not be restricted to, the following:

(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square ft (9.3 square m)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square ft ( 4.6 square m), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory-or field -applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a tour of the facility with the Safety Technician on July 31, 2012, the oxygen storage room was observed.

July 31, 2012 - Outpatient Surgical Center

At 11:40 a.m., the door to the piped in gas room, failed to close and latch. The med gas room is located off the corridor, in the basement (lower floor).

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by emergency lighting units that failed to illuminate when tested. This affected 1 of 3 lighting units in the Outpatient Imaging Center. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors.

NFPA 101 Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with hospital staff, the emergency lighting units were observed and tested in the Outpatient Imaging Center at 25455 Barton Road.

August 2, 2012

At 11:06 a.m., the emergency lighting unit failed to illuminate when tested, for the light located by the entrance to CT Imaging 103B.

Based on observation and interview, the facility failed to maintain their exit signs, as evidenced by an exit sign that failed to indicate the direction to egress. This could delay evacuation and cause potential harm to patients in the event of a fire emergency. This affected 1 of 9 floors in the Medical Center.

Findings:

During a tour of the facility with the Plumber II, Director of Facility Management, Office of Environmental Health and Safety staff, and Quality Analyst, on August 1, 2012, the exit signs were observed in the Medical Center.

Medical Center - Second floor
At 9:30 a.m., there was an exit sign on the west side of Room 2602, without directional guidance (an arrow) to indicate the exit path. The sign was at the end of a hallway with options to turn left or right. The right turn would lead to the exit door.

During an interview, at 9:31 a.m., the Director of Facility Management confirmed the sign failed to provide the direction to egress.

Based on observation and interview, the facility failed to maintain their fire alarm system in accordance with NFPA 72. This was evidenced by won doors that failed to close, and by strobes and audio devices that failed during alarm testing. This affected 2 of 9 floors and the pharmacy and could allow for the spread of smoke and fire in the event of a fire emergency.

Findings:

During fire alarm testing with the Plumber II, Director of Facility Management, Officer of Environmental Health and Safety, Alarm Technician, and Quality Analyst, On August 1, 2012 and August 2, 2012, the fire alarm components were tested, observed, and staff was interviewed.

August 1, 2012
Medical Center - Level B floor
1. At 8:47 a.m., the won door, near the Level B south wing visitor elevator, failed to close completely and latch. The door closed approximately 70 percent and stopped.

August 2, 2012
Medical Center - Level A floor
2. At 9:10 a.m., the won door, near Level A Elevators 17 and 18, failed to close completely when the fire alarm system was activated. The won door closed approximately 75 percent and stopped.

At 9:11 a.m., the Alarm technician confirmed the door failed to close.


29566

During fire alarm system testing, with the Safety Technician, on August 1, 2012, the strobes and audio alarm boxes were observed.
August 1, 2012 - Meridian Pharmacy
3. At 10:35 a.m., 3 of 3 audio alarm boxes and strobes failed to activate during testing in the outpatient pharmacy (Meridian Pharmacy) suite.

Based on observation, the facility failed to ensure their sprinkler system had supervised valves in accordance with NFPA 72. This was evidenced by a Post Indicator Valve (PIV) and a control valve on the riser, that were not equipped with a tamper alarm or a supervisory signal. This affected 1 of 1 smoke compartment in the Sleep Disorder Clinic. This could result in a delay in staff response if the water was shut off to the sprinkler system, and the possible failure of the sprinkler system to activate in the event of a fire.

NFPA 101 Life Safety Code 2000 Edition
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 72 National Fire Alarm Code 1999 Edition
1-5.4.4 Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

3-8.3.3.1 General. The provisions of 3-8.3.3 shall apply to the monitoring of sprinkler systems, other fire suppression systems, and other systems for the protection of life and property for the initiation of a supervisory signal indicating an off-normal condition that could adversely affect the performance of the system.

Findings:

During the facility tour with facility staff on August 1, 2012, the automatic sprinkler system was tested.

Sleep Disorder Clinic

At 2:22 p.m., there was no tamper or supervisory alarm on the PIV located in front of the building, or the riser water valve located in a locked room in front of the building. When the valves were closed no tamper alarm or supervisory signal was initiated at the panel or at an off site monitoring location.

August 2, 2012 - Sleep Center
At 11:23 a.m., during record review, no documentation was provided for quarterly sprinkler testing, during 4 of 4 quarters, at the Sleep Center.

At 1:34 p.m., during an interview, the Fire Safety Technician stated that property management staff was on vacation. He stated he would try to get the documentation by Monday August 6, 2012.

On August 6, 2012, at 12:00 p.m., no documentation was provided by the facility for quarterly testing of the sprinkler system, at the Sleep Center.



29566

July 30, 2012 - Cardiac Imaging Clinic, Suite 105

At 3:40 p.m., the sprinkler head in Room 119 (storage room) was obstructed by boxes and linens located on the top shelf. The boxes and linens were less than 2 inches directly below the sprinkler deflector.

July 31, 2012 - Outpatient Surgery center buildings (2 Buildings- multiple departments)

At 11:01 a.m., 1 of 2 sets of fire department connections, at the front of the surgery center buildings, did not rotate when tested. The couplings or swivels did not rotate.


29626

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by a damaged sprinkler, by no documented evidence for quarterly sprinkler testing for 4 of 4 quarters at the sleep center, by an impeded sprinkler head in the Cardiac Imaging Clinic, by the failure to maintain fire department connections, and by no key to unlock and test the Post Indicator Valve (PIV). This affected 1 of 6 smoke compartments at the East Campus Hospital, the entire Sleep Center, the Cardiac Imaging Clinic, 3 of 3 smoke compartments at the Heart and Surgical Hospital, and 1 of 2 Outpatient Surgery Center buildings. This could result in the failure of the sprinkler system in the event of a fire, and could delay access to the fire department connections, increasing the risk of harm to patients, visitors, and staff.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

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.

NFPA 13, Standard for the 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.

Findings:

During a tour of the facility with hospital staff on August 1, 2012 and August 2, 2012, the sprinkler system was tested and observed, and testing documents were requested.

August 1, 2012 - East Campus Hospital
At 11:21 a.m., the sprinkler head deflector was damaged and bent, in the room containing the Fire Alarm Control Panel . The deflector creates the water spray pattern when the sprinkler is activated.

NFPA 25, Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection System, 1998 Edition
9-7.1 Fire department connections shall be inspected quarterly.
The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly

July 31, 2012 - Heart and Surgical Hospital

At 2:45 p.m., there were bushes, (ground landscaping), blocking access to the fire department connections outside of the Heart and Surgical Hospital. The bushes were approximately 1.5 feet thick and reached approximately half way up the pipe.

At 2:46 p.m., staff was unable to test the PIV because the key was not available to unlock the lock.

At 3:30 p.m., a key was located and the PIV was tested.

Based on observation, the facility failed to maintain their gas cylinders in accordance with NFPA 99. This was evidenced by an unsecured gas cylinder in one area. This affected 1 of 3 suites in the Outpatient Imaging Center. This had the potential for the cylinder to get damaged.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

During a tour of the facility with the hospital staff, the medical gas cylinders were observed.

August 2, 2012 - Outpatient Imaging Center at 25455 Barton Road

At 10:54 a.m., the MRI control room had a storage area with a H-sized (approximately 250 cubic feet) cylinder laying on the floor. There was no tag on the cylinder to identify the type of gas. The MRI staff confirmed that the cylinder contained helium gas.

Based on observation, the facility failed to maintain their emergency oxygen shut off valves, as evidenced by an emergency oxygen valve that was impeded from view and access. This could delay access to shut off oxygen in the event of a fire emergency. This affected 1 of 9 floors at the Medical Center.

NFPA 99 Standard for Healthcare Facilities, 1999 Edition
4-3.1.2.3 Gas Shutoff Valves, Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled "SOURCE VALVE FOR THE (SOURCE NAME)."
(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings:

During a tour of the facility with the Plumber II, Director of Facility Management, Office of Environmental Health and Safety staff, and Quality Analyst, from July 30, 2012, through August 2, 2012, the oxygen shut off valves were observed.

July 30, 2012
Medical Center - Fourth floor
At 2:40 p.m., there was a coat and coat rack impeding the view and access to an emergency oxygen shut off valve in Room 4727.

July 30, 2012
Medical Center - Ninth floor

At 10:43 a.m., there was no clearance around the electrical panel 9N2 in room 9114. The panel was marked "Maintain a 36 inch clearance." There was a laundry cart stored in front of the electrical panel.

At 10:44 a.m., there was no clearance around the electrical panel 9E2 in room 9114. There was a computer on wheels stored in front of the electrical panel. The panel was marked "Maintain a 36 inch clearance."

At 11:11 a.m., there was a refrigerator and an extension cord plugged into a surge protector in room 9020.




26387

Based on observation and interview, the facility failed to maintain their electrical system, as evidenced by unmarked circuit breakers, by the use of extension cords, by appliances plugged into surge protectors, by failing to maintain a 36 inch clearance around electrical panels, and by failing to protect energized parts. This increased the risk for electrical shock or fire and could delay staff from shutting off electrical power in an emergency. This affected 4 of 9 floors in the Medical Center and 1 of 6 smoke compartments at the East Campus Hospital.

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

110.32 Work Space About Equipment
Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall no be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 feet (914 m) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34 (a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or board.

240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

400-8. Uses Not Permitted.
400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(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

Findings:

During a tour of the facility with the Plumber II, Director of Facility Management, Office of Environmental Health and Safety staff, and Quality Analyst, from July 30, 2012, through August 2, 2012, the electrical system and wiring was observed.

July 30, 2012
Medical Center - Eighth floor

At 10:35 a.m., there were 7 of 21 circuits in an electrical Panel 8E4 in the on position in Room 8001A. Circuits 9, 11, 13, 15, 17, 19, and 21 were unidentified.

At 10:36 a.m., the Director of Facility Management stated during an interview "I do not know what those circuits are connected to."

Medical Center - Fifth floor

At 2:07 p.m., there was an orange extension cord plugged into a Workstation on Wheels, in Room 12, in the 5200 wing.

July 31, 2012
Medical Center - Second floor

At 10:38 a.m., there were two uncovered electrical receptacles under the Pharmacy Reception desk in the second floor Pharmacy.


29626


August 1, 2012 - East Campus Hospital.

At 2:17 p.m., there was a blank circuit in spot number 20, with no cover to protect its energized parts, in Circuit Panel "L," located in the Operating Room corridor.

At 2:18 p.m., there was a blank circuit in spot number 16, with a loose cover, that did not fully protect its energized parts, in Circuit Panel "ED" located in the Operating Room corridor.

July 31, 2012 - Heart and Surgical Hospital
At 3:40 p.m., there was an approximately 1/2 inch unsealed penetration around the overhead light and monitoring equipment, in the ceiling of Operating Room 2.

Based on observation, the facility failed to maintain the integrity of the walls and ceiling, as evidenced by two penetration in the ceilings. This affected 1 of 2 smoke compartments in the Pediatric Speciality Team Center and 1 of 3 smoke compartments on the lower level of the Heart and Surgical Hospital. This could result in the spread of smoke and fire and increase the risk of injury to patients and staff in the event of a fire.

Findings:

During the facility tour with Safety Technician on July 30, 2012, and July 31, 2012, the ceilings were observed in two offsite locations.

Pediatric Speciality Team Center
At 4:20 p.m., there were two approximately 1/2 inch penetrations, around 2 conduits, in the ceiling of the Receiving Room.

Based on observation, the facility failed to maintain the integrity of the building construction of corridor walls. This was evidenced by two penetrations in corridor walls, affecting 1 of 6 smoke compartments at the East Campus Hospital. This could result in the spread of fire and smoke, potentially harming patients, visitors, and staff evacuating through the corridors.

Findings:

During a tour of the facility with hospital staff on August 1, 2012, the corridor walls were observed at the East Campus Hospital.

At 2:43 p.m., there were two penetrations in the corridor wall by the entrance to the Operating Rooms. The penetrations were located above the drop down tiled ceiling in the wall shared with the storage rooms. The first penetration measured approximately 1-inch in diameter and was by the anchor cable to the ceiling tile. The second penetration measured approximately 2-inches around electrical conduits.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by corridor doors that failed to close and latch, and by corridor doors that were impeded from closing. This affected 4 of 9 floors in the Medical Center and would allow the spread of smoke and fire to other areas in the building.

Findings:

During a tour of the facility with the Plumber II, Director of Facility Management, Office of Environmental Health and Safety, and Quality Analyst from July 30, 2012, through August 2, 2012, the corridor doors were observed.

July 30, 2012
Medical Center - Seventh floor
At 1:11 p.m., the corridor door to Room 7212 was impeded from closing by a Workstation on Wheels (WOW) that was in the door way.

Medical Center - Fourth floor
At 2:49 p.m., the self-closing corridor door to Room 4835 failed to latch when closed.

July 31, 2012
Medical Center - Fourth floor
At 3:36 p.m., the self-closing corridor door to Room 4770 failed to close and latch.

During an interview at 3:37 p.m., the Environmental Health and Safety Officer stated" the closure arm has been disconnected to the door."

August 1, 2012
Medical Center - Second floor
At 9:19 a.m., the two roll down doors were impeded from closing, at Radiology, near Room 2221. The front door was impeded by a coffee size can placed in the door's path. The side door was impeded by a 4 inch by 5 inch box.

August 1, 2012
Medical Center - Third floor
At 10:24 a.m., the corridor door, to Nursing Station Triage (near Room 3000), was impeded from closing by a refrigerator that was in front of the door.

August 2, 2012
Medical Center - Level A Basement
At 8:35 a.m., the door to Room A-323 in the Emergency Room was impeded from closing by two chairs.

At 8:36 a.m., the Office of Environmental Health and Safety person stated, "I see that the door is blocked."

Based on observation, the facility failed to maintain smoke barrier doors held open by magnetic devices. This was evidenced by doors that failed to release from the magnets when the fire alarm system was activated. This affected 1 of 6 smoke compartments at the East Campus Hospital. This could result in the spread of fire and smoke to other smoke compartments, increasing the risk of harm to the patients, visitors, and staff.

Finding:

During a tour of the facility with the hospital staff on August 1, 2012, the cross-corridor fire doors were observed.

August 1, 2012 - East Campus Hospital

At 1:51 p.m., 1 of 2 cross-corridor doors, located by Room 229, failed to release from the magnet hold open device. The door failed to release and self-close when the fire alarm was activated.
At 1:52 p.m., the fire alarm was activated a second time. The same door failed to release and self-close.

Based on observation and interview, the facility failed to maintain their smoke barrier walls, as evidenced by smoke barrier walls with penetrations. This would allow the spread of smoke and fire to other compartments within the buildings. This affected 2 of 9 floors in the Medical Center, 2 of 6 smoke compartments at the East Campus Hospital, the Outpatient Diabetic Treatment Center, and two of two smoke compartments in the Pediatric Specialty Building.

Findings:

NFPA 101 Life Safety Code, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke 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 smoke barrier, the sleeve shall be solidly set in the smoke 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 smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Plumber II, Director of Facility Management, Officer of Environmental Health and Safety, Safety Technician and Quality Analyst, from July 30, 2012, through August 2, 2012, the smoke barrier walls were observed in the hospital and out buildings.

July 31, 2012
Medical Center - Third floor
At 9:25 a.m., there was an approximate 6 inch by 6 inch unsealed penetration in the smoke barrier wall between the elevator lobby and Room 3400 on the third floor.

At 9:26 a.m., the Director of Facility Management confirmed during an interview, "I agree that the hole is about 6 by 6 inches."

At 9:47 a.m., there was an approximate 5 foot by 3 foot unsealed penetration in the smoke barrier wall near the South entrance to 3800. The drywall was missing on the south side of the entrance.

August 1, 2012
Medical Center - Second floor
At 9:49 a.m., there was an approximately 2 inch by 3 inch unsealed penetration in the smoke barrier wall on the second floor near the entrance to the Surgery Unit.

At 9:50 a.m., the Director of Facility Management confirmed the penetration.

At 10:15 a.m., there was an approximately 3 inch unsealed pipe in the smoke barrier wall near Room 2712 on the second floor.


29566

During a tour of facility with the Safety Technician on July 30, 2012, the smoke barrier walls were observed in the Outpatient Diabetic Treatment Center.

At 3:10 p.m., there was missing sheet rock in the smoke barrier wall in the attic space near Room 3. The open area measured 1 1/2 by 3 feet.


August 1, 2012 - Pediatric Speciality Team Center.

At 2:55 p.m., above Room 17, there was a penetration around a one inch copper pipe in the draft stop barrier.

At 3:05 p.m., there was a one inch penetration in the smoke barrier wall by the restroom.


29626

August 1, 2012 - East Campus Hospital.

At 11:14 a.m., there was an approximately 2 by 1 inch penetration, in the smoke barrier wall by the exit door leading into the Healing Garden. There was red colored caulking material surrounding the penetration in the attic space.

Based on observation and interview, the facility failed to maintain their smoke barrier doors to prevent the spread of smoke and fire. This was evidenced by smoke barrier doors that were equipped with latching hardware, that failed to close and latch. This could allow the spread of smoke and fire to other compartments and cause potential harm to patients. This affected 2 of 9 floors within the Medical Center, 1 of 3 fire doors separating smoke compartments at the 1500 Unit, East Campus Hospital, and 2 of 2 smoke compartments in the Heart and Surgical Hospital.

Findings:

During fire alarm testing with the Plumber II, Director of Facility Management, Office of Environmental Health and Safety staff, and Quality Analyst, on August 1, 2012 and August 2, 2012, the smoke barrier doors were tested and observed.

August 1, 2012
Medical Center - First floor
At 1:24 p.m., the smoke barrier doors (both) failed to latch, after activation of the fire alarm system, near Elevator 1.

At 1:55 p.m., the South smoke barrier door, near Elevators 17 and 18, failed to latch after activation of the fire alarm system.

During an interview, at 1:56 p.m., the Director of Facility Management stated he thought this was an air handling issue.

August 2, 2012
Medical Center - Level B floor
At 10:08 a.m., the smoke barrier door near Room B255 failed to close completely and latch.

At 10:34 a.m., the East smoke barrier door failed to latch after activation of the fire alarm system, near the Nuclear Med Lobby, level B.

At 10:35 a.m., during an interview, the Director of Facility Management stated he thought this was an air handling issue.


29626

August 1, 2012
1500 Unit - East Campus Hospital

At 3:41 p.m., 1 of 2 cross-corridor fire doors, located by Room 1508, failed to fully close and positive latch upon activation of the fire alarm system. The fire alarm was activated a second time at 3:45 p.m. The cross-corridor smoke barrier doors failed to close and positive latch.

During facility alarm testing with Facilities staff on July 31, 2012, the smoke barrier door was observed in the Heart & Surgical Hospital.

At 2:01 p.m., the smoke barrier door by Room 2120 failed to release and close during fire alarm testing.

Based on observation, the facility failed to protect a hazardous area as evidenced by one oxygen storage room door that failed to close and latch. This affected 1 of 2 floors in the Outpatient Surgical Center. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

National Fire Prevention Association 101, Life Safety Code 2000 Edition:
19.3.2.1 Hazardous Areas. Any Hazardous area shall be safe-guarded by a fire barrier having a 1 -hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic closing. Hazardous areas shall include, but shall not be restricted to, the following:

(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square ft (9.3 square m)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square ft ( 4.6 square m), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory-or field -applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a tour of the facility with the Safety Technician on July 31, 2012, the oxygen storage room was observed.

July 31, 2012 - Outpatient Surgical Center

At 11:40 a.m., the door to the piped in gas room, failed to close and latch. The med gas room is located off the corridor, in the basement (lower floor).

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by emergency lighting units that failed to illuminate when tested. This affected 1 of 3 lighting units in the Outpatient Imaging Center. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors.

NFPA 101 Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with hospital staff, the emergency lighting units were observed and tested in the Outpatient Imaging Center at 25455 Barton Road.

August 2, 2012

At 11:06 a.m., the emergency lighting unit failed to illuminate when tested, for the light located by the entrance to CT Imaging 103B.

Based on observation and interview, the facility failed to maintain their exit signs, as evidenced by an exit sign that failed to indicate the direction to egress. This could delay evacuation and cause potential harm to patients in the event of a fire emergency. This affected 1 of 9 floors in the Medical Center.

Findings:

During a tour of the facility with the Plumber II, Director of Facility Management, Office of Environmental Health and Safety staff, and Quality Analyst, on August 1, 2012, the exit signs were observed in the Medical Center.

Medical Center - Second floor
At 9:30 a.m., there was an exit sign on the west side of Room 2602, without directional guidance (an arrow) to indicate the exit path. The sign was at the end of a hallway with options to turn left or right. The right turn would lead to the exit door.

During an interview, at 9:31 a.m., the Director of Facility Management confirmed the sign failed to provide the direction to egress.

Based on observation and interview, the facility failed to maintain their fire alarm system in accordance with NFPA 72. This was evidenced by won doors that failed to close, and by strobes and audio devices that failed during alarm testing. This affected 2 of 9 floors and the pharmacy and could allow for the spread of smoke and fire in the event of a fire emergency.

Findings:

During fire alarm testing with the Plumber II, Director of Facility Management, Officer of Environmental Health and Safety, Alarm Technician, and Quality Analyst, On August 1, 2012 and August 2, 2012, the fire alarm components were tested, observed, and staff was interviewed.

August 1, 2012
Medical Center - Level B floor
1. At 8:47 a.m., the won door, near the Level B south wing visitor elevator, failed to close completely and latch. The door closed approximately 70 percent and stopped.

August 2, 2012
Medical Center - Level A floor
2. At 9:10 a.m., the won door, near Level A Elevators 17 and 18, failed to close completely when the fire alarm system was activated. The won door closed approximately 75 percent and stopped.

At 9:11 a.m., the Alarm technician confirmed the door failed to close.


29566

During fire alarm system testing, with the Safety Technician, on August 1, 2012, the strobes and audio alarm boxes were observed.
August 1, 2012 - Meridian Pharmacy
3. At 10:35 a.m., 3 of 3 audio alarm boxes and strobes failed to activate during testing in the outpatient pharmacy (Meridian Pharmacy) suite.

Based on observation, the facility failed to ensure their sprinkler system had supervised valves in accordance with NFPA 72. This was evidenced by a Post Indicator Valve (PIV) and a control valve on the riser, that were not equipped with a tamper alarm or a supervisory signal. This affected 1 of 1 smoke compartment in the Sleep Disorder Clinic. This could result in a delay in staff response if the water was shut off to the sprinkler system, and the possible failure of the sprinkler system to activate in the event of a fire.

NFPA 101 Life Safety Code 2000 Edition
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 72 National Fire Alarm Code 1999 Edition
1-5.4.4 Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

3-8.3.3.1 General. The provisions of 3-8.3.3 shall apply to the monitoring of sprinkler systems, other fire suppression systems, and other systems for the protection of life and property for the initiation of a supervisory signal indicating an off-normal condition that could adversely affect the performance of the system.

Findings:

During the facility tour with facility staff on August 1, 2012, the automatic sprinkler system was tested.

Sleep Disorder Clinic

At 2:22 p.m., there was no tamper or supervisory alarm on the PIV located in front of the building, or the riser water valve located in a locked room in front of the building. When the valves were closed no tamper alarm or supervisory signal was initiated at the panel or at an off site monitoring location.

August 2, 2012 - Sleep Center
At 11:23 a.m., during record review, no documentation was provided for quarterly sprinkler testing, during 4 of 4 quarters, at the Sleep Center.

At 1:34 p.m., during an interview, the Fire Safety Technician stated that property management staff was on vacation. He stated he would try to get the documentation by Monday August 6, 2012.

On August 6, 2012, at 12:00 p.m., no documentation was provided by the facility for quarterly testing of the sprinkler system, at the Sleep Center.



29566

July 30, 2012 - Cardiac Imaging Clinic, Suite 105

At 3:40 p.m., the sprinkler head in Room 119 (storage room) was obstructed by boxes and linens located on the top shelf. The boxes and linens were less than 2 inches directly below the sprinkler deflector.

July 31, 2012 - Outpatient Surgery center buildings (2 Buildings- multiple departments)

At 11:01 a.m., 1 of 2 sets of fire department connections, at the front of the surgery center buildings, did not rotate when tested. The couplings or swivels did not rotate.


29626

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by a damaged sprinkler, by no documented evidence for quarterly sprinkler testing for 4 of 4 quarters at the sleep center, by an impeded sprinkler head in the Cardiac Imaging Clinic, by the failure to maintain fire department connections, and by no key to unlock and test the Post Indicator Valve (PIV). This affected 1 of 6 smoke compartments at the East Campus Hospital, the entire Sleep Center, the Cardiac Imaging Clinic, 3 of 3 smoke compartments at the Heart and Surgical Hospital, and 1 of 2 Outpatient Surgery Center buildings. This could result in the failure of the sprinkler system in the event of a fire, and could delay access to the fire department connections, increasing the risk of harm to patients, visitors, and staff.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

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.

NFPA 13, Standard for the 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.

Findings:

During a tour of the facility with hospital staff on August 1, 2012 and August 2, 2012, the sprinkler system was tested and observed, and testing documents were requested.

August 1, 2012 - East Campus Hospital
At 11:21 a.m., the sprinkler head deflector was damaged and bent, in the room containing the Fire Alarm Control Panel . The deflector creates the water spray pattern when the sprinkler is activated.

NFPA 25, Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection System, 1998 Edition
9-7.1 Fire department connections shall be inspected quarterly.
The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly

July 31, 2012 - Heart and Surgical Hospital

At 2:45 p.m., there were bushes, (ground landscaping), blocking access to the fire department connections outside of the Heart and Surgical Hospital. The bushes were approximately 1.5 feet thick and reached approximately half way up the pipe.

At 2:46 p.m., staff was unable to test the PIV because the key was not available to unlock the lock.

At 3:30 p.m., a key was located and the PIV was tested.

Based on observation, the facility failed to maintain their gas cylinders in accordance with NFPA 99. This was evidenced by an unsecured gas cylinder in one area. This affected 1 of 3 suites in the Outpatient Imaging Center. This had the potential for the cylinder to get damaged.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

During a tour of the facility with the hospital staff, the medical gas cylinders were observed.

August 2, 2012 - Outpatient Imaging Center at 25455 Barton Road

At 10:54 a.m., the MRI control room had a storage area with a H-sized (approximately 250 cubic feet) cylinder laying on the floor. There was no tag on the cylinder to identify the type of gas. The MRI staff confirmed that the cylinder contained helium gas.

Based on observation, the facility failed to maintain their emergency oxygen shut off valves, as evidenced by an emergency oxygen valve that was impeded from view and access. This could delay access to shut off oxygen in the event of a fire emergency. This affected 1 of 9 floors at the Medical Center.

NFPA 99 Standard for Healthcare Facilities, 1999 Edition
4-3.1.2.3 Gas Shutoff Valves, Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled "SOURCE VALVE FOR THE (SOURCE NAME)."
(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings:

During a tour of the facility with the Plumber II, Director of Facility Management, Office of Environmental Health and Safety staff, and Quality Analyst, from July 30, 2012, through August 2, 2012, the oxygen shut off valves were observed.

July 30, 2012
Medical Center - Fourth floor
At 2:40 p.m., there was a coat and coat rack impeding the view and access to an emergency oxygen shut off valve in Room 4727.

July 30, 2012
Medical Center - Ninth floor

At 10:43 a.m., there was no clearance around the electrical panel 9N2 in room 9114. The panel was marked "Maintain a 36 inch clearance." There was a laundry cart stored in front of the electrical panel.

At 10:44 a.m., there was no clearance around the electrical panel 9E2 in room 9114. There was a computer on wheels stored in front of the electrical panel. The panel was marked "Maintain a 36 inch clearance."

At 11:11 a.m., there was a refrigerator and an extension cord plugged into a surge protector in room 9020.




26387

Based on observation and interview, the facility failed to maintain their electrical system, as evidenced by unmarked circuit breakers, by the use of extension cords, by appliances plugged into surge protectors, by failing to maintain a 36 inch clearance around electrical panels, and by failing to protect energized parts. This increased the risk for electrical shock or fire and could delay staff from shutting off electrical power in an emergency. This affected 4 of 9 floors in the Medical Center and 1 of 6 smoke compartments at the East Campus Hospital.

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

110.32 Work Space About Equipment
Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall no be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 feet (914 m) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34 (a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or board.

240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

400-8. Uses Not Permitted.
400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(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

Findings:

During a tour of the facility with the Plumber II, Director of Facility Management, Office of Environmental Health and Safety staff, and Quality Analyst, from July 30, 2012, through August 2, 2012, the electrical system and wiring was observed.

July 30, 2012
Medical Center - Eighth floor

At 10:35 a.m., there were 7 of 21 circuits in an electrical Panel 8E4 in the on position in Room 8001A. Circuits 9, 11, 13, 15, 17, 19, and 21 were unidentified.

At 10:36 a.m., the Director of Facility Management stated during an interview "I do not know what those circuits are connected to."

Medical Center - Fifth floor

At 2:07 p.m., there was an orange extension cord plugged into a Workstation on Wheels, in Room 12, in the 5200 wing.

July 31, 2012
Medical Center - Second floor

At 10:38 a.m., there were two uncovered electrical receptacles under the Pharmacy Reception desk in the second floor Pharmacy.


29626


August 1, 2012 - East Campus Hospital.

At 2:17 p.m., there was a blank circuit in spot number 20, with no cover to protect its energized parts, in Circuit Panel "L," located in the Operating Room corridor.

At 2:18 p.m., there was a blank circuit in spot number 16, with a loose cover, that did not fully protect its energized parts, in Circuit Panel "ED" located in the Operating Room corridor.