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Based on random observation during the survey walk-through, not all exit access corridors have interior finishes verified to be in accordance with 19.3.3. This deficiency could affect all lower level patients in the facility, as well as any staff and visitors present, because the lack of protection for the surfaces could result in fire and smoke compromising the use of the facility's exit access corridors.

Finding include:
A. The main entry Admiting/Registration area open to the corridor has wood paneling which could not be verified to have a minimum Class C finish rating to comply with 19.3.3.2 Exception.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1 or otherwise protected in accordance with the exceptions. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result in smoke compromising the use of the facility's exit access corridors.

Findings include:
A. A waiting area with two chairs is stationed outside Nuclear Med on the upper level which obstructs the 8'-0" corridor and is not provided with smoke detection to comply with 19.3.6.1, Exception No. 2 parts (b) and (c).

B. A weighing station with scales is open to the corridor adjacent the north stair on the upper level which obstructs the 8'-0" corridor and is not provided with smoke detection to comply with 19.3.6.1, Exception No. 1 parts (c) and (d).

C. The lower level X-ray Nurse station is not staffed 24-hours and is open to the corridor without being provided with smoke detection to comply with 19.3.6.1 Exceptions. The area was not otherwise identified as being within a defined suite.

D. The lower level X-ray area dressing/changing rooms are open to the corridor and not provided with smoke detection to comply with 19.3.6.1 Exceptions. The area was not otherwise identified as being within a defined suite.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients on the floor of the facility, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:
A. The Janitor closet door at the upper level Outpatient Clinic lacks a latchset.

B. The upper level Linen Storage room door is not latching. This door also has an unapproved foot peg hold-open device.

C. The ER storage room corridor door is not latching. The Ultrasound room located behind this room does not comply with 7.5.1.7 because the storage room is a hazardous area.

Based on random observation during the survey walk-through, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:
A. Miscellaneous pipe and conduit penetrations were observed not to be sealed in accordance with fire/smoke rated tested design assemblies. Locations observed include but are not necessarily limited to the following:

1. Pipe penetrations at the far east end of the West Penthouse were not protected to afford the required 2-hour rated separation from the floor below.

2. Conduit penetrations at the electrical panels along the south wall of the East Penthouse were not protected to afford the required 2-hour rated separation from the floor below.

3. Duct penetrations at the far east end of the West Penthouse were observed not to have the fire dampers installed within the floor thickness. (These ducts lacked the concrete curbs installed at other ducts.)

4. Duct penetrations for Ref.-4 and Ex.-6 in the East Penthouse could not be verified to have fire dampers because the ducts lacked access doors.

5. The 6" sprinkler main located in the chase behind the Upper Level Outpatient Clinic Medical Records Storage room was not sealed to afford the required 2-hour rated separation from the floor below.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients on the upper and lower levels of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:
A. The sprinklered Soiled Utility room for the ICU/CCU did not have self-closing doors (two doors) to comply with 19.3.2.1(5), 8.4.1.2 and 8.2.4.3.5.

B. The sprinklered ICU #4 room was utilized for storage and did not have a self-closing door to comply with 19.3.2.1(5), 8.4.1.2 and 8.2.4.3.5.

C. The Generator room door closer was disconnected. The required 2-hour separation of the generator was not maintained in accordance with NFPA 110-1999, 5-2.1.

D. Large recycling containers (greater than 32 gal. capacity) were observed stationed in exit access corridors near Administration offices and the CT Scan room in non-compliance with 19.7.5.5.

E. The corridor door at the Ambulance garage was observed to have the fire rating label painted. Verification of the required 1 1/2-hour rating for the door in the designated 2-hour wall was not possible.

Based on random observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4. Locations observed include but are not necessarily limited to the following:

1. At the upper level Nurse Managers offiice near ICU/CCU.

2. At upper level Outpatient Clinic Clean Utility.

3. At upper level Outpatient Clinic Doctor's Dictation.

4. At upper level Outpatient Clinic two Exam rooms.

5. At upper level Outpatient Clinic room adjacent Nuclear Med.

6. At upper level Nuclear Med room.

7. At the upper level toilet room between the Outpatient Clinic room and the Nuclear Med. room, One door has a dead bolt and latch and the other door has a slide bolt and a latch.

8. At both sets of the cross corridor doors exiting surgery.

9. At the lower level main entry horizontal sliding doors. The dead bolt prevents the operation of the break and swing feature.

Based on random observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:
A. Not all exterior exit discharge doors are provided with lighting to comply with 7.8.1.4 because two fixtures or two lamps are not provided that are of the incandescent, fluorescent, quartz, LED or similar instant-on type lamp. Single lamp fixtures or a combination of fixtures in which the lighting was of the HID (High Intensity Discharge) type were observed. Locations observed include but are not necessarily limited to the following:

1. At the west stair discharge, one fluorescent & one HID.

2. At the west stair adjacent the Ambulance garage, two HID.

3. At the Stair #2 discharge, one fluorescent & one HID.

4. At the north stair discharge, pole lights are Metal Halide type.

Based on random observation and document review during the survey walk-through not all portions of the facility's emergency battery powered lighting are tested and maintained in accordance with NFPA 101 2000.

Findings include:
A. The emergency light located in the emergency generator room did not light when the test switch was pushed in. During an interview held at the location on January 24, 2012 in was discovered the facility did not have a testing schedule in accordance with 7-9.3.

1. Monthly for 30 seconds.

2. Annually for 90 minutes.

Failure of the fixture could cause injury to staff due to darkness in the area.

B. During document review, a "Maintenance Program Inspection Schedule" checklist was reviewed that indicated "Means of egress- illumination devices functioning (battery powered emergency lighting)" was signed as being checked on 1-4-11, 5-31-11, 9-30-11 and 12-7-11 but the Director of Maintenance indicated the no battery powered lighting was in use at the facility.

Based on random observation during the survey walk-through, exit signs did not identify available paths of egress in all cases in accordance with 19.2.5.9, 19.2.10.1. and 7.10. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the smoke compartment or building.

Findings include:
A. Exit signage was not provided at the following locations to identify the available egress paths:

1. At the north end of the upper level Outpatient Clinic near the nurse station as viewed from the south.

2. At the east end of the upper level Outpatient Clinic west of the single swing cross corridor doors as viewed from the west.

3. At the west end of the lower level corridor near the Kitchen as viewed from the east.

4. At the east end of the lower level Ramp corridor leading from Administration.

Based on record review it was determined that the facility failed to document that fire drills are being conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required. Fire drills are not being held at unexpected times under varying conditions, at least quarterly on each shift.

Findings include:
A. During a record review it was determined that quarterly fire drills do not meet the requirement of varying conditions (times) in all shifts throughout the annual cycle. NFPA 101 Section 19.7.1.2 requires varying times per shift to be documented.

1. Fire drill documentation recorded times did not consistantly differienciate between AM and PM times. Therefore, it was difficult to discern from the records how each of the two shifts were being covered.

2. Documentation for the first shift (7am-7pm) was not available for the 2nd quarter of 2011.

3. The drills conducted within 1 hour after midnight are consistantly "silent" alarms. Other 2nd shift drills are consistantly between 7pm and 1am. No drills appear to be conducted nearer to the end of the 2nd shift.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are maintained in accordance with 19.3.4.

Findings include:
A. On the morning of the survey, the fire alarm panel was indicated to be in the alarm condition. Service technicians had been called to repair the system. No testing of the fire alarm system was conducted during the survey due to the technician still working on repairs at the time of surveyor exit. Testing of the fire alarm system will require testing upon a follow-up survey.

Based on random observation during the survey walk-through on January 24, 2012 not all portions of the facility's fire alarm system are installed in accordance with NFPA 70 and 72 1999.

Findings include:
A. During the building walk-through smoke detectors were observed less than 3' from diffusers in multiple locations and not in accordance with NFPA 72, 2-3.5.1. The deficiencies could cause injury due to fire alarm devices not alarming. Areas included, but may not be limited to include:

1. At the admitting area near the main entrance.

2. At the corner room with windows being remodeled in the lower level near the main entrance.

3. In the corridor near respiratory therapy on the upper level.

B. During the walk-through of the upper level near the 2-hour fire barrier doors near ICU a conduit was observed with a red fire alarm cable wire tied to it and not supported by the structure in accordance with NFPA 70 760-54. Similar support of fire alarm wiring may exist throughout the building.

Based on random observation during the survey walk-through, not all portions of the facility's sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:
A. During the penthouse walk-through on January 24, 2012, not all ductwork connected to ASU 5 over 48" wide are provided with sprinkler coverage under the duct in accordance with 5-5.5.3.1.

This deficiency could cause smoke to develop and injure patients and staff due to lack of water at the source of the fire.

B. Sidewall sprinklers installed at typical patient room locations were observed to be obstructed by bracket mounted televisions. Deficiency compromises the coverage and effectiveness of the sprinkler system.

C. Ceiling tile was observed to be removed where no workmen were performing work. The removed tile compromises the effectiveness of the sprinkler system by allowing heat to escape to the above ceiling cavity reducing the activation time of the sprinkler head. Locations observed include:

1. At the lower level Food Storage room.

2. At the lower level Elevator Pump room.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:
A. Medical gas tanks were observed being stored with combustibles within 5'-0" not in compliance with NFPA 99-1999, 8-3.1.11.2(c)(2). This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials. Locations observed include but are not necessarily limited to the following:

1. At the Respiratory Therapy storage room.

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through of the lower level a 3/8" copper line was observed to be silver brazed and marked with green tape. During an interview held at that location the Director of Maintenance indicated he was not sure what it served. If verified to be a piped medical gas line the installation requirements of NFPA 99 Chapter 4 must be complied with.

Based on random observation during the survey walk-through not all portions of the facility's Type 1 emergency system are installed in accordance with NFPA 99-1999 and NFPA 110-1999.

Findings include:
A. At the generator location it was discovered the generator was not provided with a battery powered emergency light connected to the load side of the transfer switch in accordance with NFPA 99, 3-4.2.2.2 (b).

B. At the generator location it was discovered the generator was not provided with a duplex outlet connected to the load side of the transfer switch in accordance with NFPA 99, 3-4.2.2.2 (b).

C. The generator was observed with wires connected to the battery terminals other than the starting cables for the generator in accordance with NFPA 110, 5-12.6.

D. The generator room was observed with duct work and other supplies stored in the room and not in accordance with NFPA 110, 5-11.1.

These deficiencies could cause a delay in trouble shooting of a problem with the generator or compromise the starting condition of the generator resulting in injury to patients.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through of the laboratory area, not all portions of laboratory safety devices are installed in accordance with NFPA 99 1999 10-6.

Findings include:

A. The eye wash appeared to be mounted on a sink gooseneck faucet without pressure and temperature adjusting devices.

B. The emergency shower did not appear to have a floor receptor installed and/or was mounted over the top of equipment.

These deficiencies could result in staff injury due to injurious water pressure/temperature and inaccessibility for use of the safety devices.

Based on random observation and document review during the survey walk-through on January 24, 2012, not all portions of the facility's emergency electrical system are tested and maintained in accordance with NFPA 99-1999 and NFPA 110-1999.

Findings include:
A. During the morning record review process, records were found to be incomplete for the following equipment for the Level 1 emergency electrical system. The following items were identified:

1. Records were incomplete for 12 consecutive months of the 450 KW generator under load conditions in accordance with NFPA 110, 6-4.1.

2. Records were incomplete for 12 consecutive months of testing the 3 transfer switches in accordance with NFPA 110, 6-4.5.

3. Records were incomplete for 52 consecutive weeks of the visual generator checks in accordance with NFPA 110, 6-3.6 because battery electrolyte levels were not documented.

4. Records failed to show amperage readings for assessing the percentage of load for annual load bank testing in accordance with NFPA 110, 6-4.2.2.

5. Records were not available for annual transfer switch maintenance in accordance with NFPA 110, 6-3.5.

The deficiencies could cause generator failure resulting to injury to patients and staff.

B. During the morning record review process records were found to be incomplete for the following equipment on the level 2 emergency electric system. The following items were identified:

1. Records were incomplete for 12 consecutive month of the 350 KW generator under load conditions in accordance with NFPA 110, 6-4.1.

2. Records were incomplete for 12 consecutive months of testing the transfer switch in accordance with NFPA 110, 6-4.5.

3. Records were incomplete for 52 consecutive weeks of the visual generator checks in accordance with NFPA 110, 6-3.6 because battery electrolyte levels were not documented.

4. Records failed to show amperage readings for assessing the percentage of load for annual load bank testing in accordance with NFPA 110, 6-4.2.

5. Records were not available for annual transfer switch maintenance in accordance with NFPA 110, 6-3.5.

Based on random observation, staff interview and document review, not all portions of the facility's emergency electrical system are identified and maintained in accordance with NFPA 70-1999 and NFPA 99-1999.

Findings include:
A. During the penthouse walk-through, an interview was held with the Director of Maintenance on how the facility identified electric panels on the emergency electrical system and the reply was not descriptive of how they were identified. During the survey walk-through the emergency electric system was not identified consistently in accordance with NFPA 99, 3-4.2.2.2 and NFPA 70, 517-30(c) for the 3 branches of Life Safety, Critical and Equipment branch.

B. During the survey walk-through of critical care areas as defined in NFPA 99, outlets connected to the emergency electrical system were not labeled consistently in accordance with NFPA 70, 517-19 as to the panel and circuit number serving the outlet.

C. During the document review records for testing Line Isolation Monitors (LIM), monthly in accordance with NFPA 99, 3-3.3.3.4.2(b).

D. LIM 3ME 2101 observed in the operating room area, test switch did not work when depressed showing it in need of repair in accordance with NFPA 99, 3-3.3.4.2(c).

E. The 3 transfer switches connected to the 450 KW generator did not have a green light illuminated to show connection to the normal electric system and therefore in need of repair in accordance with NFPA 110, 4-2.4.11.

F. Patient rooms on the upper level was observed without an emergency circuit serving an outlet in the room in accordance with NFPA 70, 517-18.

G. During the survey walk-through of the Emergency Room bed location 2 was observed with only emergency power outlets and no normal power outlets in accordance with NFPA 70, 517-19(a).

H. During the survey walk-through of the Emergency Room bed location 2 was observed with four receptacles and not six in accordance with NFPA 70, 517-19(b).

The deficiencies listed above could cause injury to patients and staff due to equipment failure.

Based on random observation during the survey walk-through, not all portions of the facility's normal electrical system are installed and maintained in accordance with NFPA 70-1999.

Findings include:
A. During the walk-through of the mechanical penthouse an electric panel (BPPH-A) was observed without a blank off cover to protect staff from coming in contact with live buss bars in accordance with 70 110-12(a).

B. Electrical box covers were observed to be missing and not in compliance with NFPA 70, 370-25. Deficiencies expose persons to electrical shock. Locations observed include:

1. At the Mechanical Penthouse near the Seimans CWP-7 disconnect.

2. At the Mechaincal Penthouse below Panel BPEM-PH.

3. At the upper level on the east side of the smoke barrier near room 203.

Based on random observation during the survey walk-through, not all exit access corridors have interior finishes verified to be in accordance with 19.3.3. This deficiency could affect all lower level patients in the facility, as well as any staff and visitors present, because the lack of protection for the surfaces could result in fire and smoke compromising the use of the facility's exit access corridors.

Finding include:
A. The main entry Admiting/Registration area open to the corridor has wood paneling which could not be verified to have a minimum Class C finish rating to comply with 19.3.3.2 Exception.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1 or otherwise protected in accordance with the exceptions. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result in smoke compromising the use of the facility's exit access corridors.

Findings include:
A. A waiting area with two chairs is stationed outside Nuclear Med on the upper level which obstructs the 8'-0" corridor and is not provided with smoke detection to comply with 19.3.6.1, Exception No. 2 parts (b) and (c).

B. A weighing station with scales is open to the corridor adjacent the north stair on the upper level which obstructs the 8'-0" corridor and is not provided with smoke detection to comply with 19.3.6.1, Exception No. 1 parts (c) and (d).

C. The lower level X-ray Nurse station is not staffed 24-hours and is open to the corridor without being provided with smoke detection to comply with 19.3.6.1 Exceptions. The area was not otherwise identified as being within a defined suite.

D. The lower level X-ray area dressing/changing rooms are open to the corridor and not provided with smoke detection to comply with 19.3.6.1 Exceptions. The area was not otherwise identified as being within a defined suite.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients on the floor of the facility, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:
A. The Janitor closet door at the upper level Outpatient Clinic lacks a latchset.

B. The upper level Linen Storage room door is not latching. This door also has an unapproved foot peg hold-open device.

C. The ER storage room corridor door is not latching. The Ultrasound room located behind this room does not comply with 7.5.1.7 because the storage room is a hazardous area.

Based on random observation during the survey walk-through, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:
A. Miscellaneous pipe and conduit penetrations were observed not to be sealed in accordance with fire/smoke rated tested design assemblies. Locations observed include but are not necessarily limited to the following:

1. Pipe penetrations at the far east end of the West Penthouse were not protected to afford the required 2-hour rated separation from the floor below.

2. Conduit penetrations at the electrical panels along the south wall of the East Penthouse were not protected to afford the required 2-hour rated separation from the floor below.

3. Duct penetrations at the far east end of the West Penthouse were observed not to have the fire dampers installed within the floor thickness. (These ducts lacked the concrete curbs installed at other ducts.)

4. Duct penetrations for Ref.-4 and Ex.-6 in the East Penthouse could not be verified to have fire dampers because the ducts lacked access doors.

5. The 6" sprinkler main located in the chase behind the Upper Level Outpatient Clinic Medical Records Storage room was not sealed to afford the required 2-hour rated separation from the floor below.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients on the upper and lower levels of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:
A. The sprinklered Soiled Utility room for the ICU/CCU did not have self-closing doors (two doors) to comply with 19.3.2.1(5), 8.4.1.2 and 8.2.4.3.5.

B. The sprinklered ICU #4 room was utilized for storage and did not have a self-closing door to comply with 19.3.2.1(5), 8.4.1.2 and 8.2.4.3.5.

C. The Generator room door closer was disconnected. The required 2-hour separation of the generator was not maintained in accordance with NFPA 110-1999, 5-2.1.

D. Large recycling containers (greater than 32 gal. capacity) were observed stationed in exit access corridors near Administration offices and the CT Scan room in non-compliance with 19.7.5.5.

E. The corridor door at the Ambulance garage was observed to have the fire rating label painted. Verification of the required 1 1/2-hour rating for the door in the designated 2-hour wall was not possible.

Based on random observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4. Locations observed include but are not necessarily limited to the following:

1. At the upper level Nurse Managers offiice near ICU/CCU.

2. At upper level Outpatient Clinic Clean Utility.

3. At upper level Outpatient Clinic Doctor's Dictation.

4. At upper level Outpatient Clinic two Exam rooms.

5. At upper level Outpatient Clinic room adjacent Nuclear Med.

6. At upper level Nuclear Med room.

7. At the upper level toilet room between the Outpatient Clinic room and the Nuclear Med. room, One door has a dead bolt and latch and the other door has a slide bolt and a latch.

8. At both sets of the cross corridor doors exiting surgery.

9. At the lower level main entry horizontal sliding doors. The dead bolt prevents the operation of the break and swing feature.

Based on random observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:
A. Not all exterior exit discharge doors are provided with lighting to comply with 7.8.1.4 because two fixtures or two lamps are not provided that are of the incandescent, fluorescent, quartz, LED or similar instant-on type lamp. Single lamp fixtures or a combination of fixtures in which the lighting was of the HID (High Intensity Discharge) type were observed. Locations observed include but are not necessarily limited to the following:

1. At the west stair discharge, one fluorescent & one HID.

2. At the west stair adjacent the Ambulance garage, two HID.

3. At the Stair #2 discharge, one fluorescent & one HID.

4. At the north stair discharge, pole lights are Metal Halide type.

Based on random observation and document review during the survey walk-through not all portions of the facility's emergency battery powered lighting are tested and maintained in accordance with NFPA 101 2000.

Findings include:
A. The emergency light located in the emergency generator room did not light when the test switch was pushed in. During an interview held at the location on January 24, 2012 in was discovered the facility did not have a testing schedule in accordance with 7-9.3.

1. Monthly for 30 seconds.

2. Annually for 90 minutes.

Failure of the fixture could cause injury to staff due to darkness in the area.

B. During document review, a "Maintenance Program Inspection Schedule" checklist was reviewed that indicated "Means of egress- illumination devices functioning (battery powered emergency lighting)" was signed as being checked on 1-4-11, 5-31-11, 9-30-11 and 12-7-11 but the Director of Maintenance indicated the no battery powered lighting was in use at the facility.

Based on random observation during the survey walk-through, exit signs did not identify available paths of egress in all cases in accordance with 19.2.5.9, 19.2.10.1. and 7.10. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the smoke compartment or building.

Findings include:
A. Exit signage was not provided at the following locations to identify the available egress paths:

1. At the north end of the upper level Outpatient Clinic near the nurse station as viewed from the south.

2. At the east end of the upper level Outpatient Clinic west of the single swing cross corridor doors as viewed from the west.

3. At the west end of the lower level corridor near the Kitchen as viewed from the east.

4. At the east end of the lower level Ramp corridor leading from Administration.

Based on record review it was determined that the facility failed to document that fire drills are being conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required. Fire drills are not being held at unexpected times under varying conditions, at least quarterly on each shift.

Findings include:
A. During a record review it was determined that quarterly fire drills do not meet the requirement of varying conditions (times) in all shifts throughout the annual cycle. NFPA 101 Section 19.7.1.2 requires varying times per shift to be documented.

1. Fire drill documentation recorded times did not consistantly differienciate between AM and PM times. Therefore, it was difficult to discern from the records how each of the two shifts were being covered.

2. Documentation for the first shift (7am-7pm) was not available for the 2nd quarter of 2011.

3. The drills conducted within 1 hour after midnight are consistantly "silent" alarms. Other 2nd shift drills are consistantly between 7pm and 1am. No drills appear to be conducted nearer to the end of the 2nd shift.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are maintained in accordance with 19.3.4.

Findings include:
A. On the morning of the survey, the fire alarm panel was indicated to be in the alarm condition. Service technicians had been called to repair the system. No testing of the fire alarm system was conducted during the survey due to the technician still working on repairs at the time of surveyor exit. Testing of the fire alarm system will require testing upon a follow-up survey.

Based on random observation during the survey walk-through on January 24, 2012 not all portions of the facility's fire alarm system are installed in accordance with NFPA 70 and 72 1999.

Findings include:
A. During the building walk-through smoke detectors were observed less than 3' from diffusers in multiple locations and not in accordance with NFPA 72, 2-3.5.1. The deficiencies could cause injury due to fire alarm devices not alarming. Areas included, but may not be limited to include:

1. At the admitting area near the main entrance.

2. At the corner room with windows being remodeled in the lower level near the main entrance.

3. In the corridor near respiratory therapy on the upper level.

B. During the walk-through of the upper level near the 2-hour fire barrier doors near ICU a conduit was observed with a red fire alarm cable wire tied to it and not supported by the structure in accordance with NFPA 70 760-54. Similar support of fire alarm wiring may exist throughout the building.

Based on random observation during the survey walk-through, not all portions of the facility's sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:
A. During the penthouse walk-through on January 24, 2012, not all ductwork connected to ASU 5 over 48" wide are provided with sprinkler coverage under the duct in accordance with 5-5.5.3.1.

This deficiency could cause smoke to develop and injure patients and staff due to lack of water at the source of the fire.

B. Sidewall sprinklers installed at typical patient room locations were observed to be obstructed by bracket mounted televisions. Deficiency compromises the coverage and effectiveness of the sprinkler system.

C. Ceiling tile was observed to be removed where no workmen were performing work. The removed tile compromises the effectiveness of the sprinkler system by allowing heat to escape to the above ceiling cavity reducing the activation time of the sprinkler head. Locations observed include:

1. At the lower level Food Storage room.

2. At the lower level Elevator Pump room.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:
A. Medical gas tanks were observed being stored with combustibles within 5'-0" not in compliance with NFPA 99-1999, 8-3.1.11.2(c)(2). This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials. Locations observed include but are not necessarily limited to the following:

1. At the Respiratory Therapy storage room.

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through of the lower level a 3/8" copper line was observed to be silver brazed and marked with green tape. During an interview held at that location the Director of Maintenance indicated he was not sure what it served. If verified to be a piped medical gas line the installation requirements of NFPA 99 Chapter 4 must be complied with.

Based on random observation during the survey walk-through not all portions of the facility's Type 1 emergency system are installed in accordance with NFPA 99-1999 and NFPA 110-1999.

Findings include:
A. At the generator location it was discovered the generator was not provided with a battery powered emergency light connected to the load side of the transfer switch in accordance with NFPA 99, 3-4.2.2.2 (b).

B. At the generator location it was discovered the generator was not provided with a duplex outlet connected to the load side of the transfer switch in accordance with NFPA 99, 3-4.2.2.2 (b).

C. The generator was observed with wires connected to the battery terminals other than the starting cables for the generator in accordance with NFPA 110, 5-12.6.

D. The generator room was observed with duct work and other supplies stored in the room and not in accordance with NFPA 110, 5-11.1.

These deficiencies could cause a delay in trouble shooting of a problem with the generator or compromise the starting condition of the generator resulting in injury to patients.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through of the laboratory area, not all portions of laboratory safety devices are installed in accordance with NFPA 99 1999 10-6.

Findings include:

A. The eye wash appeared to be mounted on a sink gooseneck faucet without pressure and temperature adjusting devices.

B. The emergency shower did not appear to have a floor receptor installed and/or was mounted over the top of equipment.

These deficiencies could result in staff injury due to injurious water pressure/temperature and inaccessibility for use of the safety devices.

Based on random observation and document review during the survey walk-through on January 24, 2012, not all portions of the facility's emergency electrical system are tested and maintained in accordance with NFPA 99-1999 and NFPA 110-1999.

Findings include:
A. During the morning record review process, records were found to be incomplete for the following equipment for the Level 1 emergency electrical system. The following items were identified:

1. Records were incomplete for 12 consecutive months of the 450 KW generator under load conditions in accordance with NFPA 110, 6-4.1.

2. Records were incomplete for 12 consecutive months of testing the 3 transfer switches in accordance with NFPA 110, 6-4.5.

3. Records were incomplete for 52 consecutive weeks of the visual generator checks in accordance with NFPA 110, 6-3.6 because battery electrolyte levels were not documented.

4. Records failed to show amperage readings for assessing the percentage of load for annual load bank testing in accordance with NFPA 110, 6-4.2.2.

5. Records were not available for annual transfer switch maintenance in accordance with NFPA 110, 6-3.5.

The deficiencies could cause generator failure resulting to injury to patients and staff.

B. During the morning record review process records were found to be incomplete for the following equipment on the level 2 emergency electric system. The following items were identified:

1. Records were incomplete for 12 consecutive month of the 350 KW generator under load conditions in accordance with NFPA 110, 6-4.1.

2. Records were incomplete for 12 consecutive months of testing the transfer switch in accordance with NFPA 110, 6-4.5.

3. Records were incomplete for 52 consecutive weeks of the visual generator checks in accordance with NFPA 110, 6-3.6 because battery electrolyte levels were not documented.

4. Records failed to show amperage readings for assessing the percentage of load for annual load bank testing in accordance with NFPA 110, 6-4.2.

5. Records were not available for annual transfer switch maintenance in accordance with NFPA 110, 6-3.5.

Based on random observation, staff interview and document review, not all portions of the facility's emergency electrical system are identified and maintained in accordance with NFPA 70-1999 and NFPA 99-1999.

Findings include:
A. During the penthouse walk-through, an interview was held with the Director of Maintenance on how the facility identified electric panels on the emergency electrical system and the reply was not descriptive of how they were identified. During the survey walk-through the emergency electric system was not identified consistently in accordance with NFPA 99, 3-4.2.2.2 and NFPA 70, 517-30(c) for the 3 branches of Life Safety, Critical and Equipment branch.

B. During the survey walk-through of critical care areas as defined in NFPA 99, outlets connected to the emergency electrical system were not labeled consistently in accordance with NFPA 70, 517-19 as to the panel and circuit number serving the outlet.

C. During the document review records for testing Line Isolation Monitors (LIM), monthly in accordance with NFPA 99, 3-3.3.3.4.2(b).

D. LIM 3ME 2101 observed in the operating room area, test switch did not work when depressed showing it in need of repair in accordance with NFPA 99, 3-3.3.4.2(c).

E. The 3 transfer switches connected to the 450 KW generator did not have a green light illuminated to show connection to the normal electric system and therefore in need of repair in accordance with NFPA 110, 4-2.4.11.

F. Patient rooms on the upper level was observed without an emergency circuit serving an outlet in the room in accordance with NFPA 70, 517-18.

G. During the survey walk-through of the Emergency Room bed location 2 was observed with only emergency power outlets and no normal power outlets in accordance with NFPA 70, 517-19(a).

H. During the survey walk-through of the Emergency Room bed location 2 was observed with four receptacles and not six in accordance with NFPA 70, 517-19(b).

The deficiencies listed above could cause injury to patients and staff due to equipment failure.

Based on random observation during the survey walk-through, not all portions of the facility's normal electrical system are installed and maintained in accordance with NFPA 70-1999.

Findings include:
A. During the walk-through of the mechanical penthouse an electric panel (BPPH-A) was observed without a blank off cover to protect staff from coming in contact with live buss bars in accordance with 70 110-12(a).

B. Electrical box covers were observed to be missing and not in compliance with NFPA 70, 370-25. Deficiencies expose persons to electrical shock. Locations observed include:

1. At the Mechanical Penthouse near the Seimans CWP-7 disconnect.

2. At the Mechaincal Penthouse below Panel BPEM-PH.

3. At the upper level on the east side of the smoke barrier near room 203.