HospitalInspections.org

Based on observation, the facility failed to maintain their doors. This was evidenced by corridors doors obstructed from closing and doors that failed to close and latch. This affected 2 of 2 floors of the Main Hospital. This could result in the spread of smoke and fire throughout the facility and the increased risk of injury to the patients due to smoke and fire.

Findings:

During facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, the doors were observed.

Main Hospital
1/29/15
1. At 11:15 a.m., a plastic door wedge positioned under the door leaf obstructed Environmental Services door on the 2nd floor from closing.

2. At 11:21 a.m., Room 213, a trash can and laundry bin blocked the door from closing.

3. At 3:03 p.m., in the Inpatient Rehabilitation Unit, both Dining Room doors failed to close and latch. The doors were equipment with self-closing devices.

4. At 3:14 p.m., in the Inpatient Rehabilitation Unit, plastic wedge door stopper positioned under the door leaf of the Community Program Coordinator office obstructed the door from closing.

Based on observation, the facility failed to maintain its smoke barrier doors. This was evidenced by smoke barrier doors that failed to latch. This affected 2 of 2 floors of the Main Hospital and 2 of 2 floors of Critical Care Pavilion(CCP). This finding could result in the spread of smoke from one smoke compartment to another and increase the risk of injury to patients and staff in the event of a fire.

Findings:

During the facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, the smoke barrier doors were observed.

Main Hospital
1/28/15

1. At 9:43 a.m., the smoke barrier double doors by 1 North Laboratory were held open with electronic automatic-closing devices. The left door failed to latch when closed upon activation of the fire alarm system.

2. At 10:16 a.m., the smoke barrier double doors by Room 211 were held open with electronic automatic-closing devices. The left door failed to latch when closed upon activation of the fire alarm system.

3. At 10:27 a.m., the smoke barrier double doors by Room 270 were held open with electronic automatic-closing devices. The left door failed to latch when closed upon activation of the fire alarm system.

Critical Care Pavilion
1/28/15
4. At 10:48 a.m., the Emergency Department waiting room smoke barrier double doors were held open with electronic automatic-closing devices. The left door failed to latch when closed upon activation of the fire alarm system.

Based on record review, the facility failed to maintain their battery-powered emergency lights. This was evidenced by no records of monthly and annual testing of the emergency lights. This affected patients undergoing procedures in the Birthing Pavilion Operating Room 2 (BP OR 2) at the Main Hospital and patients at the Outpatient Rehabilitation building. This could result in a delay in evacuation in the event of an emergency due to limited visibility.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

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 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 1/27/15 to 1/29/15, the emergency lights were observed and testing records were reviewed.

Outpatient Rehabilitation
1/29/15

1. At 4:35 p.m., the building plans for the Outpatient Rehabilitation suite were provided. Sheet E2.1, the emergency lighting plan, showed that multiple ballasts were equipped with 90-minute battery back up. There were no records of testing monthly and annual testing of these emergency lights.

Main Hospital
1/30/15

2. At 8:45 a.m., there were no records of monthly and annual testing of the ballast lights, equipped with emergency battery power, in BP OR 2 (also named C-Section Room 2).

Based on observation, the facility failed to maintain their emergency exit signs. This was evidenced by expired exit photo-luminous signs and no records of testing the exit signs. This affected 1 of 2 floors of the Main hospital, 1 of 3 floors of Outpatients Pre-operative Building and Outpatient Rehabilitation. This could result a delay evacuation in the event of an emergency due to limited visibility and possible harm to patients..

NFPA 101 Life Safety Code, 2000 Edition

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceeds 30 days.

NFPA 101, Life Safety Code, 2000 Edition.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

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 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.


Findings:

During tour of facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the photo-luminous signs were observed.

310 Building Out-patients pre-operative
1/28/15
1. At 2:20 p.m., the photo-luminous exit sign above exit door of Suite 105 had an expiration date of 1999.

Main Hospital
1/29/15
2. At 3:18 p.m., the photo-luminous exit sign by exit door of the Inpatient Rehabilitation lobby had an expiration date of 1996.



29665

During record review with staff from 1/27/15 to 1/30/15, the exit signs were observed and maintenance records reviewed.

Outpatient Rehabilitation
1/28/15

3. At 1:57 p.m., the Outpatient Rehabilitation suite had hard-wired exit signs that were equipped with battery back-up power.
During an interview at 1:58 p.m., Facilities Staff 83 stated that the exit signs were not tested monthly or annually.

Based on observation and interview, the facility failed to instruct their staffs on their role to protect their patients in the event of an emergency. This was evidenced by the staff's lack of familiarity with their duties in an emergency event and facility emergency policy did not match staffs safety practices. This could result in delayed response from staff and potential harm to patients in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

9.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2)Transmission of alarm to fire department
(3)Response to alarm
(4)Isolation of fire
(5)Evacuation of immediate area
(6)Evacuation of Smoke compartment
(7)Preparation of floors and building for evacuation
(8)Extinguishment of fire

Findings:

During the facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, staffs were interviewed to determine their knowledge of facility written safety plan.
The Emergency Management(ENC-FW-EM-4011)policy indicated Evacuation will be to the nearest area of refuge, at a minimum to the nearest smoke compartment(beyond the nearest building corridor fire rated door).

Facility policy on Chemical or biological Spill or Contamination(S-FW-EM-4010)indicated for the laboratory hazardous materials were Acids, Bases, Acetone- xylene and Formaldehyde(Formalin).

Main Hospital
1/29/15
1. At 11:18 a.m., during interview with Housekeeping Staff 74, she was unfamiliar with evacuation to an area of refuge or smoke compartment(beyond the nearest building corridor fire rated door).

2. At 11:42 a.m., during interview with Laboratory Staff 76, she stated the facility was not equipped with hazardous materials as far as she knew and would be unfamiliar with emergency spill procedures for hazardous materials. Laboratory Staff 76 was unfamiliar with facility hazardous materials used in the laboratory and the emergency spill procedures for hazardous materials.

3. At 2:42 p.m., during interview with Registered Nurse (RN)71, she was unfamiliar with the definition of evacuation to safe area on the floor.

310 Building- Outpatient pre-operative
1/28/15

4. At 2:13 p.m., Facility disaster manual located within the suite stated facility staff would dial 7770 for PBX(at the Main Hospital )to announce a Code Red for a fire. The suite was located on the first floor of a three stories sprinklered only building.

310 Building- Outpatient Pre-operative
1/30/15

5. At 10:15 a.m., during interview with Registered Nurse 77 and 78, they both stated they would call 911 if they discover a fire and that the sprinkler system would activate automatically within the building to notified occupants of a fire. They stated that the activation of one sprinkler head will activate all there others within the building.

Registered Nurses 77 and 78 were unfamiliar with how the building sprinkler system operate in the event of a fire, and facility Disaster manual did not match the actions RNs stated they would take in the event of a fire.



29665

Main Building
1/28/15

6. At 9:24 p.m., Laboratory Staff 86 was asked what procedures she would perform in the event of a fire. She failed to indicate that she would activate a manual pull station to alert the rest of the building.

Outpatient Rehabilitation
1/28/15

7. At 1:46 p.m., the Outpatient Rehabilitation was observed. The building was not equipped with any fire alarm devices and was not provided with overhead paging capabilities. There was no fire response policy provided.
During an interview at 1:47 p.m., Safety Staff 83 stated that the outpatient building did not have its own specific fire response policy.

8. During an interview at 1:48 p.m., Outpatient Rehabilitation Staff 84 stated that a power outage occurred at the facility approximately 1 month ago and the facility continued to see some patients during the outage. Outpatient Rehabilitation Staff 84 was unsure if the facility was equipped with emergency lighting. He stated that facility staff used flashlights from the emergency kits. There were two working flashlights, two still in their packaging, and one lantern that failed to illuminate when tested.
During an interview at 1:54 p.m., Safety Staff 83 stated that the outpatient building did not have its own specific power outage policy.

Facilities Staff 82, Safety Staff 83, and Outpatient Rehabilitation Staff 84 did not state that the facility was equipped with battery-powered ballast lights as confirmed the facility's building plans.

1/29/15

9. At 9:44 a.m., a "Code White" policy for power outages was provided as the policy to be used at the Outpatient Rehabilitation Building. One of the "mitigation capabilities" listed in the policy was "Emergency Power system (red outlets)" and one of the "actions to be taken" was to restrict electrical consumption to essential needs and "plug essential equipment into red outlets." The Outpatient Rehabilitation Building did not have red outlets or emergency power.

During an interview at 1:30 p.m., Administrative Staff 85 confirmed that the outpatient buildings do not have their own specific policies for fire response and other emergencies.

Based on record review, the facility failed to accomplish all of the requirements for fire drills for laboratory staff in the last 12 months. This was evidenced by the facility failure to provide documents to show 3 of 4 fire drills were conducted in the last 12 months and ensure employees participated in fire drills and familiar with fire and or fire drills policies. This could result in staff members not accomplishing all of the tasks required of him or her during conditions that are expected to exist in the event of a fire and increased risk of injury to the patients.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During record review with the Facilities Staff 82 from 1/27/15 to 1/30/15, the fire drill records were reviewed.
Facilities written policy on discover of fire (CODE RED -ENC-FW-EM-4011) was RACE.
Rescue: Evacuate all persons in immediate danger from the involved area.
Alarm: Notify the Fire Department by activating the nearest fire alarm box and call the communications center operator (PBX) at the appropriate emergency number, giving location of the fire and your name.
Confine: Confine the fire to one area by closing all doors, windows and securing oxygen in the vicinity of the fire, only if this can be accomplished without jeopardizing individual safety.
Extinguish: Take actions to put out or reduce fire until arrival of emergency response personnel.

Communications Center Operator (PBX)
1. Will alert the facility
2. Will ensure notification to the supporting fire department has been accomplished
3. Will make other notification in accordance with standard operation procedures of the facility.

Main Hospital
1/27/15

At 12:05 p.m., the laboratory fire drills indicated only 1 of 4 fire drills were conducted in the last 12 months. Facility failed to provide documents to show 3 of 4 fire drills conducted for laboratory staff.

At 12:06 p.m., 80 percent of fire drills record indicated action taken in response to the fire doors were marked "not applicable."

At 12:06 p.m., during interview with Facilities Staff 82, he stated drills were conducted per department and only department staff participated in the drills for their department. Facilities Staff 82 stated the fire doors were disabled from the fire alarm system during fire drills.


At 12:10 p.m., the fire drills record indicated that not all employees participated in the fire drills.

At 3:41 p.m., during interview with Chef 72, he stated that during kitchen fire, he believed the ansul automatic suppression system of the Kitchen will automatically call the Fire Department and notify the Facility Security and Security will notify the whole building.

At 3:55 p.m., during interview with Staff 73, he stated the extinguisher in the Kitchen is for electric fire and combustible.

1/29/15

At 12:09 p.m., during interview with Scheduler Staff 77, she stated she would dial the fire code and alert her manager if she discover a fire. She also stated she should do more but could not remember all the actions and has worked for the facility for 8 years.

At 2:42 p.m., during interview with Registered Nurse 71, she stated the action she would take if she discover a fire would be to evacuate. Registered Nurse 71 worked for facility for 15 years.

At 4:21 p.m., during interview with the Housekeeping Staff 75, she was unfamiliar with the actions to take if she discover a fire. Housekeeping Staff 75 stated she would use a fire extinguisher if she discover a fire. Housekeeping Staff stated she has worked for the facility for 15 years.

Facility failed to ensure all employees participates in fire drills and familiar with facility fire and fire drill policies.

Based on observation, the facility failed to maintain their fire alarm system. This was evidenced by the failure to provide dates of installation for two sealed lead-acid batteries at a fire alarm panel, by the failure of sprinkler system waterflow devices to initiate an alarm within 90 seconds and fire alarm panel room was not equipped with a early detection device. This affected two of two stories in the Main Building and the 310 Building and could result in a delay in notification, in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

4.1.1 Fire and Similar Emergency. The goal of this Code is to provide an environment for the occupants that is reasonably safe from fire and similar emergencies by the following means:
(1) Protection of occupants not intimate with the initial fire development
(2) Improvement of the survivability of occupants intimate with the initial fire development.

4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-6 Sprinkler Waterflow Alarm-Initiating Devices.
2-6.1 The provisions of Section 2-6 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Table 7-3.2 Testing Frequencies
6. Batteries - Fire Alarm Systems
d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years.)

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a facility tour with staff from 1/27/15 to 1/30/15, the fire alarm system was observed and maintenance records were reviewed.

Main Building
1/28/15

1. At 9:43 a.m., there were two sealed-lead acid batteries in the fire alarm panel, located in the IS Room by the loading dock. The batteries were not dated. The date of installation of the batteries was requested from facility staff but never provided. It could not be confirmed if the batteries were replaced in the last four years.

2. At 10:14 a.m., the Inspector's Test Valve (ITV) in the electrical closet of the Neonatal Intensive Care Unit (NICU) was tested by Facilities Staff 87. The alarms activated after 1 minute and 31 seconds of the waterflow. The ITV failed to activate an alarm within 90 seconds.

310 Building ( Outpatient Pre-Operative)
1/28/15

3. At 2:23 p.m., the ITV on the third floor was opened by Facilitiy Staff 88. After 2 minutes, the sprinkler alarm bell failed to activate.
During an interview at 2:36 p.m., Facilities Staff 88 stated that the monitoring company did not receive any alarm signals.
The ITV failed to initiate an alarm within 90 seconds.



29566

National Fire Protection Association, 72 National Fire Alarm Code, 1999 Edition.
1-5.6* Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit (s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

During facility tour with the Facilities Staff 82 from 1/28/15 to 1/30/18, the fire alarm panel was observed.

310 Building- Outpatients Pre-operative
1/28/15

4. At 2:31 p.m., the fire alarm panel was mounted in a room on the lower level of out-patient pre-operative building. The room was not equipped with a smoke detector.

Facilities Staff 2 concurred with the finding above.

Based on observation and interview, the facility failed to maintain their sprinkler control valves. This was evidenced by two supervised outside screw and yolk (OS&Y) valves that failed to activate a supervisory alarm when closed. This affected the 310 building and could result in a delay in response, in the event the valves are tampered with.
NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

19.3.5.2 Where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.
9.7.2 Supervision.
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
2-9 Supervisory Signal-Initiating Devices.
2-9.1 Control Valve Supervisory Signal-Initiating Device.
2-9.1.1 Two separate and distinct signals shall be initiated: one indicating movement of the valve from its normal position and the other indicating restoration of the valve to its normal position. The off-normal signal shall be initiated during the first two revolutions of the hand wheel or during one-fifth of the travel distance of the valve control apparatus from its normal position. The off-normal signal shall not be restored at any valve position except normal.

Findings:

During a facility tour with staff from 1/27/15 to 1/30/15, the tamper switches on the sprinkler control valves were tested.

310 Building
1/28/15

1. At 2:30 p.m., the North OS&Y valve was closed all the way by Facilities Staff 88. Closure of the valve failed to initiate a supervisory signal at the fire alarm panel.

2. At 2:31 p.m., the South OS&Y valve was closed all the way by Facilities Staff 88. Closure of the valve failed to initiate a supervisory signal at the fire alarm panel.

During an interview at 2:36 p.m., Facilities Staff 88 stated that the monitoring company did not receive any supervisory signals.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system in reliable operating condition. This was evidenced by sprinkler heads exhibited signs of corrosion and had built-up of debris. This affected Main Hospital, Outpatient Pre-operative building, and Outpatient Imaging(320 building). This could result in reduced effectiveness of the sprinkler system and cause injury to patients from fire.

Findings:

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.


9.7.3 Other Automatic Extinguishing Equipment.
9.7.3.1 In any occupancy where the character of the potential fuel for fire is such that extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as water mist, carbon dioxide, dry chemical, foam, Halon 1301, water spray, or a standard extinguishing system of another type, that system shall be permitted to be installed in lieu of an automatic sprinkler system. Such systems shall be installed, inspected, and maintained in accordance with appropriate NFPA standards.


9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.


NFPA 2001, Standard on Clean Agent Fire Extinguishing Systems, 2000 Edition.
4-1.1 At least annually, all systems shall be thoroughly inspected and tested for proper operation by competent personnel. Discharge tests are not required.
4-1.2 The inspection report with recommendations shall be filed with the owner.
4-1.3 At least semiannually, the agent quantity and pressure of refillable containers shall be checked.
4-2.1 U.S. Department of Transportation (DOT), Canadian Transport Commission (CTC), or similar design clean agent containers shall not be recharged without retesting if more than 5 years have elapsed since the date of the last test and inspection. For halocarbon agent storage containers, the retest shall be permitted to consist of a complete visual inspection as described in 49 CFR 173.34(e)(10).
Transporting charged containers that have not been tested within 5 years could be illegal. Federal and local regulations should be consulted.
4-2.2 Cylinders continuously in service without discharging shall be given a complete external visual inspection every 5 years or more frequently if required. The visual inspection shall be in accordance with Section 3 of CGA C-6, Standard for Visual Inspection of Steel Compressed Gas Cylinders, except that the cylinders need not be emptied or stamped while under pressure. Inspections shall be made only by competent personnel and the results recorded on both of the following:
(1) A record tag permanently attached to each cylinder
(2) A suitable inspection report
A completed copy of the inspection report shall be furnished to the owner of the system or an authorized representative. These records shall be retained by the owner for the life of the system.
4-3.2.1 All hose shall be tested every 5 years.
4-3.2.2 All hose shall be tested at 11/2 times the maximum container pressure at 130¢XF (54.4¢XC). The testing procedure shall be as follows:
(a) The hose is removed from any attachment.
(b) The hose assembly is then placed in a protective enclosure designed to permit visual observation of the test.
(c) The hose must be completely filled with water before testing.
(d) Pressure then is applied at a rate-of-pressure rise to reach the test pressure within a minimum of 1 minute. The
test pressure is maintained for 1 full minute. Observations are then made to note any distortion or leakage.
(e) If the test pressure has not dropped or if the couplings have not moved, the pressure is released. The hose assembly is then considered to have passed the hydrostatic test if no permanent distortion has taken place.
(f) Hose assembly passing the test must be completely dried internally. If heat is used for drying, the temperature must not exceed the manufacturer ' s specifications.
(g) Hose assemblies failing a hydrostatic test must be marked and destroyed and be replaced with new assemblies.
(h) Each hose assembly passing the hydrostatic test is marked to show the date of test.


NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition.
5-5.5 Obstructions to Sprinkler Discharge.
5-5.5.1 Performance Objective. Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-5.5.2 and 5-5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. (See Figure A-5-5.5.1.)
5-5.5.2 Obstructions to Sprinkler Discharge Pattern Development.
5-5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2.
5-5.5.2.2 Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of Sections 5-6 through 5-11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.
5-5.5.3 Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.
5-5.5.3.1 Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place such as conference tables.
5-5.5.3.2 Sprinklers installed under open gratings shall be of the intermediate level/rack storage type or otherwise shielded from the discharge of overhead sprinklers.
5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1: Where other standards specify greater minimums, they shall be followed.
Exception No.2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the 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.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1: Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-3.2 Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

Table 9-1 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance indicates that backflow prevention assemblies are required to be tested annually in accordance with Section 9-6.2.

9-6.2.1 All backflow preventers installed in fire protection system piping shall be tested annually in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

9-6.2.2 All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

9-6.3.1 Maintenance of all backflow prevention assemblies shall be conducted by a trained individual following the manufacturer's instructions in accordance with the procedure and policies of the authority having jurisdiction.

9-7 Fire Department Connections.
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.

Findings:

During a facility tour with staff from 1/27/15 to 1/30/15, the automatic fire extinguishing systems were observed and maintenance records were reviewed.

Main Hospital
FM-200 Clean Agent System in IS Room by Loading Dock
1/29/15

1. At 8:50 a.m., the maintenance records provided showed that the FM-200 extinguishing system was inspected on 2/4/14 and 8/5/14. The vendor indicated on the 2/4/14 report that the activation hose was due to be replaced. There was no records provided showing if the hose was replaced.

2. At 8:51 a.m., there were no records provided of a five year inspection conducted on the FM-200 system.

3. At 8:52 a.m., the 2/4/14 the records indicated that the system's last hydrostatic test was in 1998. On the 8/5/14 record, the hydrostatic date was listed as 8/8/1999. The correct hydrostatic testing date was not confirmed by staff. According to the records provided, there has not been a hydrostatic test conducted in more than 14 years.

Main Hospital
1/28/15

4. At 4:12 p.m., the west outside screw & yolk (OS&Y) valve, outside the conference center, was leaking at the stem.

Main Hospital
1/29/15

5. At 9:00 a.m., records provided showed that the system side OS&Y for the Conference Center failed an inspection on 5/7/14. Descriptions of the failure could not be confirmed because of incomplete documentation. Records of repairing the failed OS&Y valve were not provided.

6. At 10:54 a.m., the discharge pattern of the sprinkler head in the 2 North electrical closet was obstructed by cable bundles. The cable bundles were less than one inch from the head.

7. At 2:51 p.m., the sprinkler head in the storage closet (Door 2-01-5101) was missing an escutcheon ring.


310 Building-Outpatients Pre-operative
1/28/15

8. At 2:11 p.m., the sticker on the sprinkler riser indicated that the sprinkler system was last certified by a vendor in July 2010. Records of that five-year testing was requested from facility staff but not provided. During an interview at 2:14 p.m., Facilities Staff 88 stated he tests the waterflows and tampers once a year. He provided a monitoring report from the central station showing that the waterflow was tested on 10/3/14. There were no other records of testing and inspecting the sprinkler system.
There were no records of quarterly testing of the Inspector's Test Valve (ITV), quarterly inspections of the fire department connections (FDCs), and annual testing of the two tamper switches.

9. At 2:32 p.m., the exterior control valves were labeled with identification signs that were not legible due to weather exposure.

10. At 2:33 p.m., during inspection of the FDCs, one cap was broken.

320 Building (Imaging)
1/28/15

11. At 2:58 p.m., the ITV was tested by Facilities Staff 88. The audible/visual notification devices in the building were activated within 48 seconds. The exterior sprinkler bell failed to alarm.




29566

During tour of facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the sprinkler heads were observed.

Main Hospital
1/27/15

12. At 10:24 a.m., in the Kitchen walk-in refrigerators, there were 2 sprinklers heads exhibited signs of corrosion. There were rust on the pendent arms and base connection.

1/29/15

13. At 2:56 p.m., two sprinkler heads in hallway by Room 150 of in-patient Rehabilitation had built-up of debris on their deflectors and pendant arms.

Out-patients pre-operative building
1/28/15

14. At 2:11 p.m., three sprinklers heads had built-up of debris on the sprinklers' deflectors and pendant arms in the hallway of Suite 105.

Based on observation and interview, the facility failed to maintain their fire extinguisher. This was evidenced by fire extinguisher not installed in accordance with NFPA 110, 1998 Edition and items blocking access to fire extinguisher. This could cause a delay in reaching the fire extinguisher and the potential of the fire spreading and causing harm to patients and staff in the event of a fire emergency. This affected 1 of 2 floors of main hospital and 1 of 3 floors of out-patients pre-operative building.

NFPA 10, Standards for Portable Fire Extinguishers 1998 Edition: 1-6.3 Fire extinguishers shall be conspicuously located where
they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal
paths of travel, including exits from areas.

1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb.(18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft.(1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg)(except wheeled type) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft. (1.07 m)above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.(10.2 cm).


Findings:

During the facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, the fire extinguishers were observed.

Main Hospital

1/27/15
At 4:06 p.m., boxes of supplies and a waste basket blocked readily access to fire extinguisher mounted on the wall in Bio-Med Room on first floor.

1/29/15
At 10:15 a.m., a fire extinguisher was placed standing on the floor by the entrance of the broiler room.

310 Building-Outpatients Pre-operative
1/28/15
At 2:09 p.m., the fire extinguisher in hallway of Suite 105 was mounted 64 inches from the floor.

Based on observation, record review and interview, the facility failed to ensure that the installed ventilation equipment were in compliance with all applicable codes. This was evidenced by no records of approval for the installation of a window mounted air exhaust/filtration appliance used to convert a patient room into a negative pressure isolation room. This was also evidenced by no records of testing the device in accordance with the manufacturer's specifications. This affected patients who receive treatment in that room.

NFPA 101, Life Safety Code, 2000 Edition.
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.
2-1.3 Equipment shall be guarded for personnel protection and against the intake of foreign matter into the system.

Findings:
During tour of the facility with staff from 1/27/15 to 1/30/15, the patients rooms were observed.

Main Building
1/29/15

1. At 3:37 p.m., there was a window-mounted air exhaust/HEPA filtration device in Labor Room 105. The system was installed to turn the patient room into a negative pressure isolation room.
There were no records of installation of the device in accordance with the manufacturer's specifications and approval from authority having jurisdiction.

1/30/15

2. At 10:14 a.m., maintenance logs provided by Facilities Staff 81 indicated that Facilities Staff 89 conducts negative pressure air balance tests on a monthly basis.
During an interview at 10:45 a.m., Facilities Staff 89 stated that he does not conduct an air balance test. He visually checks the prefilter every month.
The monthly logs were not documented accurately.

3. At 10:17 a.m., the device's instruction manual stated the only maintenance that the device needs is changing the filters (both the prefilters and hepafilters). The manual states that the way to determine if the filters need changing is by adjusting the (cubic feet per minute) CFM dialer that controls the exhaust flowrate. The color of the indicator light is an indication that one of the filters needs replacement.
During an interview at 10:47 a.m., Facilities Staff 89 stated that he changes the prefilter based on the amount of debris visible. He did not mention inspecting the CFM indicator light.

4. At 10:50 a.m., records showed that the most recent air balance test was conducted by vendor on 7/14/14. In the report, the vendor stated that the required exhaust CFM for the room was not provided so the exhaust reading measured during the test could not be compared with the required value.

Based on observation, interview and record review, the facility failed to maintain their Kitchen Hood to prevent grease fire. This was evidenced by layer of grease in the hood of the stove area and on the fire suppression system. This affected 1 of 2 floors of the Main Hospital. This could result in increased risk of fire and potential cause injury to patients and staff from fire.



NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition 8.3.1* Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Table 8-3.1

Type or Volume of Cooking Frequency

Systems serving high-volume cooking operations such as
24-hour cooking, charbroiling or wok cooking. Quarterly



Findings:

During a tour of the facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the Kitchen was observed.

Main Hospital
1/27/15

At 10:22 p.m., there was a built-up of grease inside the hood of the stove and grills. There were deposit of grease on the fire suppression system pipes inside the hood and dripping of grease on inside the hood. There were built-up of grease and debris on the fire suppression pipes over the stove and grill. The filters had grease and debris.

At 1:47 p.m., Facilities Staff 81 stated the area around the stove and grill was closed for weeks and due to installation of new flooring under the stove and grill.

During record review, the kitchen records indicated the last cleaning of the hood was done on 7/3/14.

Based on observation and record review, the facility failed to ensure that portable space heaters used in non-sleeping staff areas complied with the requirements of NFPA 101, 2000 Edition. This was evidenced by the use of space heaters with heating element temperatures exceeding 212 degrees Fahrenheit. This affected 1 of 2 floors of main hospital. This could result in increased risk of fire and potential cause injury to patients and staff from fire.


NFPA 101, Life Safety Code, 2000 Edition.
19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212¿EF (100¿E
Findings:

During a facility tour with the Safety Staff 83 from 1/27/15 to 1/30/15, portable space-heaters were observed

Main Building
1/29/15

1. At 8:39 a.m., a policy titled "Space Heater, Guidelines" with identifier ENC-FW-EC-1056,last revised 09/12, was provided. The policy indicated that the temperature of the space heater heating elements shall not exceed 212¿EF.
When the manufacturer specifications for the heater model, approved for use by the facility, was requested, a "Certificate of Conformance" signed by manager from the manufacturer was provided. The product manual was not provided.
In the Certificate of Conformance, the maximum operating temperature of the heating element was listed as 257¿EF.

The portable space heaters observed during the survey were the model described in the Certificate of Conformance.

2. At 11:52 a.m., there was a portable space heater in the doctor sleep room (Door 4-01-6136) in the east ICU corridor.

3. At 11:56 a.m., there was a portable space heater in the surgical administration office (Door 4-01-6132) in the east ICU corridor.



29566



During a tour of the facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, non-sleeping staff room was observed.

Main Hospital
1/28/15

4. At 9:21 a.m., a portable space heater was placed on the floor between office furniture's in the PBX (private branch exchange) office.

Based on observation, the facility failed to maintain the access to a primary means of escape as evidenced by furniture and items blocked egress corridors. This could result in the delay in the evacuation of the facility and the increased risk of injury to the patients and staff due to fire.
Findings:
During the facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, the egress's corridors were observed.
Outpatient Physical Therapy
1/28/15
1. At 1:43 p.m., an industrial copier machine and open-faced storage cube furniture located in the egress corridor path in-front of the exit door to the side parking lot.
Main Hospital
1/29/15
2. At 11:27 a.m., by the linen room on the first floor, there were two linen carts approximately measured 4 feet by 2 feet and 70 inches in height each stored in the egress corridor. One of two linen carts was observed in the corridor at approximately 10:20 a.m.
3. At 11:37 a.m., employees mail-slots cupboard, and trash bin on the right and employee lockers cabinet on the left of the egress path in-front of the laboratory suite exit door. The egress path measured approximately 38 inches in width. Furniture and items blocked the egress path and reduced egress width to the exit door of the laboratory suite.

Based on observation and interview, the facility failed to maintain cylinder safety in accrodance with NFPA 99, 1999 Edition. This was evidenced by more than one cylinder secured with one chain and cylinders exposed to the elements. This affected 1 of 2 floors of the Main Hospital and 1 of 2 floors of Critical Care Pavilion (CCP). This could cause a potential hazard for the facility and possible harm to patients and staff due to a hazardous condition.
National Fire Protection Association Health Care Facilities -99, 1999 Edition-
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.5.2.2 (b)Nonflammable Gases
3. Cylinders stored in open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter, cylinders stored in the open shall be protected against accumulations of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.
Findings:
During tour of the facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the oxygen cylinders piped-in storage areas were observed.
Main Hospital
1/29/15
At 10:40 a.m., there were more than one H- sized cylinders secured with one chain. Cylinders were movable with light pressure to secure them.
CCP
1/29/15
At 10:54 a.m., there were 7 H-sized cylinders standing in water(approximately 1/2 inches of water)in the oxygen piped-in gas storage area.
At 10:55 a.m., Facilities Staff 82 stated the water under the cylinders were due to the morning dew and weather.

Based on record review, the facility failed to provide documentation that they were electing to lower the relative humidity to 20 percent in accordance to S & C 13-25. This was evidenced by the facility's adopting humidity levels in the operating rooms between 20% and 60%, without categorical waiver, by records showing the relative humidity levels in the operating rooms falling below 35%, and by records showing that surgeries were conducted in the operating rooms on days where the humidity levels were not recorded. This was also evidenced by no battery-powered lighting in one anesthetizing location. These deficient practices could result in the increased risk of a fire. This affected surgical patients undergoing procedures in the main operating rooms and the Birthing Pavilion operating rooms, located on the first floor of the Main Building.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.2 All Patient Care Areas. (See Chapter 2 for definition of Patient Care Area.)
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Chapter 2 definitions:
Patient care area. Any portion of a health care facility wherein patients are intended to be examined or treated.

Anesthetizing Location. Any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.

Relative Analgesia. A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).

Chapter 5 Environmental Systems
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

5-6.1 Anesthetizing Locations.
5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures.

NFPA 70, National Electrical Code, 1999 Edition
700-12 (e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment

The batteries shall be of suitable rating and capacity to supply and maintain at not less than 871/2 percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 11/2 hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 11/2 hours. Storage batteries, whether of the acid or alkali type, shall be designed and constructed to meet the requirements of emergency service.

Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.

Exception: In a separate and uninterrupted area supplied by a minimum of three normal lighting circuits, a separate branch circuit for unit equipment shall be permitted if it originates from the same panelboard as that of the normal lighting circuits and is provided with a lock-on feature.

Findings:

During a facility tour with staff from 1/27/15 to 1/30/15, the anesthetizing locations were observed and relative humidity records were reviewed.

Main Building
1/27/15

1. At 3:16 p.m., the "Temperature and Related Humidity Ranges, Preventative Maintenance and Monitoring" policy, dated 08/14, indicated that the relative humidity in the operating rooms (ORs) was to be monitored to ensure that it falls between 20% and 60%.
The facility did not provide an approved categorical waiver in accordance with the provisions of a Survey and Certification memorandum (S&C-13-25-LSC) published by the Centers for Medicare & Medicaid Services (CMS) on 4/19/13, allowing for facilities to lower the relative humidity in the ORs from 35% to 20%.

2. At 3:25 p.m., the humidity and temperature logs provided showed that the relative humidity fell below 35% in the following ORs:

a. On 12/25/14, the relative humidity was recorded as 26% in Birthing Pavilion Operating Room (BP OR) 1.
b. On 12/26/14, the relative humidity was recorded as 25% in BP OR 1.
c. On 12/27/14, the relative humidity was recorded as 22% in BP OR 1.
d. On 12/28/14, the relative humidity was recorded as 31.2% in OR 1, 29.5% in OR 2, 29.3% in OR 3, 30% in OR 4, and 27% in BP OR 1.
e. On 12/29/14, the relative humidity was recorded as 33% in BP OR 1.
f. On 12/30/14, the relative humidity was recorded as 35% in BP OR 2.
g. On 12/31/14, the relative humidity was recorded as 26% in OR 1, 29% in OR 2, 22% in OR 3, 21% in OR 4, and 26% in BP OR 1.
h. On 1/5/15, the relative humidity was recorded as 29% in OR 4 and 25% in BP OR 1.
i. On 1/24/15, the relative humidity was recorded as 21% in OR 1, 24% in OR 2, 24% in OR 3, 22% in OR 4, and 24% in BP OR 1.
j. On 1/25/15, the relative humidity was recorded as 20.2% in OR 1, 20.4% in OR 2, 21% in OR 3, 29.6% in OR 4, and 27% in BP OR 1.

3. At 3:30 p.m., the temperature and humidity logs indicated that the relative humidity was recorded as UTM1 on several occasions. The legend on the form indicated that UTM1 meant "unable to measure." The relative humidity was recorded as UTM1 on the following days:

a. On 10/9/14, the relative humidity in OR 2 was recorded as UTM1.
b. On 11/26/14, the relative humidity in OR 1 was recorded as UTM1.
c. On 12/1/14, the relative humidity in OR 3 was recorded as UTM1.
d. On 1/6/15, the relative humidity in OR 1 was recorded as UTM1.
e. On 1/8/15, the relative humidity in BP OR 1 was recorded as UTM1.
f. On 1/12/15, the relative humidity was recorded as UTM1 for OR 1, OR 2, OR 3, OR 4, and BP OR 1.

Surgery schedules provided by Administrative Staff 85 showed that procedures were conducted in all the rooms during the dates above where their relative humidity levels were not measured and recorded.

Main Building
1/29/15

4. At 3:21 p.m., there were no battery-powered lights in Birthing Pavilion Operating Room (BP OR 1).
During an interview at 4:43 p.m., Facilities Staff 81 confirmed that BP OR 1 was not equipped with battery-powered lights.

Based on observation and interview, the facility failed to maintain fire safety in their old emergency department area. This was evidenced by converting the old emergency suite into central supplies storage for the hospital without approval from authority having jurisdiction. The authority having jurisdiction ensure hospitals' facilities/suites meets applicable fire and safety codes. This affected 1 of 2 floors of the Main Hospital. This could result in fire sprinklers system protection ineffective in the event of a fire due to high hazard load and potential harm patients and staff.

Code of Federal Regulations:

§482.41 (a)Standard: Buildings. The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.
(c) Standard: Facilities. The hospital must maintain adequate facilities for its services.
(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.



Findings:

During tour of facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the emergency suite was observed.

Main Hospital

1/29/15
1. At 2:28 p.m., the old emergency suite on the first floor was converted to Central Supplies storage for the Hospital. The suite stored boxes of supplies(combustibles materials) in old bed stalls and egress path of the suite. Facility failed to ensure the suite meet approval for storage of more than average amount of stored supplies, fire sprinkler coverage would be adequate for the area and storage materials. Facility failed to ensure the approval from authority having jurisdiction that the emergency suite conversion to a storage suite was an acceptable level of safety for patients.

2. At 2:28 p.m. one of the door leaf of a double doors removed within the emergency suite.

3. At 2:30 p.m., interview with Facilities Staff 82, he stated the space conversion was done August, 2014 without approval from authority having jurisdiction.

1/30/15
4. At 8:30 a.m., reviewed of all the Facilities' approval plans from authority having jurisdiction given to surveyors did not indicate prior approval for the emergency suite conversion to central supplies storage room.

Based on observation and interview, facility failed to maintain oxygen cylinder safety in accordance with NFPA 99, 1999 Edition. This was evidenced by rooms that stored oxygen cylinders not equipped with a precautionary signs on the door. This affected 2 of 2 floors. This could potential cause a hazard and increase the risk of injury to staff and patients.
NFPA 99, Health Care Facilities 1999 Edition
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft.(1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES)STORED WITHIN
NO SMOKING

Findings:
During facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, the corridor rooms were observed.
Main Hospital
1/27/15
1. At 4:04 p.m., the door to the Bio-Med room was not equipped with a pre-cautionary sign. The Bio-Med room stored oxygen cylinder.
1/29/15
2. At 11:10 a.m., on the second floor, the door to Respiratory room was not equipped with a pre-cautionary sign. The Respiratory room stored oxygen cylinder.
Facility Respiratory staff concurred that the room stored oxygen cylinder.

Based on interview and observation, the facility failed to maintain the emergency generator. This was evidenced by items stored in the generator enclosure/room. This affected 2 of 2 floors of the Main Hospital. This could create a potential hazard and could result in a potential risk of injury to the patients in the event of an emergency.

NFPA 101 Life Safety Code 200 Edition,
9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

National Fire Protection Association 110, Standard for Emergency and Standby Power System, 1999 Edition:


5-11.1 The room in which the EPS equipment is located shall not be used for storage purposes.

Findings:

During tour of the facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the generator room was observed.

Main Hospital
1/29/15

At 10:29 a.m., there was construction supplies(metal piping and sheets) stored in the generator enclosure. Facilities Staff 82 was unable to open the right panel door of generator due to construction supplies obstructed the panel from fully opening.

Facilities Staff 82 concurred with the above finding.

Based on observation, the facility failed to maintain electrical safety in accrodance with NFPA 101, 2000 Edition and NFPA 99, 1999 Editon. This was evidenced by electrical appliances plugged into multi-plug, surged protector power-strips, overloaded power strips, and not maintaining power-strips used in anesthesia location. This affected 2 of 2 floors and 1 of 3 floors of Outpatient pre-operative Building. This could potentially cause a fire and potential harm to patients and staff in the event of a fire emergency.


NFPA 99 Health Care Facilities 1999 Editions.
7-6.2.4* Electrical equipment used within oxygen delivery equipment shall be listed for use in oxygen-enriched atmospheres, or sold with the intent to be used in oxygen-enriched atmospheres.

NFPA 70 Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:

(1) As a substitute for a 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, or floors

(6) Where installed in raceways, except as otherwise permitted in this code



Section 210-20 (b) Receptacles. 2. Where connected to branch circuit supplying tow or more receptacle or outlets, a receptacle shall not supply a total cord-and plug connected load in excess of the maximum specified in Table 210-21 (b)(2).

Table -21 (b)(2). Maximum Cord- and Plug Connected Load to Receptacle

Circuit Rating Receptacle Rating Maximum Load
(Amperes) (Amperes) (Amperes)
15 or 20 15 12
20 20 16
30 30 24



Findings:

During a tour of the facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the facility electrical outlets were observed. Facility did not have a categorical waiver for power-strips.

Main Hospital
1/27/15
1. At 4:01 p.m., in Bio-Med room on the first floor, there was a power-strip plugged into another power-strip.

1/29/15
2. At 11:09 a.m., a coffee machine was plugged into a power-strip in the Respiratory office on the second floor.

3. At 12:05 p.m., a toaster over, Keurig coffee pot, microwave and Pure Water- water cooler dispenser plugged into a power-strip in surgery employee lounge.

4. At 12:12 p.m., there was no maintenance tag attached to the multi-plugs power-strip strapped to the anesthesia machine in the Operating Room 3 and next to the power-strip were two E-sized oxygen cylinders installed on the anesthesia machine.

5. At 12:13 p.m., there was a multi-plug power-strip fixed to the wall in Operating Room 3.

During interview with Facilities Staff 82, he stated facilities engineer did not do any maintenance and leak test for both the power-strips installed in the Operating Room 3 and could not verified if the power strips meet the requirements for anesthesia location.

Outpatient Pre-operative Building
1/28/15
6. At 2:18 p.m., a micro-wave, toaster, office hole-puncher, and refrigerator plugged into the same multi-plug power-strip(Triplite power tap 58 M7). Per manufactory label, the refrigerator was 15 amperes, the micro-wave 1.3 amperes, and toaster 1.1 amperes making the total amperes for the power-strip 17.4 amperes.



29665

Main Building
1/29/15

7. At 2:34 p.m., there was a refrigerator plugged into a power strip in the physicians dictation room (Door 1-01-5137) located in the Cardiopulmonary corridor.

8. At 2:50 p.m., there was refrigerator, microwave, and coffee machine plugged into a power strip in the alcove across from Door 2-01-5104.

Based on observation, the facility failed to maintain their doors. This was evidenced by corridors doors obstructed from closing and doors that failed to close and latch. This affected 2 of 2 floors of the Main Hospital. This could result in the spread of smoke and fire throughout the facility and the increased risk of injury to the patients due to smoke and fire.

Findings:

During facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, the doors were observed.

Main Hospital
1/29/15
1. At 11:15 a.m., a plastic door wedge positioned under the door leaf obstructed Environmental Services door on the 2nd floor from closing.

2. At 11:21 a.m., Room 213, a trash can and laundry bin blocked the door from closing.

3. At 3:03 p.m., in the Inpatient Rehabilitation Unit, both Dining Room doors failed to close and latch. The doors were equipment with self-closing devices.

4. At 3:14 p.m., in the Inpatient Rehabilitation Unit, plastic wedge door stopper positioned under the door leaf of the Community Program Coordinator office obstructed the door from closing.

Based on observation, the facility failed to maintain its smoke barrier doors. This was evidenced by smoke barrier doors that failed to latch. This affected 2 of 2 floors of the Main Hospital and 2 of 2 floors of Critical Care Pavilion(CCP). This finding could result in the spread of smoke from one smoke compartment to another and increase the risk of injury to patients and staff in the event of a fire.

Findings:

During the facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, the smoke barrier doors were observed.

Main Hospital
1/28/15

1. At 9:43 a.m., the smoke barrier double doors by 1 North Laboratory were held open with electronic automatic-closing devices. The left door failed to latch when closed upon activation of the fire alarm system.

2. At 10:16 a.m., the smoke barrier double doors by Room 211 were held open with electronic automatic-closing devices. The left door failed to latch when closed upon activation of the fire alarm system.

3. At 10:27 a.m., the smoke barrier double doors by Room 270 were held open with electronic automatic-closing devices. The left door failed to latch when closed upon activation of the fire alarm system.

Critical Care Pavilion
1/28/15
4. At 10:48 a.m., the Emergency Department waiting room smoke barrier double doors were held open with electronic automatic-closing devices. The left door failed to latch when closed upon activation of the fire alarm system.

Based on record review, the facility failed to maintain their battery-powered emergency lights. This was evidenced by no records of monthly and annual testing of the emergency lights. This affected patients undergoing procedures in the Birthing Pavilion Operating Room 2 (BP OR 2) at the Main Hospital and patients at the Outpatient Rehabilitation building. This could result in a delay in evacuation in the event of an emergency due to limited visibility.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

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 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 1/27/15 to 1/29/15, the emergency lights were observed and testing records were reviewed.

Outpatient Rehabilitation
1/29/15

1. At 4:35 p.m., the building plans for the Outpatient Rehabilitation suite were provided. Sheet E2.1, the emergency lighting plan, showed that multiple ballasts were equipped with 90-minute battery back up. There were no records of testing monthly and annual testing of these emergency lights.

Main Hospital
1/30/15

2. At 8:45 a.m., there were no records of monthly and annual testing of the ballast lights, equipped with emergency battery power, in BP OR 2 (also named C-Section Room 2).

Based on observation, the facility failed to maintain their emergency exit signs. This was evidenced by expired exit photo-luminous signs and no records of testing the exit signs. This affected 1 of 2 floors of the Main hospital, 1 of 3 floors of Outpatients Pre-operative Building and Outpatient Rehabilitation. This could result a delay evacuation in the event of an emergency due to limited visibility and possible harm to patients..

NFPA 101 Life Safety Code, 2000 Edition

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceeds 30 days.

NFPA 101, Life Safety Code, 2000 Edition.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

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 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.


Findings:

During tour of facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the photo-luminous signs were observed.

310 Building Out-patients pre-operative
1/28/15
1. At 2:20 p.m., the photo-luminous exit sign above exit door of Suite 105 had an expiration date of 1999.

Main Hospital
1/29/15
2. At 3:18 p.m., the photo-luminous exit sign by exit door of the Inpatient Rehabilitation lobby had an expiration date of 1996.



29665

During record review with staff from 1/27/15 to 1/30/15, the exit signs were observed and maintenance records reviewed.

Outpatient Rehabilitation
1/28/15

3. At 1:57 p.m., the Outpatient Rehabilitation suite had hard-wired exit signs that were equipped with battery back-up power.
During an interview at 1:58 p.m., Facilities Staff 83 stated that the exit signs were not tested monthly or annually.

Based on observation and interview, the facility failed to instruct their staffs on their role to protect their patients in the event of an emergency. This was evidenced by the staff's lack of familiarity with their duties in an emergency event and facility emergency policy did not match staffs safety practices. This could result in delayed response from staff and potential harm to patients in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

9.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2)Transmission of alarm to fire department
(3)Response to alarm
(4)Isolation of fire
(5)Evacuation of immediate area
(6)Evacuation of Smoke compartment
(7)Preparation of floors and building for evacuation
(8)Extinguishment of fire

Findings:

During the facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, staffs were interviewed to determine their knowledge of facility written safety plan.
The Emergency Management(ENC-FW-EM-4011)policy indicated Evacuation will be to the nearest area of refuge, at a minimum to the nearest smoke compartment(beyond the nearest building corridor fire rated door).

Facility policy on Chemical or biological Spill or Contamination(S-FW-EM-4010)indicated for the laboratory hazardous materials were Acids, Bases, Acetone- xylene and Formaldehyde(Formalin).

Main Hospital
1/29/15
1. At 11:18 a.m., during interview with Housekeeping Staff 74, she was unfamiliar with evacuation to an area of refuge or smoke compartment(beyond the nearest building corridor fire rated door).

2. At 11:42 a.m., during interview with Laboratory Staff 76, she stated the facility was not equipped with hazardous materials as far as she knew and would be unfamiliar with emergency spill procedures for hazardous materials. Laboratory Staff 76 was unfamiliar with facility hazardous materials used in the laboratory and the emergency spill procedures for hazardous materials.

3. At 2:42 p.m., during interview with Registered Nurse (RN)71, she was unfamiliar with the definition of evacuation to safe area on the floor.

310 Building- Outpatient pre-operative
1/28/15

4. At 2:13 p.m., Facility disaster manual located within the suite stated facility staff would dial 7770 for PBX(at the Main Hospital )to announce a Code Red for a fire. The suite was located on the first floor of a three stories sprinklered only building.

310 Building- Outpatient Pre-operative
1/30/15

5. At 10:15 a.m., during interview with Registered Nurse 77 and 78, they both stated they would call 911 if they discover a fire and that the sprinkler system would activate automatically within the building to notified occupants of a fire. They stated that the activation of one sprinkler head will activate all there others within the building.

Registered Nurses 77 and 78 were unfamiliar with how the building sprinkler system operate in the event of a fire, and facility Disaster manual did not match the actions RNs stated they would take in the event of a fire.



29665

Main Building
1/28/15

6. At 9:24 p.m., Laboratory Staff 86 was asked what procedures she would perform in the event of a fire. She failed to indicate that she would activate a manual pull station to alert the rest of the building.

Outpatient Rehabilitation
1/28/15

7. At 1:46 p.m., the Outpatient Rehabilitation was observed. The building was not equipped with any fire alarm devices and was not provided with overhead paging capabilities. There was no fire response policy provided.
During an interview at 1:47 p.m., Safety Staff 83 stated that the outpatient building did not have its own specific fire response policy.

8. During an interview at 1:48 p.m., Outpatient Rehabilitation Staff 84 stated that a power outage occurred at the facility approximately 1 month ago and the facility continued to see some patients during the outage. Outpatient Rehabilitation Staff 84 was unsure if the facility was equipped with emergency lighting. He stated that facility staff used flashlights from the emergency kits. There were two working flashlights, two still in their packaging, and one lantern that failed to illuminate when tested.
During an interview at 1:54 p.m., Safety Staff 83 stated that the outpatient building did not have its own specific power outage policy.

Facilities Staff 82, Safety Staff 83, and Outpatient Rehabilitation Staff 84 did not state that the facility was equipped with battery-powered ballast lights as confirmed the facility's building plans.

1/29/15

9. At 9:44 a.m., a "Code White" policy for power outages was provided as the policy to be used at the Outpatient Rehabilitation Building. One of the "mitigation capabilities" listed in the policy was "Emergency Power system (red outlets)" and one of the "actions to be taken" was to restrict electrical consumption to essential needs and "plug essential equipment into red outlets." The Outpatient Rehabilitation Building did not have red outlets or emergency power.

During an interview at 1:30 p.m., Administrative Staff 85 confirmed that the outpatient buildings do not have their own specific policies for fire response and other emergencies.

Based on record review, the facility failed to accomplish all of the requirements for fire drills for laboratory staff in the last 12 months. This was evidenced by the facility failure to provide documents to show 3 of 4 fire drills were conducted in the last 12 months and ensure employees participated in fire drills and familiar with fire and or fire drills policies. This could result in staff members not accomplishing all of the tasks required of him or her during conditions that are expected to exist in the event of a fire and increased risk of injury to the patients.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During record review with the Facilities Staff 82 from 1/27/15 to 1/30/15, the fire drill records were reviewed.
Facilities written policy on discover of fire (CODE RED -ENC-FW-EM-4011) was RACE.
Rescue: Evacuate all persons in immediate danger from the involved area.
Alarm: Notify the Fire Department by activating the nearest fire alarm box and call the communications center operator (PBX) at the appropriate emergency number, giving location of the fire and your name.
Confine: Confine the fire to one area by closing all doors, windows and securing oxygen in the vicinity of the fire, only if this can be accomplished without jeopardizing individual safety.
Extinguish: Take actions to put out or reduce fire until arrival of emergency response personnel.

Communications Center Operator (PBX)
1. Will alert the facility
2. Will ensure notification to the supporting fire department has been accomplished
3. Will make other notification in accordance with standard operation procedures of the facility.

Main Hospital
1/27/15

At 12:05 p.m., the laboratory fire drills indicated only 1 of 4 fire drills were conducted in the last 12 months. Facility failed to provide documents to show 3 of 4 fire drills conducted for laboratory staff.

At 12:06 p.m., 80 percent of fire drills record indicated action taken in response to the fire doors were marked "not applicable."

At 12:06 p.m., during interview with Facilities Staff 82, he stated drills were conducted per department and only department staff participated in the drills for their department. Facilities Staff 82 stated the fire doors were disabled from the fire alarm system during fire drills.


At 12:10 p.m., the fire drills record indicated that not all employees participated in the fire drills.

At 3:41 p.m., during interview with Chef 72, he stated that during kitchen fire, he believed the ansul automatic suppression system of the Kitchen will automatically call the Fire Department and notify the Facility Security and Security will notify the whole building.

At 3:55 p.m., during interview with Staff 73, he stated the extinguisher in the Kitchen is for electric fire and combustible.

1/29/15

At 12:09 p.m., during interview with Scheduler Staff 77, she stated she would dial the fire code and alert her manager if she discover a fire. She also stated she should do more but could not remember all the actions and has worked for the facility for 8 years.

At 2:42 p.m., during interview with Registered Nurse 71, she stated the action she would take if she discover a fire would be to evacuate. Registered Nurse 71 worked for facility for 15 years.

At 4:21 p.m., during interview with the Housekeeping Staff 75, she was unfamiliar with the actions to take if she discover a fire. Housekeeping Staff 75 stated she would use a fire extinguisher if she discover a fire. Housekeeping Staff stated she has worked for the facility for 15 years.

Facility failed to ensure all employees participates in fire drills and familiar with facility fire and fire drill policies.

Based on observation, the facility failed to maintain their fire alarm system. This was evidenced by the failure to provide dates of installation for two sealed lead-acid batteries at a fire alarm panel, by the failure of sprinkler system waterflow devices to initiate an alarm within 90 seconds and fire alarm panel room was not equipped with a early detection device. This affected two of two stories in the Main Building and the 310 Building and could result in a delay in notification, in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

4.1.1 Fire and Similar Emergency. The goal of this Code is to provide an environment for the occupants that is reasonably safe from fire and similar emergencies by the following means:
(1) Protection of occupants not intimate with the initial fire development
(2) Improvement of the survivability of occupants intimate with the initial fire development.

4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-6 Sprinkler Waterflow Alarm-Initiating Devices.
2-6.1 The provisions of Section 2-6 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Table 7-3.2 Testing Frequencies
6. Batteries - Fire Alarm Systems
d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years.)

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a facility tour with staff from 1/27/15 to 1/30/15, the fire alarm system was observed and maintenance records were reviewed.

Main Building
1/28/15

1. At 9:43 a.m., there were two sealed-lead acid batteries in the fire alarm panel, located in the IS Room by the loading dock. The batteries were not dated. The date of installation of the batteries was requested from facility staff but never provided. It could not be confirmed if the batteries were replaced in the last four years.

2. At 10:14 a.m., the Inspector's Test Valve (ITV) in the electrical closet of the Neonatal Intensive Care Unit (NICU) was tested by Facilities Staff 87. The alarms activated after 1 minute and 31 seconds of the waterflow. The ITV failed to activate an alarm within 90 seconds.

310 Building ( Outpatient Pre-Operative)
1/28/15

3. At 2:23 p.m., the ITV on the third floor was opened by Facilitiy Staff 88. After 2 minutes, the sprinkler alarm bell failed to activate.
During an interview at 2:36 p.m., Facilities Staff 88 stated that the monitoring company did not receive any alarm signals.
The ITV failed to initiate an alarm within 90 seconds.



29566

National Fire Protection Association, 72 National Fire Alarm Code, 1999 Edition.
1-5.6* Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit (s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

During facility tour with the Facilities Staff 82 from 1/28/15 to 1/30/18, the fire alarm panel was observed.

310 Building- Outpatients Pre-operative
1/28/15

4. At 2:31 p.m., the fire alarm panel was mounted in a room on the lower level of out-patient pre-operative building. The room was not equipped with a smoke detector.

Facilities Staff 2 concurred with the finding above.

Based on observation and interview, the facility failed to maintain their sprinkler control valves. This was evidenced by two supervised outside screw and yolk (OS&Y) valves that failed to activate a supervisory alarm when closed. This affected the 310 building and could result in a delay in response, in the event the valves are tampered with.
NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

19.3.5.2 Where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.
9.7.2 Supervision.
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
2-9 Supervisory Signal-Initiating Devices.
2-9.1 Control Valve Supervisory Signal-Initiating Device.
2-9.1.1 Two separate and distinct signals shall be initiated: one indicating movement of the valve from its normal position and the other indicating restoration of the valve to its normal position. The off-normal signal shall be initiated during the first two revolutions of the hand wheel or during one-fifth of the travel distance of the valve control apparatus from its normal position. The off-normal signal shall not be restored at any valve position except normal.

Findings:

During a facility tour with staff from 1/27/15 to 1/30/15, the tamper switches on the sprinkler control valves were tested.

310 Building
1/28/15

1. At 2:30 p.m., the North OS&Y valve was closed all the way by Facilities Staff 88. Closure of the valve failed to initiate a supervisory signal at the fire alarm panel.

2. At 2:31 p.m., the South OS&Y valve was closed all the way by Facilities Staff 88. Closure of the valve failed to initiate a supervisory signal at the fire alarm panel.

During an interview at 2:36 p.m., Facilities Staff 88 stated that the monitoring company did not receive any supervisory signals.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system in reliable operating condition. This was evidenced by sprinkler heads exhibited signs of corrosion and had built-up of debris. This affected Main Hospital, Outpatient Pre-operative building, and Outpatient Imaging(320 building). This could result in reduced effectiveness of the sprinkler system and cause injury to patients from fire.

Findings:

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.


9.7.3 Other Automatic Extinguishing Equipment.
9.7.3.1 In any occupancy where the character of the potential fuel for fire is such that extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as water mist, carbon dioxide, dry chemical, foam, Halon 1301, water spray, or a standard extinguishing system of another type, that system shall be permitted to be installed in lieu of an automatic sprinkler system. Such systems shall be installed, inspected, and maintained in accordance with appropriate NFPA standards.


9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.


NFPA 2001, Standard on Clean Agent Fire Extinguishing Systems, 2000 Edition.
4-1.1 At least annually, all systems shall be thoroughly inspected and tested for proper operation by competent personnel. Discharge tests are not required.
4-1.2 The inspection report with recommendations shall be filed with the owner.
4-1.3 At least semiannually, the agent quantity and pressure of refillable containers shall be checked.
4-2.1 U.S. Department of Transportation (DOT), Canadian Transport Commission (CTC), or similar design clean agent containers shall not be recharged without retesting if more than 5 years have elapsed since the date of the last test and inspection. For halocarbon agent storage containers, the retest shall be permitted to consist of a complete visual inspection as described in 49 CFR 173.34(e)(10).
Transporting charged containers that have not been tested within 5 years could be illegal. Federal and local regulations should be consulted.
4-2.2 Cylinders continuously in service without discharging shall be given a complete external visual inspection every 5 years or more frequently if required. The visual inspection shall be in accordance with Section 3 of CGA C-6, Standard for Visual Inspection of Steel Compressed Gas Cylinders, except that the cylinders need not be emptied or stamped while under pressure. Inspections shall be made only by competent personnel and the results recorded on both of the following:
(1) A record tag permanently attached to each cylinder
(2) A suitable inspection report
A completed copy of the inspection report shall be furnished to the owner of the system or an authorized representative. These records shall be retained by the owner for the life of the system.
4-3.2.1 All hose shall be tested every 5 years.
4-3.2.2 All hose shall be tested at 11/2 times the maximum container pressure at 130¢XF (54.4¢XC). The testing procedure shall be as follows:
(a) The hose is removed from any attachment.
(b) The hose assembly is then placed in a protective enclosure designed to permit visual observation of the test.
(c) The hose must be completely filled with water before testing.
(d) Pressure then is applied at a rate-of-pressure rise to reach the test pressure within a minimum of 1 minute. The
test pressure is maintained for 1 full minute. Observations are then made to note any distortion or leakage.
(e) If the test pressure has not dropped or if the couplings have not moved, the pressure is released. The hose assembly is then considered to have passed the hydrostatic test if no permanent distortion has taken place.
(f) Hose assembly passing the test must be completely dried internally. If heat is used for drying, the temperature must not exceed the manufacturer ' s specifications.
(g) Hose assemblies failing a hydrostatic test must be marked and destroyed and be replaced with new assemblies.
(h) Each hose assembly passing the hydrostatic test is marked to show the date of test.


NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition.
5-5.5 Obstructions to Sprinkler Discharge.
5-5.5.1 Performance Objective. Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-5.5.2 and 5-5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. (See Figure A-5-5.5.1.)
5-5.5.2 Obstructions to Sprinkler Discharge Pattern Development.
5-5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2.
5-5.5.2.2 Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of Sections 5-6 through 5-11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.
5-5.5.3 Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.
5-5.5.3.1 Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place such as conference tables.
5-5.5.3.2 Sprinklers installed under open gratings shall be of the intermediate level/rack storage type or otherwise shielded from the discharge of overhead sprinklers.
5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1: Where other standards specify greater minimums, they shall be followed.
Exception No.2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the 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.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1: Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-3.2 Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

Table 9-1 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance indicates that backflow prevention assemblies are required to be tested annually in accordance with Section 9-6.2.

9-6.2.1 All backflow preventers installed in fire protection system piping shall be tested annually in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

9-6.2.2 All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

9-6.3.1 Maintenance of all backflow prevention assemblies shall be conducted by a trained individual following the manufacturer's instructions in accordance with the procedure and policies of the authority having jurisdiction.

9-7 Fire Department Connections.
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.

Findings:

During a facility tour with staff from 1/27/15 to 1/30/15, the automatic fire extinguishing systems were observed and maintenance records were reviewed.

Main Hospital
FM-200 Clean Agent System in IS Room by Loading Dock
1/29/15

1. At 8:50 a.m., the maintenance records provided showed that the FM-200 extinguishing system was inspected on 2/4/14 and 8/5/14. The vendor indicated on the 2/4/14 report that the activation hose was due to be replaced. There was no records provided showing if the hose was replaced.

2. At 8:51 a.m., there were no records provided of a five year inspection conducted on the FM-200 system.

3. At 8:52 a.m., the 2/4/14 the records indicated that the system's last hydrostatic test was in 1998. On the 8/5/14 record, the hydrostatic date was listed as 8/8/1999. The correct hydrostatic testing date was not confirmed by staff. According to the records provided, there has not been a hydrostatic test conducted in more than 14 years.

Main Hospital
1/28/15

4. At 4:12 p.m., the west outside screw & yolk (OS&Y) valve, outside the conference center, was leaking at the stem.

Main Hospital
1/29/15

5. At 9:00 a.m., records provided showed that the system side OS&Y for the Conference Center failed an inspection on 5/7/14. Descriptions of the failure could not be confirmed because of incomplete documentation. Records of repairing the failed OS&Y valve were not provided.

6. At 10:54 a.m., the discharge pattern of the sprinkler head in the 2 North electrical closet was obstructed by cable bundles. The cable bundles were less than one inch from the head.

7. At 2:51 p.m., the sprinkler head in the storage closet (Door 2-01-5101) was missing an escutcheon ring.


310 Building-Outpatients Pre-operative
1/28/15

8. At 2:11 p.m., the sticker on the sprinkler riser indicated that the sprinkler system was last certified by a vendor in July 2010. Records of that five-year testing was requested from facility staff but not provided. During an interview at 2:14 p.m., Facilities Staff 88 stated he tests the waterflows and tampers once a year. He provided a monitoring report from the central station showing that the waterflow was tested on 10/3/14. There were no other records of testing and inspecting the sprinkler system.
There were no records of quarterly testing of the Inspector's Test Valve (ITV), quarterly inspections of the fire department connections (FDCs), and annual testing of the two tamper switches.

9. At 2:32 p.m., the exterior control valves were labeled with identification signs that were not legible due to weather exposure.

10. At 2:33 p.m., during inspection of the FDCs, one cap was broken.

320 Building (Imaging)
1/28/15

11. At 2:58 p.m., the ITV was tested by Facilities Staff 88. The audible/visual notification devices in the building were activated within 48 seconds. The exterior sprinkler bell failed to alarm.




29566

During tour of facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the sprinkler heads were observed.

Main Hospital
1/27/15

12. At 10:24 a.m., in the Kitchen walk-in refrigerators, there were 2 sprinklers heads exhibited signs of corrosion. There were rust on the pendent arms and base connection.

1/29/15

13. At 2:56 p.m., two sprinkler heads in hallway by Room 150 of in-patient Rehabilitation had built-up of debris on their deflectors and pendant arms.

Out-patients pre-operative building
1/28/15

14. At 2:11 p.m., three sprinklers heads had built-up of debris on the sprinklers' deflectors and pendant arms in the hallway of Suite 105.

Based on observation and interview, the facility failed to maintain their fire extinguisher. This was evidenced by fire extinguisher not installed in accordance with NFPA 110, 1998 Edition and items blocking access to fire extinguisher. This could cause a delay in reaching the fire extinguisher and the potential of the fire spreading and causing harm to patients and staff in the event of a fire emergency. This affected 1 of 2 floors of main hospital and 1 of 3 floors of out-patients pre-operative building.

NFPA 10, Standards for Portable Fire Extinguishers 1998 Edition: 1-6.3 Fire extinguishers shall be conspicuously located where
they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal
paths of travel, including exits from areas.

1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb.(18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft.(1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg)(except wheeled type) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft. (1.07 m)above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.(10.2 cm).


Findings:

During the facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, the fire extinguishers were observed.

Main Hospital

1/27/15
At 4:06 p.m., boxes of supplies and a waste basket blocked readily access to fire extinguisher mounted on the wall in Bio-Med Room on first floor.

1/29/15
At 10:15 a.m., a fire extinguisher was placed standing on the floor by the entrance of the broiler room.

310 Building-Outpatients Pre-operative
1/28/15
At 2:09 p.m., the fire extinguisher in hallway of Suite 105 was mounted 64 inches from the floor.

Based on observation, record review and interview, the facility failed to ensure that the installed ventilation equipment were in compliance with all applicable codes. This was evidenced by no records of approval for the installation of a window mounted air exhaust/filtration appliance used to convert a patient room into a negative pressure isolation room. This was also evidenced by no records of testing the device in accordance with the manufacturer's specifications. This affected patients who receive treatment in that room.

NFPA 101, Life Safety Code, 2000 Edition.
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.
2-1.3 Equipment shall be guarded for personnel protection and against the intake of foreign matter into the system.

Findings:
During tour of the facility with staff from 1/27/15 to 1/30/15, the patients rooms were observed.

Main Building
1/29/15

1. At 3:37 p.m., there was a window-mounted air exhaust/HEPA filtration device in Labor Room 105. The system was installed to turn the patient room into a negative pressure isolation room.
There were no records of installation of the device in accordance with the manufacturer's specifications and approval from authority having jurisdiction.

1/30/15

2. At 10:14 a.m., maintenance logs provided by Facilities Staff 81 indicated that Facilities Staff 89 conducts negative pressure air balance tests on a monthly basis.
During an interview at 10:45 a.m., Facilities Staff 89 stated that he does not conduct an air balance test. He visually checks the prefilter every month.
The monthly logs were not documented accurately.

3. At 10:17 a.m., the device's instruction manual stated the only maintenance that the device needs is changing the filters (both the prefilters and hepafilters). The manual states that the way to determine if the filters need changing is by adjusting the (cubic feet per minute) CFM dialer that controls the exhaust flowrate. The color of the indicator light is an indication that one of the filters needs replacement.
During an interview at 10:47 a.m., Facilities Staff 89 stated that he changes the prefilter based on the amount of debris visible. He did not mention inspecting the CFM indicator light.

4. At 10:50 a.m., records showed that the most recent air balance test was conducted by vendor on 7/14/14. In the report, the vendor stated that the required exhaust CFM for the room was not provided so the exhaust reading measured during the test could not be compared with the required value.

Based on observation, interview and record review, the facility failed to maintain their Kitchen Hood to prevent grease fire. This was evidenced by layer of grease in the hood of the stove area and on the fire suppression system. This affected 1 of 2 floors of the Main Hospital. This could result in increased risk of fire and potential cause injury to patients and staff from fire.



NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition 8.3.1* Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Table 8-3.1

Type or Volume of Cooking Frequency

Systems serving high-volume cooking operations such as
24-hour cooking, charbroiling or wok cooking. Quarterly



Findings:

During a tour of the facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the Kitchen was observed.

Main Hospital
1/27/15

At 10:22 p.m., there was a built-up of grease inside the hood of the stove and grills. There were deposit of grease on the fire suppression system pipes inside the hood and dripping of grease on inside the hood. There were built-up of grease and debris on the fire suppression pipes over the stove and grill. The filters had grease and debris.

At 1:47 p.m., Facilities Staff 81 stated the area around the stove and grill was closed for weeks and due to installation of new flooring under the stove and grill.

During record review, the kitchen records indicated the last cleaning of the hood was done on 7/3/14.

Based on observation and record review, the facility failed to ensure that portable space heaters used in non-sleeping staff areas complied with the requirements of NFPA 101, 2000 Edition. This was evidenced by the use of space heaters with heating element temperatures exceeding 212 degrees Fahrenheit. This affected 1 of 2 floors of main hospital. This could result in increased risk of fire and potential cause injury to patients and staff from fire.


NFPA 101, Life Safety Code, 2000 Edition.
19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212¿EF (100¿E
Findings:

During a facility tour with the Safety Staff 83 from 1/27/15 to 1/30/15, portable space-heaters were observed

Main Building
1/29/15

1. At 8:39 a.m., a policy titled "Space Heater, Guidelines" with identifier ENC-FW-EC-1056,last revised 09/12, was provided. The policy indicated that the temperature of the space heater heating elements shall not exceed 212¿EF.
When the manufacturer specifications for the heater model, approved for use by the facility, was requested, a "Certificate of Conformance" signed by manager from the manufacturer was provided. The product manual was not provided.
In the Certificate of Conformance, the maximum operating temperature of the heating element was listed as 257¿EF.

The portable space heaters observed during the survey were the model described in the Certificate of Conformance.

2. At 11:52 a.m., there was a portable space heater in the doctor sleep room (Door 4-01-6136) in the east ICU corridor.

3. At 11:56 a.m., there was a portable space heater in the surgical administration office (Door 4-01-6132) in the east ICU corridor.



29566



During a tour of the facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, non-sleeping staff room was observed.

Main Hospital
1/28/15

4. At 9:21 a.m., a portable space heater was placed on the floor between office furniture's in the PBX (private branch exchange) office.

Based on observation, the facility failed to maintain the access to a primary means of escape as evidenced by furniture and items blocked egress corridors. This could result in the delay in the evacuation of the facility and the increased risk of injury to the patients and staff due to fire.
Findings:
During the facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, the egress's corridors were observed.
Outpatient Physical Therapy
1/28/15
1. At 1:43 p.m., an industrial copier machine and open-faced storage cube furniture located in the egress corridor path in-front of the exit door to the side parking lot.
Main Hospital
1/29/15
2. At 11:27 a.m., by the linen room on the first floor, there were two linen carts approximately measured 4 feet by 2 feet and 70 inches in height each stored in the egress corridor. One of two linen carts was observed in the corridor at approximately 10:20 a.m.
3. At 11:37 a.m., employees mail-slots cupboard, and trash bin on the right and employee lockers cabinet on the left of the egress path in-front of the laboratory suite exit door. The egress path measured approximately 38 inches in width. Furniture and items blocked the egress path and reduced egress width to the exit door of the laboratory suite.

Based on observation and interview, the facility failed to maintain cylinder safety in accrodance with NFPA 99, 1999 Edition. This was evidenced by more than one cylinder secured with one chain and cylinders exposed to the elements. This affected 1 of 2 floors of the Main Hospital and 1 of 2 floors of Critical Care Pavilion (CCP). This could cause a potential hazard for the facility and possible harm to patients and staff due to a hazardous condition.
National Fire Protection Association Health Care Facilities -99, 1999 Edition-
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.5.2.2 (b)Nonflammable Gases
3. Cylinders stored in open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter, cylinders stored in the open shall be protected against accumulations of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.
Findings:
During tour of the facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the oxygen cylinders piped-in storage areas were observed.
Main Hospital
1/29/15
At 10:40 a.m., there were more than one H- sized cylinders secured with one chain. Cylinders were movable with light pressure to secure them.
CCP
1/29/15
At 10:54 a.m., there were 7 H-sized cylinders standing in water(approximately 1/2 inches of water)in the oxygen piped-in gas storage area.
At 10:55 a.m., Facilities Staff 82 stated the water under the cylinders were due to the morning dew and weather.

Based on record review, the facility failed to provide documentation that they were electing to lower the relative humidity to 20 percent in accordance to S & C 13-25. This was evidenced by the facility's adopting humidity levels in the operating rooms between 20% and 60%, without categorical waiver, by records showing the relative humidity levels in the operating rooms falling below 35%, and by records showing that surgeries were conducted in the operating rooms on days where the humidity levels were not recorded. This was also evidenced by no battery-powered lighting in one anesthetizing location. These deficient practices could result in the increased risk of a fire. This affected surgical patients undergoing procedures in the main operating rooms and the Birthing Pavilion operating rooms, located on the first floor of the Main Building.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.2 All Patient Care Areas. (See Chapter 2 for definition of Patient Care Area.)
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Chapter 2 definitions:
Patient care area. Any portion of a health care facility wherein patients are intended to be examined or treated.

Anesthetizing Location. Any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.

Relative Analgesia. A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).

Chapter 5 Environmental Systems
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

5-6.1 Anesthetizing Locations.
5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures.

NFPA 70, National Electrical Code, 1999 Edition
700-12 (e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment

The batteries shall be of suitable rating and capacity to supply and maintain at not less than 871/2 percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 11/2 hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 11/2 hours. Storage batteries, whether of the acid or alkali type, shall be designed and constructed to meet the requirements of emergency service.

Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.

Exception: In a separate and uninterrupted area supplied by a minimum of three normal lighting circuits, a separate branch circuit for unit equipment shall be permitted if it originates from the same panelboard as that of the normal lighting circuits and is provided with a lock-on feature.

Findings:

During a facility tour with staff from 1/27/15 to 1/30/15, the anesthetizing locations were observed and relative humidity records were reviewed.

Main Building
1/27/15

1. At 3:16 p.m., the "Temperature and Related Humidity Ranges, Preventative Maintenance and Monitoring" policy, dated 08/14, indicated that the relative humidity in the operating rooms (ORs) was to be monitored to ensure that it falls between 20% and 60%.
The facility did not provide an approved categorical waiver in accordance with the provisions of a Survey and Certification memorandum (S&C-13-25-LSC) published by the Centers for Medicare & Medicaid Services (CMS) on 4/19/13, allowing for facilities to lower the relative humidity in the ORs from 35% to 20%.

2. At 3:25 p.m., the humidity and temperature logs provided showed that the relative humidity fell below 35% in the following ORs:

a. On 12/25/14, the relative humidity was recorded as 26% in Birthing Pavilion Operating Room (BP OR) 1.
b. On 12/26/14, the relative humidity was recorded as 25% in BP OR 1.
c. On 12/27/14, the relative humidity was recorded as 22% in BP OR 1.
d. On 12/28/14, the relative humidity was recorded as 31.2% in OR 1, 29.5% in OR 2, 29.3% in OR 3, 30% in OR 4, and 27% in BP OR 1.
e. On 12/29/14, the relative humidity was recorded as 33% in BP OR 1.
f. On 12/30/14, the relative humidity was recorded as 35% in BP OR 2.
g. On 12/31/14, the relative humidity was recorded as 26% in OR 1, 29% in OR 2, 22% in OR 3, 21% in OR 4, and 26% in BP OR 1.
h. On 1/5/15, the relative humidity was recorded as 29% in OR 4 and 25% in BP OR 1.
i. On 1/24/15, the relative humidity was recorded as 21% in OR 1, 24% in OR 2, 24% in OR 3, 22% in OR 4, and 24% in BP OR 1.
j. On 1/25/15, the relative humidity was recorded as 20.2% in OR 1, 20.4% in OR 2, 21% in OR 3, 29.6% in OR 4, and 27% in BP OR 1.

3. At 3:30 p.m., the temperature and humidity logs indicated that the relative humidity was recorded as UTM1 on several occasions. The legend on the form indicated that UTM1 meant "unable to measure." The relative humidity was recorded as UTM1 on the following days:

a. On 10/9/14, the relative humidity in OR 2 was recorded as UTM1.
b. On 11/26/14, the relative humidity in OR 1 was recorded as UTM1.
c. On 12/1/14, the relative humidity in OR 3 was recorded as UTM1.
d. On 1/6/15, the relative humidity in OR 1 was recorded as UTM1.
e. On 1/8/15, the relative humidity in BP OR 1 was recorded as UTM1.
f. On 1/12/15, the relative humidity was recorded as UTM1 for OR 1, OR 2, OR 3, OR 4, and BP OR 1.

Surgery schedules provided by Administrative Staff 85 showed that procedures were conducted in all the rooms during the dates above where their relative humidity levels were not measured and recorded.

Main Building
1/29/15

4. At 3:21 p.m., there were no battery-powered lights in Birthing Pavilion Operating Room (BP OR 1).
During an interview at 4:43 p.m., Facilities Staff 81 confirmed that BP OR 1 was not equipped with battery-powered lights.

Based on observation and interview, the facility failed to maintain fire safety in their old emergency department area. This was evidenced by converting the old emergency suite into central supplies storage for the hospital without approval from authority having jurisdiction. The authority having jurisdiction ensure hospitals' facilities/suites meets applicable fire and safety codes. This affected 1 of 2 floors of the Main Hospital. This could result in fire sprinklers system protection ineffective in the event of a fire due to high hazard load and potential harm patients and staff.

Code of Federal Regulations:

§482.41 (a)Standard: Buildings. The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.
(c) Standard: Facilities. The hospital must maintain adequate facilities for its services.
(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.



Findings:

During tour of facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the emergency suite was observed.

Main Hospital

1/29/15
1. At 2:28 p.m., the old emergency suite on the first floor was converted to Central Supplies storage for the Hospital. The suite stored boxes of supplies(combustibles materials) in old bed stalls and egress path of the suite. Facility failed to ensure the suite meet approval for storage of more than average amount of stored supplies, fire sprinkler coverage would be adequate for the area and storage materials. Facility failed to ensure the approval from authority having jurisdiction that the emergency suite conversion to a storage suite was an acceptable level of safety for patients.

2. At 2:28 p.m. one of the door leaf of a double doors removed within the emergency suite.

3. At 2:30 p.m., interview with Facilities Staff 82, he stated the space conversion was done August, 2014 without approval from authority having jurisdiction.

1/30/15
4. At 8:30 a.m., reviewed of all the Facilities' approval plans from authority having jurisdiction given to surveyors did not indicate prior approval for the emergency suite conversion to central supplies storage room.

Based on observation and interview, facility failed to maintain oxygen cylinder safety in accordance with NFPA 99, 1999 Edition. This was evidenced by rooms that stored oxygen cylinders not equipped with a precautionary signs on the door. This affected 2 of 2 floors. This could potential cause a hazard and increase the risk of injury to staff and patients.
NFPA 99, Health Care Facilities 1999 Edition
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft.(1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES)STORED WITHIN
NO SMOKING

Findings:
During facility tour with the Facilities Staff 82 from 1/27/15 to 1/30/15, the corridor rooms were observed.
Main Hospital
1/27/15
1. At 4:04 p.m., the door to the Bio-Med room was not equipped with a pre-cautionary sign. The Bio-Med room stored oxygen cylinder.
1/29/15
2. At 11:10 a.m., on the second floor, the door to Respiratory room was not equipped with a pre-cautionary sign. The Respiratory room stored oxygen cylinder.
Facility Respiratory staff concurred that the room stored oxygen cylinder.

Based on interview and observation, the facility failed to maintain the emergency generator. This was evidenced by items stored in the generator enclosure/room. This affected 2 of 2 floors of the Main Hospital. This could create a potential hazard and could result in a potential risk of injury to the patients in the event of an emergency.

NFPA 101 Life Safety Code 200 Edition,
9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

National Fire Protection Association 110, Standard for Emergency and Standby Power System, 1999 Edition:


5-11.1 The room in which the EPS equipment is located shall not be used for storage purposes.

Findings:

During tour of the facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the generator room was observed.

Main Hospital
1/29/15

At 10:29 a.m., there was construction supplies(metal piping and sheets) stored in the generator enclosure. Facilities Staff 82 was unable to open the right panel door of generator due to construction supplies obstructed the panel from fully opening.

Facilities Staff 82 concurred with the above finding.

Based on observation, the facility failed to maintain electrical safety in accrodance with NFPA 101, 2000 Edition and NFPA 99, 1999 Editon. This was evidenced by electrical appliances plugged into multi-plug, surged protector power-strips, overloaded power strips, and not maintaining power-strips used in anesthesia location. This affected 2 of 2 floors and 1 of 3 floors of Outpatient pre-operative Building. This could potentially cause a fire and potential harm to patients and staff in the event of a fire emergency.


NFPA 99 Health Care Facilities 1999 Editions.
7-6.2.4* Electrical equipment used within oxygen delivery equipment shall be listed for use in oxygen-enriched atmospheres, or sold with the intent to be used in oxygen-enriched atmospheres.

NFPA 70 Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:

(1) As a substitute for a 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, or floors

(6) Where installed in raceways, except as otherwise permitted in this code



Section 210-20 (b) Receptacles. 2. Where connected to branch circuit supplying tow or more receptacle or outlets, a receptacle shall not supply a total cord-and plug connected load in excess of the maximum specified in Table 210-21 (b)(2).

Table -21 (b)(2). Maximum Cord- and Plug Connected Load to Receptacle

Circuit Rating Receptacle Rating Maximum Load
(Amperes) (Amperes) (Amperes)
15 or 20 15 12
20 20 16
30 30 24



Findings:

During a tour of the facility with the Facilities Staff 82 from 1/27/15 to 1/30/15, the facility electrical outlets were observed. Facility did not have a categorical waiver for power-strips.

Main Hospital
1/27/15
1. At 4:01 p.m., in Bio-Med room on the first floor, there was a power-strip plugged into another power-strip.

1/29/15
2. At 11:09 a.m., a coffee machine was plugged into a power-strip in the Respiratory office on the second floor.

3. At 12:05 p.m., a toaster over, Keurig coffee pot, microwave and Pure Water- water cooler dispenser plugged into a power-strip in surgery employee lounge.

4. At 12:12 p.m., there was no maintenance tag attached to the multi-plugs power-strip strapped to the anesthesia machine in the Operating Room 3 and next to the power-strip were two E-sized oxygen cylinders installed on the anesthesia machine.

5. At 12:13 p.m., there was a multi-plug power-strip fixed to the wall in Operating Room 3.

During interview with Facilities Staff 82, he stated facilities engineer did not do any maintenance and leak test for both the power-strips installed in the Operating Room 3 and could not verified if the power strips meet the requirements for anesthesia location.

Outpatient Pre-operative Building
1/28/15
6. At 2:18 p.m., a micro-wave, toaster, office hole-puncher, and refrigerator plugged into the same multi-plug power-strip(Triplite power tap 58 M7). Per manufactory label, the refrigerator was 15 amperes, the micro-wave 1.3 amperes, and toaster 1.1 amperes making the total amperes for the power-strip 17.4 amperes.



29665

Main Building
1/29/15

7. At 2:34 p.m., there was a refrigerator plugged into a power strip in the physicians dictation room (Door 1-01-5137) located in the Cardiopulmonary corridor.

8. At 2:50 p.m., there was refrigerator, microwave, and coffee machine plugged into a power strip in the alcove across from Door 2-01-5104.