HospitalInspections.org

Based on observation, the facility failed to ensure that doors in smoke barriers were self-closing or automatic-closing in accordance with NFPA 101. This was evidenced by one smoke barrier door that failed to close upon activation of the fire alarm system. This affected the main hospital and could result in the faster spread of smoke and fire between smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes selfclosing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During fire alarm testing from 7/6/15 to 7/9/15, the smoke barrier doors were observed.

1. At 10:10 a.m., on 7/8/15, the smoke barrier door outside the kitchen (labeled LSM 220973) failed to release from its mechanical hold open device upon activation of the fire alarm system.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by two photoluminescent exit signs that were due to be replaced in 2012. This affected the main hospital and could result in a delay in egress, in the event of a fire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.1.2 Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be
marked by an approved sign readily visible from any direction of exit access.

7.10.7.2 Photoluminescent Signs. The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the photoluminescent sign shall be in accordance with its listing. The charging illumination shall be a reliable light source as determined by the authority having jurisdiction. The charging light source shall be of a type specified in the product markings.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the exit signs were observed.

1. At 3:50 p.m., on 7/6/15, there were two photoluminescent exit signs observed outside the laboratory. Manufacturer stickers on the exit signs stated to replace the signs before July 2012.

Based on observation, record review, and interview, the facility failed to maintain openings in their fire barriers. This was evidenced by a 2-hour fire rated wall with cross-corridor double doors that were removed. This affected two of four smoke compartments in the medical/surgical (Med Surg) unit and could result in the faster spread of smoke and fire between compartments.

NFPA 101, Life Safety Code 2000 Edition
4.61.2 Any requirement that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the fire barriers were observed.

1. At 4:03 p.m., on 7/6/15, the fire wall, next to Room 1206, was observed. The cross-corridor double doors in the fire wall were removed and only the door frame, and hardware on the door frame, remained. The wall was rated as a 2-hour fire wall in the plans provided by engineering staff.

During an interview at 4:30 p.m., the director of plant operations stated that original plans for the Med Surge unit were not available but plans from the remodels would be provided. He stated that in 2002 or 2003, the two-hour wall was moved back and removal of the door was approved.

At 4:30 p.m., on 7/7/15, remodel plans approved by the Office of Statewide Health Planning and Development (OSHPD) on 9/11/08 labeled the wall next to Room 1206 as an "existing fire barrier wall."

At 2:37 p.m., on 7/8/15, Med Surge remodel plans approved by OSHPD on 8/15/13 labeled the wall next to Room 1206 as an "existing 2-hour fire wall."

There were no records provided indicating that the doors were approved to be removed from the 2-hour fire wall.

Based on observation, record review, and interview, the facility failed to maintain their laboratories. This was evidenced by the installation of portable air conditioners (ACs) without approval from the authority having jurisdiction (AHJ). This was also evidenced by the failure to maintain and install these portable ACs in accordance with the manufacturer's specifications. This was also evidenced by one portable AC that was exhausted into the same ductwork as a laboratory hood without inspection and approval. This affected the main laboratory and the blood gas laboratory in the main hospital and could result in an unapproved change in the air balance and the increased risk of a fire.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 12 Hospital Requirements
12-3.7.2 Laboratories. Equipment shall conform to the nonpatient electrical equipment requirements in Chapter 7.

12-4.2 Laboratories. Laboratories in hospitals shall comply with the requirements of Chapter 10 as applicable and the requirements of NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, as applicable.

10-3.5 Fume Hoods. Fume hoods shall conform to 5-4.3 and 5-6.2.

5-4.3.1 Fume hood and biological safety cabinet requirements shall comply with NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals.

5-4.3.4 Fume hood ventilating controls shall be so arranged that shutting off the ventilation of one fume hood will not reduce the exhaust capacity or create an imbalance between exhaust and supply for any other hood connected to the same system.
The operation of these controls shall be tested annually by a qualified person who shall certify the result of the test.

5-4.3.5 Fume hoods shall be so designed that the face velocity ventilation is adequate to prevent the backflow of contaminants into the room, especially in the presence of cross drafts or the rapid movements of an operator working at the face of the hood.

NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, 1996 Edition
1-1.4 Equivalency. Nothing in this standard is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, and safety over those prescribed by this standard, provided technical documentation is made available to the authority having jurisdiction to demonstrate equivalency and the system, method, or device is approved for the intended purpose.

6-1.1 This chapter applies to laboratory exhaust systems, including laboratory hoods, special local exhaust devices, and other systems for exhausting air from laboratory work areas in which flammable gases, vapors, or particulate matter are released.

6-2.1 This chapter establishes requirements for laboratory ventilation systems. Laboratory ventilation systems shall be designed to ensure that chemicals originating from laboratory operations shall not be recirculated. Release of chemicals into the laboratory shall be controlled by enclosure or capture to prevent flammable concentrations of vapors from reaching ignition sources.

6-2.1.1 NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, contains additional requirements for general environmental ventilating systems.

6-2.1.2 NFPA 91, Standard for Exhaust Systems for Air Conveying of Materials, contains additional requirements for general environmental ventilating systems.

6-4.3 Air exhausted from laboratory work areas shall not pass unducted through other areas.

6-13.1 When installed or modified and at least annually thereafter, laboratory hoods, laboratory hood exhaust systems, and laboratory special exhaust systems shall be inspected and tested. The following inspections and tests, as applicable, shall be made:
(a) Visual inspection of the physical condition of the hood interior, sash, and ductwork (see 5-5.2 );
(b) Flow monitor;
(c) Low airflow and loss-of-airflow alarms at each alarm location;
(d) Face velocity;
(e) Verification of inward airflow over the entire hood face; and
(f) Changes in work area conditions that might affect hood performance.

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.

2-2.4.1 Installation. Heating and cooling equipment shall be installed in accordance with the applicable NFPA standards and the manufacturer's instructions. The equipment shall be approved for the specific installation.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the laboratories were observed in the facility.

Blood Gas Laboratory -

1. At 3:09 p.m., on 7/7/15, there was a portable AC installed in the Blood Gas Lab. The portable AC was exhausted directly into the attic space through a hole in the ceiling tile. The return air vent for the room was taped off. There were no records indicating that installation of the portable AC was approved by the AHJ.

During an interview at 3:10 p.m., the director of respiratory therapy stated that the portable AC was installed approximately 1 year ago.

During an interview at 3:14 p.m., the director of plant operations stated that engineering staff installed the portable AC but there were no documents of when the unit was installed and no documentation that the installation was approved. He stated he was unsure why the return air vent in the ceiling was taped off. He confirmed that the portable AC exhausts the hot air directly into the attic.

2. At 8:16 a.m., on 7/8/15, the manufacturer's manual for the portable AC recommended cleaning the air filter at least once every two weeks. There were no records of maintaining the air filter.

During an interview at 8:45 a.m., the director of plant operations stated that the portable AC did not have an "LMS" sticker so it was not part of a preventative maintenance program and there were no records of maintenance.

Main Laboratory -

3. At 11:15 a.m., on 7/8/15, there was a portable AC installed near the hematology bench in the lab. The portable AC was exhausted into the same duct that exhausted air from the bio-flow hood. There were no records of inspecting the modified exhaust system of the hood and no records of AHJ approval of the AC installation and use.

During an interview at 11:19 a.m., the director of plant operations stated that when the weather becomes warm, usually around May, the portable AC is needed to supplement cool air into the laboratory otherwise the laboratory would have to be shutdown due to heat. He stated that information about the installation of the portable AC was not available because the engineering staff that installed and exhausted the unit no longer worked at the facility.

4. At 2:30 p.m., on 7/8/15, the manufacturer's manual for the AC unit recommended cleaning the filters once a week. There were no records of maintaining the unit in accordance with manufacturer's specifications.

Based on observation and interview, the facility failed to ensure that battery-powered emergency lighting was provided at anesthetizing locations. This was evidenced by one operating room (OR) that was not equipped with battery-powered emergency lights. This affected one of three floors in the Patient Tower and could result in a lack of illumination, in the event of a power outage.

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

7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.

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).

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 7/6/15 to 7/9/15, the emergency lighting was observed at the anesthetizing locations.

Patient Tower -
Third Floor -

1. At 12:19 p.m., on 7/8/15, the obstetrics (OB) OR was not equipped with battery-powered lights.

During an interview at 12:20 p.m., the director of plant operations confirmed that the OB OR did not have any battery-powered emergency lights and to his knowledge, the ballast fixtures were not equipped with battery back up.

Based on record review and interview, the facility failed to ensure that fire drills are conducted quarterly on each shift. This was evidenced by no records of fire drills, with simulation of fire conditions, on the overnight shift. This affected patients, staff, and visitors, in the entire hospital and could result in a delay in staff response, in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9 p.m. (2100 hours) and 6 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During record review with staff from 7/6/15 to 7/9/15, the fire drill records were reviewed.

1. At 8:30 a.m., on 7/7/15, the "Night Shift Code Red Drill/Test" documents were provided. The documentation showed that each overnight shift staff filled out a test about the facility's Code Red policies. There were no records of fire drills conducted quarterly during the overnight shifts.

During an interview at 8:43 a.m., the director of plant operations stated that in lieu of a fire drill, night shift staff were quizzed on what to do in the event of a fire.

Based on observation, record review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by one detector that failed to alarm when tested and by no records of smoke detector sensitivity testing. The fire alarm panel had the capability to continuously monitor the detector's sensitivity provided the devices were programmed correctly. There were no records indicating that all the devices were properly programmed to be monitored for sensitivity. This affected the main hospital and one of three floors of the Patient Tower. This could result in the increased risk of smoke detector failure and a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.5.1 Detection systems, where required, shall be 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.

9.6.1.7 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.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the smoke detectors were tested and maintenance records were requested.

1. At 10:36 a.m., on 7/7/15, records of smoke sensitivity testing of the smoke detectors was not provided.

During an interview at 10:37 a.m., the director of plant operations stated that the fire alarm control panel (FACP) continuously monitored the smoke detector sensitivity readings.

At 7:58 a.m., on 7/8/15, the manufacturer's manual for the FACP was provided and it stated that, in order to check the sensitivity of a device, it needed to have a programmed analog loop unit (ALU) and an address. Records from the fire alarm vendor, dated April 2015, indicated that there were two photo duct detectors with no loop and no address.

Engineering staff were able to locate one of the duct detectors (old lactation room, first floor of main hospital), but not the second. The sensitivity readings for the two duct detectors was not provided and there were no records provided to show that their sensitivity readings were continuously monitored by the FACP.

Patient Tower -
Second Floor -

2. At 9:41 a.m., on 7/8/15, the smoke detector outside the impact room was heavily sprayed with artificial canned smoke four times by the director of plant operations before it alarmed.

At 10:22 a.m., on 7/8/15, the detector was tested again and failed to alarm.

At 3:21 p.m., on 7/8/15, the director of plant operations printed the sensitivity report for the failed detector outside the impact room (ALU 2, Address 1.38) from the FACP. The sensitivity report indicated the detector was "not initialized."

Page 9 of the FACP instructions manual read that if an attempt to read the sensitivity of a sensor resulted in the message (not initialized), the sensor has to be programmed (initialized) so that the sensitivity testing may be read.

There were no records indicating that all the smoke sensors were initialized and programmed to be monitored for sensitivity.

Based on observation, the facility failed to maintain their sprinkler system control valves. This was evidenced by post indicator valve (PIV) that failed to initiate a trouble signal when closed. This affected three of three floors of the Patient Tower and could result in a delay in response, in the event that the PIV was 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 7/6/15 to 7/9/15, the supervised sprinkler control valves were observed and tested.

Patient Tower -

1. At 9:53 a.m., on 7/8/15, the director of plant operations closed the exterior Patient Tower PIV all the way. No trouble signal was initiated at the fire alarm panel.

Based on observation and interview, the facility failed to maintain their heating, ventilating, and air conditioning (HVAC) equipment. This was evidenced by storage of items that obstructed access to the chillers for the operating rooms (ORs). This affected four of four ORs. This deficient practice could result in a delay in repairing the HVAC system and increase potential for harm to patients.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
Exception: As modified in 19.5.2.2.

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.
2-1.1 Equipment shall be arranged to afford access for inspection, maintenance, and repair.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the enclosure housing the chillers for the ORs was observed.

1. At 2:05 p.m., on 7/7/15, there was housekeeping equipment stored directly against the two chillers in the enclosure. Equipment included empty trash/linen receptacles, floor buffers, and sweepers. The storage obstructed access to the equipment.

During an interview at 2:06 p.m., the director of plant operations stated that the chillers were for the ORs and that the enclosure was used for housekeeping storage due to lack of space.

Based on observation and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by a hood filters that were not tight fitting. This affected the kitchen in the main hospital and could result in the increased risk of a grease fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the commercial cooking equipment was observed.

1. At 4:26 p.m., on 7/7/15, the five hood filters above the griddle and fryer were observed. There was an approximately 1 inch to 1 1/2 inch gap between each filter that exposed the hood to grease-laden vapors.

During an interview at 4:27 p.m., the director of plant operations stated that the facility was aware that the filters were not tight fitting and new filters were on order.

Based on observation and interview, the facility failed to ensure that means of egress were free from obstructions. This was evidenced by items blocking the egress paths and corridors. This affected the surgery suite in the main hospital and could result in the delay in evacuation and the increased risk of injury to the patients and staff.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the egress paths were observed.

1. At 3:52 p.m., on 7/7/15, the egress corridor outside Operating Room (OR) 4 was obstructed. There were seven carts of supplies and one fluoro machine that reduced the 8 foot wide corridor to approximately 5 feet 8 inches in clear width. The fluoro machine was stored directly against the panic bar of the exit door near OR 4.

During an interview at 3:53 p.m., the director of plant operations stated that the carts and equipment were kept in the corridor outside OR 4 at all times.

Based on record review and interview, the facility failed to maintain their anesthetizing locations. This was evidenced by no records of relative humidity levels in the operating rooms (ORs) prior to April 2015. This affected four of four ORs at the main hospital and could result in the increased risk of a fire.

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.
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.

Findings:

During record review with staff from 7/6/15 to 7/9/15, the OR humidity logs were requested.

1. At 4:45 p.m., on 7/8/15, there were no records of relative humidity levels at ORs 1, 2, 3, and 4 for March 2015 and prior. Only records for April 2015, May 2015, June 2015, and July 2015 were provided.

During an interview at 4:46 p.m., the director of clinical quality stated that there were no relative humidity logs prior to April 2015 due to a change in management.

Based on observation and interview, the facility failed to ensure that openings in smoke barrier walls were sealed in accordance with NFPA 101. This was evidenced by one penetration that was not fully sealed and was caulked with a material of unknown fire resistance rating. This affected two of three floors of the Patient Tower and could result in the faster spread of smoke and fire from one smoke compartment to another.

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

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15 , the smoke barrier walls were inspected.

Patient Tower -
Second Floor -

1. At 3:18 p.m., on 7/6/15, there was an approximately 1 inch penetration around an orange cable in the 1 hour fire rated smoke barrier wall next to Room 2101. The penetration was 75 percent sealed with a glazed black-colored caulking substance.

During an interview at 3:19 p.m., Engineering Staff 2 confirmed that the penetration was not fully sealed. He stated that he was unsure what the specifications of the black-colored caulking substance was and if it was a fire-rated material.

During an interview at 3:20 p.m., the director of plant operations stated that the specifications for the black-colored caulking material were not available.

Based on observation and interview, the facility failed to ensure that flammable liquids were stored in accordance with NFPA 30. This was evidenced by storage of diesel fuel, a Class II liquid, in an enclosure not protected from ignition sources. This affected the exterior yard containing the magnetic resonance imaging (MRI) and two of three facility generators. This could result in the increased risk of a fire.

NFPA 30, Flammable and Combustible Liquids Code, 1996 Edition.
4.1.1.1 This chapter shall apply to the storage of liquids in drums or other containers that do not exceed 60 gal (227 L) individual capacity, in portable tanks that do not exceed 660 gal (2498 L) individual capacity, and in intermediate bulk containers that do not exceed 793 gal (3000 L) and to limited transfers incidental thereto. For portable tanks that exceed 660 gal (2500 L), Chapter 2 shall apply. This chapter shall also apply to overpack drums that do not exceed 85 gal (322 L) capacity when used for temporary containment of containers that do not exceed 60 gal (227 L) capacity. Such overpack containers shall be treated as containers as defined in Section 1.6.
4.5.6.5 Liquids in containers of greater than 5 gal (19 L) capacity shall not be stored or displayed in areas that are accessible to the public.
Exception: This shall not apply to any liquid that is exempt from the requirements of this chapter, as set forth in 4.1.1.2.

4.7.4 The storage area shall be protected against tampering or trespassers where necessary and shall be kept free of weeds, debris, and other combustible materials not necessary to the storage.

4.10 Control of Ignition Sources. Precautions shall be taken to prevent the ignition of flammable vapors. Sources of ignition include, but are not limited to, the following:
(1) Open flames
(2) Lightning
(3) Smoking
(4) Cutting or welding
(5) Hot surfaces
(6) Frictional heat
(7) Static electricity
(8) Electrical or mechanical sparks
(9) Spontaneous heating, including heat-producing chemical reactions
(10) Radiant heat

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the facility was observed for storage of combustible liquids.

1. At 1:36 p.m., on 7/7/15, there were three 5-gallon plastic canisters filled with diesel fuel in the "old gas farm" in the exterior yard near the MRI trailer. The fuel was stored outside the flammable liquids cabinet and was exposed to radiant heat from the sun, debris, and the hot cement surface.

During an interview at 1:37 p.m., the director of plant operations stated that the diesel fuel should not have been stored outside and was there temporarily for a project.

Based on observation, record review, and interview, the facility failed to maintain their emergency generators. This was evidenced by the failure to conduct a monthly 30-minute load test and by no remote annunciator panel for one of three facility generators. This affected the main hospital (including medical/surgical (Med Surg) unit, surgery, and recovery) and could result in the increased risk of a generator failure and loss of emergency power.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

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.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
(a) Type I and Type II essential electrical system power (107C) or the engine water-jacket temperature at not less than sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (See NFPA 70, National Electrical Code, Section 700-12)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency power source is operating to supply power to load
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition.
3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

6-1.1 The routine maintenance and operation testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction.
6-3.1 The emergency power supply system (EPSS) shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the duration specified for the class.
6-4.1 Level 1 and Level 2 EPSSs (emergency power supply systems), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS (emergency power supply) nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the generators were observed and maintenance records were requested. The hospital was equipped with a 250 kilowatt (kw) generator, a 400 kw generator, and a 1000 kw generator.

1. At 11:26 a.m., on 7/7/15, records indicated that on 10/5/14, the 250 kw generator was tested under load for 12 minutes. There were no records of a 30 minute load test conducted in October 2014 for the 250 kw generator.

During an interview at 12:04 p.m., the director of plant of operations stated that the load test was cut short due to a case in the operating room (OR). He stated a 30 minute test with no load was conducted on 10/9/14 but no 30 minute load test was conducted in October.

2. At 11:41 a.m., on 7/8/15, both the 400 kw and the 1000 kw generators were equipped with remote annunciator panels in the hospital. The 250 kw generator was not equipped with a remote annunciator panel.

During an interview at 11:42 a.m., the director of plant operations stated that the 250 kw generator fed the old part of the hospital including the Med Surg unit, ORs 1, 2, and 3, and OR recovery.

Based on observation, record review, and interview, the facility failed to maintain their electrical wiring. This was evidenced by the use of power strips and extension cords in lieu of permanent wiring. This was also evidenced by electrical equipment that was not installed in accordance with manufacturer's specifications. This affected the surgical suite and the laboratory and could result in the increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.

Table 210-21(b)(2). Maximum Cord- and Plug-Connected Load to Receptacle
Circuit Rating (Amperes): 20
Receptacle Rating (Amperes): 20
Maximum Load (Amperes): 16
210-23. Permissible Loads. In no case shall the load exceed the branch-circuit ampere rating. An individual circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) through (d) and as summarized in Section 210-24 and Table 210-24.

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

400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the electrical wiring was observed.

1. At 3:36 p.m., on 7/7/15 in Operating Room (OR) 1, there was a 16 Amp suction machine, a 3.75 Amp monitor, a 5.1 Amp workstation on wheels (WOW), and a 3 Amp medication dispenser plugged into a six-plug power strip that was rated at 15 Amps. The director of plant operations and Engineering Staff 2 confirmed the equipment was plugged into the power strip and confirmed the Amp rating of the equipment. The total Amp rating of the equipment, plugged into the 15 Amp power strip, was 27.85 Amps.

2. At 11:16 a.m., on 7/8/15, there was an analyzer, a printer, and a monitor plugged into a multi-plug uninterruptible power source (UPS) under the hematology bench in the laboratory. The UPS was plugged into a heavy duty extension cord.

3. At 2:39 p.m., on 7/8/15, the power cord for the portable air conditioner (AC), located near the blood bank area in the laboratory, ran under a heavy rubber mat and was plugged across the way into an outlet on the side of the hematology bench. The power cord ran under the heavy mat and where it could be stepped on by personnel.

Under the General Warnings & Cautions section of the portable AC unit's manual, Item 5 stated that heavy objects should never be placed on the power cord as this could result in damage and cause electrical shock or fire.

Based on observation, the facility failed to ensure that doors in smoke barriers were self-closing or automatic-closing in accordance with NFPA 101. This was evidenced by one smoke barrier door that failed to close upon activation of the fire alarm system. This affected the main hospital and could result in the faster spread of smoke and fire between smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes selfclosing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During fire alarm testing from 7/6/15 to 7/9/15, the smoke barrier doors were observed.

1. At 10:10 a.m., on 7/8/15, the smoke barrier door outside the kitchen (labeled LSM 220973) failed to release from its mechanical hold open device upon activation of the fire alarm system.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by two photoluminescent exit signs that were due to be replaced in 2012. This affected the main hospital and could result in a delay in egress, in the event of a fire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.1.2 Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be
marked by an approved sign readily visible from any direction of exit access.

7.10.7.2 Photoluminescent Signs. The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the photoluminescent sign shall be in accordance with its listing. The charging illumination shall be a reliable light source as determined by the authority having jurisdiction. The charging light source shall be of a type specified in the product markings.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the exit signs were observed.

1. At 3:50 p.m., on 7/6/15, there were two photoluminescent exit signs observed outside the laboratory. Manufacturer stickers on the exit signs stated to replace the signs before July 2012.

Based on observation, record review, and interview, the facility failed to maintain openings in their fire barriers. This was evidenced by a 2-hour fire rated wall with cross-corridor double doors that were removed. This affected two of four smoke compartments in the medical/surgical (Med Surg) unit and could result in the faster spread of smoke and fire between compartments.

NFPA 101, Life Safety Code 2000 Edition
4.61.2 Any requirement that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the fire barriers were observed.

1. At 4:03 p.m., on 7/6/15, the fire wall, next to Room 1206, was observed. The cross-corridor double doors in the fire wall were removed and only the door frame, and hardware on the door frame, remained. The wall was rated as a 2-hour fire wall in the plans provided by engineering staff.

During an interview at 4:30 p.m., the director of plant operations stated that original plans for the Med Surge unit were not available but plans from the remodels would be provided. He stated that in 2002 or 2003, the two-hour wall was moved back and removal of the door was approved.

At 4:30 p.m., on 7/7/15, remodel plans approved by the Office of Statewide Health Planning and Development (OSHPD) on 9/11/08 labeled the wall next to Room 1206 as an "existing fire barrier wall."

At 2:37 p.m., on 7/8/15, Med Surge remodel plans approved by OSHPD on 8/15/13 labeled the wall next to Room 1206 as an "existing 2-hour fire wall."

There were no records provided indicating that the doors were approved to be removed from the 2-hour fire wall.

Based on observation, record review, and interview, the facility failed to maintain their laboratories. This was evidenced by the installation of portable air conditioners (ACs) without approval from the authority having jurisdiction (AHJ). This was also evidenced by the failure to maintain and install these portable ACs in accordance with the manufacturer's specifications. This was also evidenced by one portable AC that was exhausted into the same ductwork as a laboratory hood without inspection and approval. This affected the main laboratory and the blood gas laboratory in the main hospital and could result in an unapproved change in the air balance and the increased risk of a fire.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 12 Hospital Requirements
12-3.7.2 Laboratories. Equipment shall conform to the nonpatient electrical equipment requirements in Chapter 7.

12-4.2 Laboratories. Laboratories in hospitals shall comply with the requirements of Chapter 10 as applicable and the requirements of NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, as applicable.

10-3.5 Fume Hoods. Fume hoods shall conform to 5-4.3 and 5-6.2.

5-4.3.1 Fume hood and biological safety cabinet requirements shall comply with NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals.

5-4.3.4 Fume hood ventilating controls shall be so arranged that shutting off the ventilation of one fume hood will not reduce the exhaust capacity or create an imbalance between exhaust and supply for any other hood connected to the same system.
The operation of these controls shall be tested annually by a qualified person who shall certify the result of the test.

5-4.3.5 Fume hoods shall be so designed that the face velocity ventilation is adequate to prevent the backflow of contaminants into the room, especially in the presence of cross drafts or the rapid movements of an operator working at the face of the hood.

NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, 1996 Edition
1-1.4 Equivalency. Nothing in this standard is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, and safety over those prescribed by this standard, provided technical documentation is made available to the authority having jurisdiction to demonstrate equivalency and the system, method, or device is approved for the intended purpose.

6-1.1 This chapter applies to laboratory exhaust systems, including laboratory hoods, special local exhaust devices, and other systems for exhausting air from laboratory work areas in which flammable gases, vapors, or particulate matter are released.

6-2.1 This chapter establishes requirements for laboratory ventilation systems. Laboratory ventilation systems shall be designed to ensure that chemicals originating from laboratory operations shall not be recirculated. Release of chemicals into the laboratory shall be controlled by enclosure or capture to prevent flammable concentrations of vapors from reaching ignition sources.

6-2.1.1 NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, contains additional requirements for general environmental ventilating systems.

6-2.1.2 NFPA 91, Standard for Exhaust Systems for Air Conveying of Materials, contains additional requirements for general environmental ventilating systems.

6-4.3 Air exhausted from laboratory work areas shall not pass unducted through other areas.

6-13.1 When installed or modified and at least annually thereafter, laboratory hoods, laboratory hood exhaust systems, and laboratory special exhaust systems shall be inspected and tested. The following inspections and tests, as applicable, shall be made:
(a) Visual inspection of the physical condition of the hood interior, sash, and ductwork (see 5-5.2 );
(b) Flow monitor;
(c) Low airflow and loss-of-airflow alarms at each alarm location;
(d) Face velocity;
(e) Verification of inward airflow over the entire hood face; and
(f) Changes in work area conditions that might affect hood performance.

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.

2-2.4.1 Installation. Heating and cooling equipment shall be installed in accordance with the applicable NFPA standards and the manufacturer's instructions. The equipment shall be approved for the specific installation.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the laboratories were observed in the facility.

Blood Gas Laboratory -

1. At 3:09 p.m., on 7/7/15, there was a portable AC installed in the Blood Gas Lab. The portable AC was exhausted directly into the attic space through a hole in the ceiling tile. The return air vent for the room was taped off. There were no records indicating that installation of the portable AC was approved by the AHJ.

During an interview at 3:10 p.m., the director of respiratory therapy stated that the portable AC was installed approximately 1 year ago.

During an interview at 3:14 p.m., the director of plant operations stated that engineering staff installed the portable AC but there were no documents of when the unit was installed and no documentation that the installation was approved. He stated he was unsure why the return air vent in the ceiling was taped off. He confirmed that the portable AC exhausts the hot air directly into the attic.

2. At 8:16 a.m., on 7/8/15, the manufacturer's manual for the portable AC recommended cleaning the air filter at least once every two weeks. There were no records of maintaining the air filter.

During an interview at 8:45 a.m., the director of plant operations stated that the portable AC did not have an "LMS" sticker so it was not part of a preventative maintenance program and there were no records of maintenance.

Main Laboratory -

3. At 11:15 a.m., on 7/8/15, there was a portable AC installed near the hematology bench in the lab. The portable AC was exhausted into the same duct that exhausted air from the bio-flow hood. There were no records of inspecting the modified exhaust system of the hood and no records of AHJ approval of the AC installation and use.

During an interview at 11:19 a.m., the director of plant operations stated that when the weather becomes warm, usually around May, the portable AC is needed to supplement cool air into the laboratory otherwise the laboratory would have to be shutdown due to heat. He stated that information about the installation of the portable AC was not available because the engineering staff that installed and exhausted the unit no longer worked at the facility.

4. At 2:30 p.m., on 7/8/15, the manufacturer's manual for the AC unit recommended cleaning the filters once a week. There were no records of maintaining the unit in accordance with manufacturer's specifications.

Based on observation and interview, the facility failed to ensure that battery-powered emergency lighting was provided at anesthetizing locations. This was evidenced by one operating room (OR) that was not equipped with battery-powered emergency lights. This affected one of three floors in the Patient Tower and could result in a lack of illumination, in the event of a power outage.

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

7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.

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).

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 7/6/15 to 7/9/15, the emergency lighting was observed at the anesthetizing locations.

Patient Tower -
Third Floor -

1. At 12:19 p.m., on 7/8/15, the obstetrics (OB) OR was not equipped with battery-powered lights.

During an interview at 12:20 p.m., the director of plant operations confirmed that the OB OR did not have any battery-powered emergency lights and to his knowledge, the ballast fixtures were not equipped with battery back up.

Based on record review and interview, the facility failed to ensure that fire drills are conducted quarterly on each shift. This was evidenced by no records of fire drills, with simulation of fire conditions, on the overnight shift. This affected patients, staff, and visitors, in the entire hospital and could result in a delay in staff response, in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9 p.m. (2100 hours) and 6 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During record review with staff from 7/6/15 to 7/9/15, the fire drill records were reviewed.

1. At 8:30 a.m., on 7/7/15, the "Night Shift Code Red Drill/Test" documents were provided. The documentation showed that each overnight shift staff filled out a test about the facility's Code Red policies. There were no records of fire drills conducted quarterly during the overnight shifts.

During an interview at 8:43 a.m., the director of plant operations stated that in lieu of a fire drill, night shift staff were quizzed on what to do in the event of a fire.

Based on observation, record review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by one detector that failed to alarm when tested and by no records of smoke detector sensitivity testing. The fire alarm panel had the capability to continuously monitor the detector's sensitivity provided the devices were programmed correctly. There were no records indicating that all the devices were properly programmed to be monitored for sensitivity. This affected the main hospital and one of three floors of the Patient Tower. This could result in the increased risk of smoke detector failure and a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.5.1 Detection systems, where required, shall be 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.

9.6.1.7 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.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the smoke detectors were tested and maintenance records were requested.

1. At 10:36 a.m., on 7/7/15, records of smoke sensitivity testing of the smoke detectors was not provided.

During an interview at 10:37 a.m., the director of plant operations stated that the fire alarm control panel (FACP) continuously monitored the smoke detector sensitivity readings.

At 7:58 a.m., on 7/8/15, the manufacturer's manual for the FACP was provided and it stated that, in order to check the sensitivity of a device, it needed to have a programmed analog loop unit (ALU) and an address. Records from the fire alarm vendor, dated April 2015, indicated that there were two photo duct detectors with no loop and no address.

Engineering staff were able to locate one of the duct detectors (old lactation room, first floor of main hospital), but not the second. The sensitivity readings for the two duct detectors was not provided and there were no records provided to show that their sensitivity readings were continuously monitored by the FACP.

Patient Tower -
Second Floor -

2. At 9:41 a.m., on 7/8/15, the smoke detector outside the impact room was heavily sprayed with artificial canned smoke four times by the director of plant operations before it alarmed.

At 10:22 a.m., on 7/8/15, the detector was tested again and failed to alarm.

At 3:21 p.m., on 7/8/15, the director of plant operations printed the sensitivity report for the failed detector outside the impact room (ALU 2, Address 1.38) from the FACP. The sensitivity report indicated the detector was "not initialized."

Page 9 of the FACP instructions manual read that if an attempt to read the sensitivity of a sensor resulted in the message (not initialized), the sensor has to be programmed (initialized) so that the sensitivity testing may be read.

There were no records indicating that all the smoke sensors were initialized and programmed to be monitored for sensitivity.

Based on observation, the facility failed to maintain their sprinkler system control valves. This was evidenced by post indicator valve (PIV) that failed to initiate a trouble signal when closed. This affected three of three floors of the Patient Tower and could result in a delay in response, in the event that the PIV was 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 7/6/15 to 7/9/15, the supervised sprinkler control valves were observed and tested.

Patient Tower -

1. At 9:53 a.m., on 7/8/15, the director of plant operations closed the exterior Patient Tower PIV all the way. No trouble signal was initiated at the fire alarm panel.

Based on observation and interview, the facility failed to maintain their heating, ventilating, and air conditioning (HVAC) equipment. This was evidenced by storage of items that obstructed access to the chillers for the operating rooms (ORs). This affected four of four ORs. This deficient practice could result in a delay in repairing the HVAC system and increase potential for harm to patients.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
Exception: As modified in 19.5.2.2.

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.
2-1.1 Equipment shall be arranged to afford access for inspection, maintenance, and repair.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the enclosure housing the chillers for the ORs was observed.

1. At 2:05 p.m., on 7/7/15, there was housekeeping equipment stored directly against the two chillers in the enclosure. Equipment included empty trash/linen receptacles, floor buffers, and sweepers. The storage obstructed access to the equipment.

During an interview at 2:06 p.m., the director of plant operations stated that the chillers were for the ORs and that the enclosure was used for housekeeping storage due to lack of space.

Based on observation and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by a hood filters that were not tight fitting. This affected the kitchen in the main hospital and could result in the increased risk of a grease fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the commercial cooking equipment was observed.

1. At 4:26 p.m., on 7/7/15, the five hood filters above the griddle and fryer were observed. There was an approximately 1 inch to 1 1/2 inch gap between each filter that exposed the hood to grease-laden vapors.

During an interview at 4:27 p.m., the director of plant operations stated that the facility was aware that the filters were not tight fitting and new filters were on order.

Based on observation and interview, the facility failed to ensure that means of egress were free from obstructions. This was evidenced by items blocking the egress paths and corridors. This affected the surgery suite in the main hospital and could result in the delay in evacuation and the increased risk of injury to the patients and staff.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the egress paths were observed.

1. At 3:52 p.m., on 7/7/15, the egress corridor outside Operating Room (OR) 4 was obstructed. There were seven carts of supplies and one fluoro machine that reduced the 8 foot wide corridor to approximately 5 feet 8 inches in clear width. The fluoro machine was stored directly against the panic bar of the exit door near OR 4.

During an interview at 3:53 p.m., the director of plant operations stated that the carts and equipment were kept in the corridor outside OR 4 at all times.

Based on record review and interview, the facility failed to maintain their anesthetizing locations. This was evidenced by no records of relative humidity levels in the operating rooms (ORs) prior to April 2015. This affected four of four ORs at the main hospital and could result in the increased risk of a fire.

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.
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.

Findings:

During record review with staff from 7/6/15 to 7/9/15, the OR humidity logs were requested.

1. At 4:45 p.m., on 7/8/15, there were no records of relative humidity levels at ORs 1, 2, 3, and 4 for March 2015 and prior. Only records for April 2015, May 2015, June 2015, and July 2015 were provided.

During an interview at 4:46 p.m., the director of clinical quality stated that there were no relative humidity logs prior to April 2015 due to a change in management.

Based on observation and interview, the facility failed to ensure that openings in smoke barrier walls were sealed in accordance with NFPA 101. This was evidenced by one penetration that was not fully sealed and was caulked with a material of unknown fire resistance rating. This affected two of three floors of the Patient Tower and could result in the faster spread of smoke and fire from one smoke compartment to another.

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

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15 , the smoke barrier walls were inspected.

Patient Tower -
Second Floor -

1. At 3:18 p.m., on 7/6/15, there was an approximately 1 inch penetration around an orange cable in the 1 hour fire rated smoke barrier wall next to Room 2101. The penetration was 75 percent sealed with a glazed black-colored caulking substance.

During an interview at 3:19 p.m., Engineering Staff 2 confirmed that the penetration was not fully sealed. He stated that he was unsure what the specifications of the black-colored caulking substance was and if it was a fire-rated material.

During an interview at 3:20 p.m., the director of plant operations stated that the specifications for the black-colored caulking material were not available.

Based on observation and interview, the facility failed to ensure that flammable liquids were stored in accordance with NFPA 30. This was evidenced by storage of diesel fuel, a Class II liquid, in an enclosure not protected from ignition sources. This affected the exterior yard containing the magnetic resonance imaging (MRI) and two of three facility generators. This could result in the increased risk of a fire.

NFPA 30, Flammable and Combustible Liquids Code, 1996 Edition.
4.1.1.1 This chapter shall apply to the storage of liquids in drums or other containers that do not exceed 60 gal (227 L) individual capacity, in portable tanks that do not exceed 660 gal (2498 L) individual capacity, and in intermediate bulk containers that do not exceed 793 gal (3000 L) and to limited transfers incidental thereto. For portable tanks that exceed 660 gal (2500 L), Chapter 2 shall apply. This chapter shall also apply to overpack drums that do not exceed 85 gal (322 L) capacity when used for temporary containment of containers that do not exceed 60 gal (227 L) capacity. Such overpack containers shall be treated as containers as defined in Section 1.6.
4.5.6.5 Liquids in containers of greater than 5 gal (19 L) capacity shall not be stored or displayed in areas that are accessible to the public.
Exception: This shall not apply to any liquid that is exempt from the requirements of this chapter, as set forth in 4.1.1.2.

4.7.4 The storage area shall be protected against tampering or trespassers where necessary and shall be kept free of weeds, debris, and other combustible materials not necessary to the storage.

4.10 Control of Ignition Sources. Precautions shall be taken to prevent the ignition of flammable vapors. Sources of ignition include, but are not limited to, the following:
(1) Open flames
(2) Lightning
(3) Smoking
(4) Cutting or welding
(5) Hot surfaces
(6) Frictional heat
(7) Static electricity
(8) Electrical or mechanical sparks
(9) Spontaneous heating, including heat-producing chemical reactions
(10) Radiant heat

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the facility was observed for storage of combustible liquids.

1. At 1:36 p.m., on 7/7/15, there were three 5-gallon plastic canisters filled with diesel fuel in the "old gas farm" in the exterior yard near the MRI trailer. The fuel was stored outside the flammable liquids cabinet and was exposed to radiant heat from the sun, debris, and the hot cement surface.

During an interview at 1:37 p.m., the director of plant operations stated that the diesel fuel should not have been stored outside and was there temporarily for a project.

Based on observation, record review, and interview, the facility failed to maintain their emergency generators. This was evidenced by the failure to conduct a monthly 30-minute load test and by no remote annunciator panel for one of three facility generators. This affected the main hospital (including medical/surgical (Med Surg) unit, surgery, and recovery) and could result in the increased risk of a generator failure and loss of emergency power.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

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.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
(a) Type I and Type II essential electrical system power (107C) or the engine water-jacket temperature at not less than sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (See NFPA 70, National Electrical Code, Section 700-12)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency power source is operating to supply power to load
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition.
3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

6-1.1 The routine maintenance and operation testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction.
6-3.1 The emergency power supply system (EPSS) shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the duration specified for the class.
6-4.1 Level 1 and Level 2 EPSSs (emergency power supply systems), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS (emergency power supply) nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the generators were observed and maintenance records were requested. The hospital was equipped with a 250 kilowatt (kw) generator, a 400 kw generator, and a 1000 kw generator.

1. At 11:26 a.m., on 7/7/15, records indicated that on 10/5/14, the 250 kw generator was tested under load for 12 minutes. There were no records of a 30 minute load test conducted in October 2014 for the 250 kw generator.

During an interview at 12:04 p.m., the director of plant of operations stated that the load test was cut short due to a case in the operating room (OR). He stated a 30 minute test with no load was conducted on 10/9/14 but no 30 minute load test was conducted in October.

2. At 11:41 a.m., on 7/8/15, both the 400 kw and the 1000 kw generators were equipped with remote annunciator panels in the hospital. The 250 kw generator was not equipped with a remote annunciator panel.

During an interview at 11:42 a.m., the director of plant operations stated that the 250 kw generator fed the old part of the hospital including the Med Surg unit, ORs 1, 2, and 3, and OR recovery.

Based on observation, record review, and interview, the facility failed to maintain their electrical wiring. This was evidenced by the use of power strips and extension cords in lieu of permanent wiring. This was also evidenced by electrical equipment that was not installed in accordance with manufacturer's specifications. This affected the surgical suite and the laboratory and could result in the increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.

Table 210-21(b)(2). Maximum Cord- and Plug-Connected Load to Receptacle
Circuit Rating (Amperes): 20
Receptacle Rating (Amperes): 20
Maximum Load (Amperes): 16
210-23. Permissible Loads. In no case shall the load exceed the branch-circuit ampere rating. An individual circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) through (d) and as summarized in Section 210-24 and Table 210-24.

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

400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 7/6/15 to 7/9/15, the electrical wiring was observed.

1. At 3:36 p.m., on 7/7/15 in Operating Room (OR) 1, there was a 16 Amp suction machine, a 3.75 Amp monitor, a 5.1 Amp workstation on wheels (WOW), and a 3 Amp medication dispenser plugged into a six-plug power strip that was rated at 15 Amps. The director of plant operations and Engineering Staff 2 confirmed the equipment was plugged into the power strip and confirmed the Amp rating of the equipment. The total Amp rating of the equipment, plugged into the 15 Amp power strip, was 27.85 Amps.

2. At 11:16 a.m., on 7/8/15, there was an analyzer, a printer, and a monitor plugged into a multi-plug uninterruptible power source (UPS) under the hematology bench in the laboratory. The UPS was plugged into a heavy duty extension cord.

3. At 2:39 p.m., on 7/8/15, the power cord for the portable air conditioner (AC), located near the blood bank area in the laboratory, ran under a heavy rubber mat and was plugged across the way into an outlet on the side of the hematology bench. The power cord ran under the heavy mat and where it could be stepped on by personnel.

Under the General Warnings & Cautions section of the portable AC unit's manual, Item 5 stated that heavy objects should never be placed on the power cord as this could result in damage and cause electrical shock or fire.