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Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by three corridor doors that were obstructed from closing. This affected three of sixteen smoke compartments and could result in a delay in containing smoke or fire to a room.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

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.

Findings:

During the facility tour and interviews with Facilities Support Staff 1 and 2 on 5/24/16, the corridor doors in the facility were observed.

1. At 11:50 a.m., the ER (Emergency Room) Fast Track self closing corridor door was in the fully open position and obstructed from closing by kick-down hardware. At 11:51 a.m., Facilities Staff 1 acknowledged that the kick-down hardware needed to be removed.

2. At 4:15 p.m., the OR (Operating Room) Equipment door failed to self close. The self closing corridor door failed to close the last two feet. At 4:16 p.m., Facility Staff 2 confirmed that the door closer was not working correctly and needed to be repaired.

3. At 5:02 p.m., the Nursery staff office self closing corridor door was in the fully open position and obstructed from closing by kick-down hardware.

Based on observation and interview, the facility failed to maintain door closing devices for hazardous area enclosures. This was evidenced by four doors that failed to self close or were obstructed from self closing. This could result in the spread of fire or smoke affecting one of sixteen 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 self-closing.
(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 the facility tour with Facilities Support Staff 1 and 2 on 5/24/16, the hazardous area enclosures were observed.

1. At 8:38 a.m., the door closer arm for Room C was disconnected. The room was greater than 100 square feet in area and was lined wall to wall with racks filled with boxed goods and paper housekeeping products.

2. At 8:44 a.m., the self closing door for Room B was obstructed from closing by kick-down hardware. The room was greater than 100 square feet in area and was filled with beds.

3. At 8:48 a.m., one door closer was missing on Room 230D and the double doors were obstructed from closing by kick-down hardware and by patient care equipment that were stored against the open doors. The room was greater than 100 square feet in area and was filled with plastic film covered patient care equipment, furnishings, and ten gallons of a combustible liquid labeled as Formalin.

4. At 9:09 a.m., the self closing doors for Room A were obstructed from closing in the fully open position by beds. The room was greater than 100 square feet in area and was filled with six hospital beds and patient care equipment.

Based on observation, interview, and record review, the facility failed to maintain doors in smoke barrier walls. This was evidenced by one self closing door that failed to close completely. This affected two of sixteen smoke compartments and could result in the spread of smoke or fire during a fire emergency.

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.
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.
7.1.10 Means of Egress Reliability.
7.2.1.5.5 Where pairs of doors are required in a means of egress, each leaf of the pair shall be provided with its own releasing device. Devices that depend on the release of one door before the other shall not be used. Exception: Where exit doors are used in pairs and approved automatic flush bolts are used, the door leaf equipped with the automatic flush bolts shall have no doorknob or surface-mounted hardware. The unlatching of any leaf shall not require more than one operation.
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 self closing.
(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 the facility tour and interview with Facilities Support Staff 2 on 5/24/16, the smoke barrier doors were observed.

1. At 8:59 a.m., the north leaf on a set of smoke barrier doors was obstructed by the south leaf latching plate. There was no sequencing hardware to prevent the south leaf from interfering with the closing of the north leaf. The smoke barrier doors were located between the old surgery area in Smoke Compartment 9 and B wing in Smoke Compartment 10. At 9:00 a.m., Facility Support Staff 2 acknowledged that the north leaf failed to close completely.

During a record review on 5/24/16 at 9:01 a.m., Facility Support Staff 1 acknowledged the doors in the smoke barrier wall were shown on the As-Built Plan A2.12, Smoke Barrier Compartments.

Based on observation and interview, the facility failed to maintain a readily available exit access to the public way. This was evidenced by storage of soiled linen containers in an exit access on B-wing and wheelchairs that obstructed the exit access in the vestibule between ER(Emergency Room) Fast Track and Total Rehab Services areas. This could result in a delayed evacuation, in the event of a fire, and affected two of sixteen smoke compartments.

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.
7.1.9 Impediments to Egress. Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.
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.

Findings:

During the facility tour and interview with Facilities Support Staff 1 and 2, from 5/23/16 to 5/24/16, the access to exits were observed.

1. On 5/23/16 at 11:50 a.m., access to the rear exit between ER Fast Track and Total Rehab Services was obstructed by five wheelchairs in the exit vestibule. The 8 foot wide vestibule opening was reduced to a clear width of five feet. At 11:51 a.m., Facilities Support Staff 1 confirmed that the wheelchairs should not have been stored at that location.

2. On 5/24/16 at 4:52 p.m., access to the direct exit from B-wing was obstructed by seven 32-gallon soiled linen containers that lined both sides of the exit access. The exit access was reduced to a clear width of 6 1/2 feet.

Based on record review and interview, the facility failed to conduct fire drills once per shift per quarter. This was evidenced by no fire drills conducted for the Outpatient Pavilion - Medical Specialty Clinic (2nd Floor) and Outpatient Surgery Center (1st Floor) during the last year. This affected the entire facility and could result in a delay in egress if staff were not familiar with their roles and responsibilities during a fire emergency.

NFPA 101 Life Safety Code 2000 Existing Codes
18.7.1.2* 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 9:00 p.m. (2100 hours) and 6:00 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 the exterior of the building.

Findings:

During record review and interview with the Safety Compliance Officer on 5/23/16, the fire drill records were requested.

1. At 2:46 p.m., there were no fire drills available during the last year for the Outpatient Pavilion - Medical Specialty Clinic (2nd Floor) and Outpatient Surgery Center (1st Floor). At 2:47 p.m., the Safety Compliance Officer confirmed that they had not performed fire drills for the Outpatient Pavilion within the last 12 months.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by a sprinkler head that was obstructed by storage. This could result in a delayed response of the automatic sprinkler system during a fire emergency. This affected one of two floors at the Outpatient Pavilion.

NFPA 101 Life Safety Code, 2000 Edition
9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

NFPA 13, Installation of Sprinkler Systems, 1999 edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During the facility tour and interview with Facilities Support Staff 1 and 2 on 5/25/16, the automatic sprinkler system was observed.

Outpatient Pavilion
2nd Floor

1. At 9:50 a.m., there was storage of items within 6 inches below the sprinkler head on the shelf along the east wall of the supplies storage room. The sprinkler did not have 18 inches of clearance.

Based on observation and interview, the facility failed to maintain their fire extinguishers as evidenced by one fire extinguisher that was mounted higher than 60 inches from floor level to the operating handle. This could result in staff's inability to readily access the fire extinguisher during a fire emergency. This affected one of sixteen smoke compartments in the hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1
9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 ½ ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During the facility tour with the Facilities Support Staff 1 and 2 on 5/24/16, the fire extinguishers were observed.

1. At 8:35 a.m., the fire extinguisher located in the old surgical area next to a bio-medical office was mounted at 65 inches from floor level. At 8:36 a.m., Facilities Support Staff 1 confirmed that the fire extinguisher mounting height was greater than five feet.

Based on observation and interview, the facility failed to protect their medical gas storage locations at the Heritage Pavilion building. This was evidenced by oxygen cylinders stored next to combustible materials and an electrical outlet on the second floor. This was also evidenced by a medical gas supply room without a door closing device, a light switch that was less than five feet above the floor, and 3 1/2 inch diameter wall penetration. This affected two of two floors at the Outpatient Pavilion and could result in an oxygen cylinder initiated emergency.

NFPA 101, 2000 Edition
18.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, 1999 edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
4-5.1.1.2 Storage Requirements (Location, Construction, Arrangement).
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electric Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 5 ft (152 cm) above the floor as a precaution against their physical damage.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.

8-3.1.11 Storage Requirements
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
8-3.1.11.2(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1m), or
2. A minimum distance of 5 ft (1.5m) if the entire storage locations protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Findings:

During the facility tour and interview with Facilities Support Staff 1 and 2 on 5/25/16, the oxygen storage areas were observed.

First Floor

1. At 9:11 a.m., there was a medical gas supply room without a door closing device. The room contained 18 H-sized oxygen cylinders, 10 H-sized nitrous oxide cylinders. and 9 H-sized nitrogen cylinders. At 9:12 a.m., Facilities Support Staff 1 acknowledged that the medical gases supplied the outpatient surgery areas. There was greater than 3000 cubic feet of oxidizing gasses stored within the room.

2. At 9:13 a.m., the light switch in the medical gas supply room was measured 46 inches from floor to the center of the light switch. The light switch was not greater than 5 feet from floor level.

3. At 9:14 a.m., there was a 3 1/2 inch diameter wall penetration near the floor below the light switch.

Second Floor

4. At 10:24 a.m., there were 4 full and 3 partial E-sized oxygen cylinders, stored inside a supplies storage room office, less than one foot from combustible paper supplies and an electrical outlet. There was no door closing device for this room. At 10:25 p.m., Facilities Support Staff 1 confirmed the cylinders were stored at the wrong location.

Based on record review and interview, the facility failed to maintain the piped-in medical gas systems. This was evidenced by the facility's failure to correct deficiencies cited on medical gas system inspection reports. This affected two of sixteen smoke compartments and could result in an increased risk of fire or a delay in providing patients with medical gas or vacuum.

NFPA 99 Standard for Health Facilities 1999 Edition
4-3.1.2.2. * General.
1. All local, master, and area alarm panels used for medical gas systems shall provide the following:
a. Separate visual indicators for each condition monitored
b. Cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal
c. A means to visually indicate a lamp or LED failure
2. Local, master, and area alarms shall indicate visually and audibly if
a. The monitored condition occurs
b.The wiring to the sensor or switch is disconnected
4-3.4.2.2 Testing.
(a) General. Inspection and testing of medical vacuum systems shall be in accordance with 4-3.4.1.1.
4-3.4.1.1* General. Inspection and testing shall be performed on all new piped gas systems, additions, renovations, installation, temporary installations, or repaired systems, to assure the facility, by a documented procedure, that all applicable provisions of this document have been adhered to and system integrity has been achieved or maintained.
4-4 Level 2 Piped Systems.
4-4.1 Piped Gas Systems (Source and Distribution). Level 2 piped gas systems shall conform to the requirements for Level 1 piped gas systems.

Findings:

During document review and interview with Facilities Support Staff 1 on 5/23/16, the annual inspection records for the piped-in medical gas systems were requested.

At 4:19 p.m., the Discrepancy Repair Logs within the annual medical gas inspection report dated 4/15/16, indicated the following repairs were needed:

1. Room 113 no vacuum flow
2. Room 114 oxygen leak, no vacuum flow
3. Room 115 no vacuum flow
4. OR A low vacuum flow, no air flow
5. OR C low vacuum flow

At 4:25 p.m., the Master Alarm Evaluation on the annual certifications dated 3/5/15 and 4/15/16 indicated the following conditions:

6. No Audible for the Med Star Panel Alarms at two NS (Nurse Stations) O(Oxygen) and N(Nitrogen)

At 5:06 p.m., Facilities Support Staff 1 explained that no repairs had been initiated since the inspection. Facilities Support Staff 1 also explained that the report was unclear as to the location of the panels with no audible alarms.

Based on observation and interview, the facility failed to maintain a smoke barrier wall. This was evidenced by an unsealed pipe penetration in a smoke barrier wall. This affected two of sixteen smoke compartments and could result in the spread of smoke or fire to other smoke compartments.

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

Findings:

During the facility tour with Facilities Support Staff 1 and 2 on 5/24/16, the smoke barrier walls were observed.

1. At 11:43 a.m., there was a 2 1/4 inch unsealed pipe sleeve containing 20 small diameter communication cables located over the smoke barrier corridor door. The open conduit sleeve passed between the B-Wing Smoke Compartments #10 and the old ICU area Smoke Compartment #11. At 11:44 a.m., Facilities Support Staff 1 confirmed the sleeve was open on both sides of the smoke barrier.

Based on observation and interview, the facility failed to maintain their electrical equipment and wiring connections. This was evidenced by a missing cover plate on a junction box and the use of extension cords and surge protected multi-outlet extension cords as substitutes for fixed wiring. This could result in an increased risk of electrical shock or fire that affected five of sixteen smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
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
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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 the facility tour and interview with Facilities Support Staff 1 and 2, from 5/24/16 to 5/25/16, the electrical devices and wiring connections were observed.

5/24/16

Hospital

1. At 4:22 p.m., there was a refrigerator plugged into an orange extension cord in the staff lounge located in the in-patient Surgery Department. Facilities Support Staff 2 confirmed there was no outlet near the refrigerator location.

2. At 4:49 p.m., there was a refrigerator and a coffee maker plugged into a surge protected extension cord in the B-Wing staff lounge.

3. At 5:09 p.m., there was a refrigerator and a microwave oven plugged into a surge protected extension cord in the Pharmacy. At 5:10 p.m., Pharmacy Staff 1 explained there were no other outlets for appliances.

5/25/16

Outpatient Pavilion

First Floor

4. At 9:29 a.m., there was a coffee maker plugged into a surge protected extension cord which was plugged into a wall outlet in the Outpatient Surgery staff lounge.

Second Floor

5. At 10:35 a.m., there were wire nuts protruding outside of the junction box in the wall above the entry door into the mechanical room. The junction box contained green black and white wires and the cover plate was missing. At 10:36 a.m., Facilities Support Staff 1 confirmed the exposed wires were powered at standard electrical outlet voltage levels.