HospitalInspections.org

Based on observations made on 5/25/2010, the facility failed to maintain the two-hour resistance rating of fire barriers and their communicating openings in the building.

In accordance with Section 19.1.2.3 of NFPA 101, LSC, 2000 edition; buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two hours as provided of additions in Section 19.1.1.4.

Findings include:

1. The two-hour fire barrier at the Clinical Educator's office in the Pulmonary Center was reviewed at 1:00 p.m. on 5/25/2010. There was a six inch by six inch hole in the fire barrier wall above the ceiling tile in the Clinical Educator's office.

2. The two-hour fire barrier near the east hospital waiting area was reviewed at 2:40 p.m. on 5/25/2010. The two-hour barrier was incomplete near the LDRP fire doors.


27244


3. The first floor two hour egress corridor was observed at 1:50 p.m. on 5/24/2010. A portion of the two hour barrier was incomplete to the floor/ceiling assembly above near the west exit.

4. The east two hour fire barrier in the large atrium was observed on 5/26/2010 at 8:45 a.m. The two hour wall above the northeast doors going to Same Day Surgery was observed and two penetrations were found as follows:

a) a 1/2 inch water pipe was not sealed around as it entered the barrier, and

b) there was also a sleeve through the two hour barrier that held one blue wire and four red wires was that was not sealed on the end of the sleeve.

Note: Both of these items were sealed at the time of survey.

5. The two hour fire barrier in the large atrium was reviewed on 5/26/2010 at 8:54 a.m. A sleeve passed through the barrier that was unsealed on the end and contained five blue wires passing through it.

Note: The end of the sleeve was filled with fire rated material at the time of survey.

Based on observations made on 5/25/2010, the facility failed to maintain the two-hour resistance rating of fire barriers and their communicating openings in the building.

In accordance with Section 19.1.2.3 of NFPA 101, LSC, 2000 edition; buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two hours as provided of additions in Section 19.1.1.4.

Findings include:

The fire barrier wall between the corridor and the north entrance to Adult Patient Psychology Center was observed at 8:20 a.m. on 5/25/2010. One Sheetrock seam along the east outside corner wall at the entrance to the Adult Patient Psych Center was not sealed with fire tape.

Note: The seam was sealed at the time of the survey process by maintenance staff.

Based on observations from 5/24 - 5/26/2010, the facility failed to maintain the fire and smoke resistance rating of wall assemblies.

Findings include:

In accordance with Section 19.1.6.1 of NFPA 101, 2000 edition, building construction type and height shall meet one of the following: 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1.

1. On 5/24/2010 at 3:10 p.m. on the hospital lower level, the dietary storage room was reviewed and at least two holes three inches in diameter in the ceiling tile were found to not be sealed.

2. On 5/24/2010 at 4:25 p.m. on the hospital lower level, there were two pipe penetrations approximately two inches in diameter which needed to be sealed. The penetrations were located at the wall above electrical panel EMCC-B.

3. On 5/25/2010 between 8:40 a.m. and 8:45 a.m. in the garage, there was a two inch unsealed hole in the exterior wall of the garage. Also, at another location in the garage there were three pipes passing through four inch penetrations in the exterior wall. These unsealed penetrations were located in the northeast corner of the garage.


27244

4. Room 5 in Endoscopy was reviewed on 5/25/2010 at 11:00 a.m. A ceiling tile was missing within the lay in tile ceiling.

Note: The ceiling tile was replaced at the time of survey.

5. The two hour fire barrier outside of the pharmacy was observed on 5/25/2010 at 11:05 a.m. Two violations were identified as follows:

a) there was a sleeve through the barrier that contained several wires that was not sealed, and

b) the barrier was not complete to the ceiling pan above.

6. The two hour fire barrier outside of the Chapel was reviewed on 5/26/2010 at 9:18 a.m. There were some security wires as described by staff that entered the barrier that were not sealed.

Note: The wires were sealed at the time of survey.

7. The Conference Center media room was reviewed on 5/26/2010 at 10:59 a.m. Two ceiling tiles were not in place in two different locations where several conduits and or wires passed through the ceiling.

Note: The ceiling tiles were replaces at the time of survey.

8. The two hour fire barrier within the Family Berthing Center atrium was examined on 5/26/2010 at 2:00 p.m. The barrier was incomplete between the floor/ceiling assembly and the two layers of sheet rock.

Note: The empty space was completed to the floor/ceiling assembly at the time of survey.

9. The Automated Teller Machine (ATM) room located inside the conference center was reviewed on 5/26/2010 at 2:20 p.m. The room which was not accessible to hospital staff was open because a technician was working on the ATM. The hard pan ceiling of the room had an approximately two foot square hole cut through both layers of sheet rock.

Based on observation on 5/25/2010, the facility failed to maintain flame spread rating for all interior finishes on ceiling spaces in a penthouse.

Findings include:

In accordance with Section 19.3.3.1 and 2 of NFPA 101, interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings shall have a flame spread rating of Class A or Class B.

Penthouse B2 of the Psychology Center was observed at 10:00 a.m. on 5/25/2010. The sprayed on flame spread material which had been applied to beams and portions of the ceiling was coming down in one corner of the penthouse. It appeared that the facility knew about a leak in the ceiling which had caused the damaged flame spread material to come down as there were work lights and tools near the area.

Note: The area was re-applied with new flame spread material and repaired at the time of the survey process.

Based on observations made on 5/26/2010, the facility failed to assure that there were no impediments to closing of corridor doors.

In accordance with section 19.6.6.3.3 of NFPA 101, 2000 edition; doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close.

Findings include:

The Medication Assistance Program office was observed at 9:25 a.m. on 5/26/2010. The corridor door to the office was being held open with a rubber wedge.

Note: The wedge was removed at the time of survey by facility staff.

Based on observations from 5/24 - 5/26/2010, the facility did not ensure all vertical openings in ceiling/floor assemblies were maintained and resistant to the passage of smoke.

Findings include:

1. On 5/26/2010 at 12:36 p.m., Penthouse #5 ws inspected. In the "5 West Control Room", there were three holes each being one inch in diameter which had been drilled in the floor and left open.

2. On 5/26/2010 at approximately 12:45 p.m. in the former air handling room in a penthouse for the surgery department, there was a three to four inch pipe located vertically in the floor of the penthouse. The "plug" being used to seal the open end of the pipe had not maintained the sealed penetration at the end of the pipe.

3. On 5/26/2010 at approximately 12:50 p.m. in the penthouse for elevators "#7 and #8", there were five holes in the floor of the penthouse. The holes were at least one inch in diameter and were unsealed.


27244


4. The Intensive Care Unit was observed on 5/26/2010 at 9:00 a.m. The locker room from surgery contained a vertical penetration of electrical to the floor above that was not sealed.

Based on observations made 5/25/2010, the facility failed to ensure that vertical openings between floors were sealed and/or enclosed by fire-resistive construction.

Findings include:

In accordance with Section 39.3.1.1 of NFPA 101 Life Safety Code, 2000 edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101 Life Safety Code, 2000 edition, 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/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. There were missing ceiling tiles and several unsealed pipe and conduit penetrations observed in the Communications closet on the east side of Coding next to the Fire Alarm Control Panel (FACP) room at 9:22 a.m. on 5/25/2010 in the basement. On 5/26/10 at 9:07 a.m., these penetrations were also observed to be not sealed at the first floor level.

2. An unsealed ceiling penetration measuring two inches by three inches was observed in the stairwell north from Transcription at 9:57 a.m. on 5/25/2010.

Note: These items were corrected by the maintenance staff during the survey.

Based on observations made on 5/25/2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 19.3.1.1 of NFPA 101, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 edition, 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/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The nurse's station at 1 South of the Psychology Center was observed at 9:15 a.m. on 5/25/2010. There were five conduits extending through the floor below the administrative desk which were not sealed to prevent the passage of fire/smoke.

Note: The conduits were sealed by maintenance staff at the time of the survey process.

2. Penthouse B-2 of the Psychology Center was observed at 10:05 a.m. on 5/25/2010. One cabinet door was missing on Unit 2 North data closet along the south wall of the penthouse. There was a two inch exposed conduit extending through the floor of the penthouse which was not sealed either at the conduit or by proper door closure.

Note: The cabinet door was replaced at the time of the survey process.

Based on observations during a tour of the hospital from 5/24 - 5/26/2010, not all doors serving fire rated barriers or hazardous area enclosures were being properly maintained.

Findings include:

1. On 5/25/2010 at 9:15 a.m. on the lower hospital level, the pair of corridor doors were open at the "Repair Shop" location. Both doors are self closing. However, one of the doors would not automatically close since a large cart on wheels had been put in the swing path of one of the doors.

2. On 5/25/2010 at 10:50 a.m. on the lower hospital level, there was no self closing device installed on the corridor door which opened into the Medical Record Storage Room which contained large quantities of combustible materials.

3. On 5/26/2010 at 7:45 a.m., a smoke barrier which separates the 300 North Wing from the Trauma Center was observed. The rated cross corridor doors at this smoke barrier were tested. When the doors were released from their magnetic "hold open"devices, one of the two doors did not close to a smoke tight seal.


27244

4. The soiled linen door for hospital surgery was observed on 5/26/2010 at 9:33 a.m. Upon three attempts to allow the door to close and latch, the door would close but would not positively latch.

Note: The maintenance staff did adjust the door handle hardware and were able to get the door to latch at the time of survey.

Based on observations made 5/25/2010, the facility failed to ensure that all smoke-rated enclosures were protected by doors that were capable of closing to positive latching.

In accordance with 39.2.2.2.1, doors complying with 7.2.1 shall be permitted. Specifically, section 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 include:

1. The west exit stairwell basement door did not latch when exercised three times at 10:40 a.m. on 5/25/2010. The door had a self closure device. The stairwell traveled between the basement and the 4th floor of the clinic.

2. The door to the west building mechanical room (located in the basement) with self closure device was exercised three times at 10:55 a.m. on 5/25/2010. The door failed to latch. The room stored boilers. The room opened into the medical record storage room in the basement. The door was held open with a paint brush. The door had a 1.5 hour fire rating.

Note: These items were corrected by the maintenance staff during the survey.

Based on observations made 5/26/2010, the facility failed to ensure that all smoke-rated enclosures were protected by doors that were capable of closing to positive latching.

In accordance with 39.2.2.2.1 Doors complying with 7.2.1 shall be permitted. Specifically, section 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 include:

The north exit stairwell door on the first floor did not latch when exercised three times at 11:17 a.m. on 5/26/2010. The the door had a self closure device. The stairwell traveled between the first and the 4th floor.

Note: This violation was corrected during the survey.

Based on observations on 5/27/2010, the facility failed to ensure that all hazardous areas and rated enclosures were protected by doors that were capable of closing to positive latching.

In accordance with 39.2.2.2.1 Doors complying with 7.2.1 shall be permitted. Specifically, section 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 include:

The door to the elevator mechanical room failed to latch at 7:58 a.m. on 5/27/10 at the basement level. The raised carpet at the threshold kept the door from closing on its own. The door had a self closure device.

Based on observations made 5/25/2010, the facility failed to ensure that doors opening into enclosed courtyards were properly identified as not being an exit way and to use exit signs with arrows to identify direction of exit to exit doors.

Findings include:

Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT or similar language per the 2000 edition of NFPA 101 Life Safety Code Section 7.10.8.1 Marking of Means of Egress.

There was not a "NO EXIT" or "Not an Exit" sign on the interior court yard door located on the east side of Coding at 8:55 a.m. on 5/25/2010.

Based on observations made on 5/24/2010; the facility failed to assure that doors opening into enclosed courtyards were properly identified as not being an exit way and to use exit signs with arrows to identify direction of exit to exit doors.

Findings include:

Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT or similar language per Section 7.10.8.1 Marking of Means of Egress of NFPA 101.

The south and east corridor doors which open into the enclosed courtyard were reviewed at 3:20 p.m. on 5/24/2010. The doors are not marked as NOT an EXIT and could be confused as an exit as one can see daylight to the outside. These corridor doors must be marked by a sign that reads NO EXIT or NOT an EXIT per Section 7.10.8.1.

Based on observations made on 5/24/2010; the facility failed to assure that doors opening into the Trauma Center Stair tower were properly identified as not being an exit.

Findings include:

Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT or similar language per the 2000 edition of NFPA 101 Section 7.10.8.1 Marking of Means of Egress.

The two hour Trauma Center stair tower leads to the first floor and is tied into a set of stairs coming from the lower level. The door to the stairs from the lower level should be labeled with a sign not an exit to avoid staff and the public from continuing to exit down the lower level.

Based on observations made on 5/24 - 5/26/2010, the facility failed to maintain the fire resistive rating of smoke barrier walls.

Findings include:

In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).

1. The smoke barrier wall in the exit stairway between the Intensive Care Unit and Pulmonary was reviewed at 1:20 p.m. on 5/25/2010. There was one penetration of the smoke wall where a communication wire extended through the wall near a sprinkler valve which was not properly sealed.

Note: The penetration was sealed at the time of the survey process.


27244

2. The Emergency Department (ED) was reviewed on 5/24/2010 at 2:30 p.m. Four penetrations were found at the center smoke barrier doors in the A Pod entrance from registration.

3. The smoke barrier for ED was reviewed on 5/24/2010 at 2:40 p.m. Three conduits entered the smoke barrier wall near the east fire corridor smoke barrier doors.

Note: The penetrations were filled at the time of survey.

4. The smoke barrier next to the Cafeteria on the east wall of Out Patient Surgery was observed on 5/26/2010 at 8:32 a.m. Several wires passed through the barrier and were previously sealed with fire rated material which had been pulled out of the barrier.

Note: The penetration was filled at the time of survey.

Based on observations made on 5/24-5/25/2010, the facility failed to maintain the fire resistive rating of smoke barrier walls.

Findings include:

In accordance with Section 8.3 of NFPA 101 LSC, smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).

1. The smoke barrier wall between the south wall of the conference room and the exit corridor was observed at 3:15 p.m. on 5/24/2010. The wall was incomplete along the south wall of the conference room.

Note: The wall was repaired to be smoke tight during the survey process.

2. The smoke barrier wall between the entrance to the Youth Inpatient Unit and the corridor was observed at 8:00 a.m. on 5/25/2010. There was a penetration through the smoke barrier wall around an electrical conduit which was not sealed properly.

Note: The penetration at the smoke barrier wall was sealed by maintenance staff at the time of the survey process.

Based on observations 5/25/2010, the facility failed to maintain or establish the fire-rated protection for hazardous areas.

Findings include:

In accordance with Section 8.4 of NFPA 101, Life Safety Code, 2000 edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 39.3.2.1 of NFPA 101 LSC.

On 5/25/2010 at 9:47 a.m., the boiler room was reviewed. There were unsealed pipe penetrations above the old boiler room doors (west side of boiler room B) extending into the stairwell located north of Transcription in the basement.

Based on observations made on 5/25 - 5/26/2010, the facility failed to maintain or establish the fire-rated protection for hazardous areas.

Findings include:

In accordance with Section 8.4 of NFPA 101, Life Safety Code, 2000 edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

1. The storage room in B Pod was observed on 5/25/2010 at 9:30 a.m. A open penetration around some wiring passing through the wall was observed. The penetration was repaired at the time of survey.

2. An unfinished room in the Emergency Department Atrium was reviewed on 5/25/2010 at 12:40 p.m. The room contained combustible items and is considered a storage area. The door to the room lacked a self closure device.

Note: A self closure device was installed by maintenance staff at the time of survey.

3. On 5/26/2010 at 8:01 a.m, the Admitting area was reviewed. Storage of cardboard boxes and other materials were noted behind the modular wall and between the black construction plastic in place for an ongoing project in Pharmacy. These items should be in a designated storage area as to not increase the fireload for staff and patients in the Admitting area.

Based on observations made on 5/27/2010, the facility failed to prevent the use of exit stairways as storage areas.

Findings include:

In accordance with 39.2.2.3.1 of NFPA 101 LSC, exit stairs shall comply with 7.2.2. In accordance with 7.2.2.5.1 of NFPA 101 LSC, all inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. In accordance with 7.1.3.2.3 of NFPA 101 LSC, an exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit.

On 8:00 a.m. on 5/27/2010, the northwest exit stairway from the Physical Therapy suite had items stored at the basement level. There was a painted sign in this area with the words "NO STORAGE".

Based on observations made on 5/25/2010, the facility failed to maintain the rating of a stair well.

Findings include:

In accordance with 19.3.1.1 of the Life Safety Code exit stairs shall comply with 8.2.5 of the Life Safety Code. In accordance with 8.2.5.2 of NFPA 101 openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

The Emergency Department east stairwell wall was observed on 5/25/2010 at 2:51 p.m. A penetration where an electrical conduit had been removed was not sealed and other areas on the barrier were in need of complete coverage with fire rated material.

Note: The one hour fire wall was repaired at the time of survey.

Based on observations made on 5/26/2010, the facility failed to maintain exit stair gates to prevent patients, staff, and members of the public from going to the lower level in an exit stairway.

According to Section 7.7.3 of NFPA 101, stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

Findings include:

The north east exit stair way in Pediatrics was reviewed on 5/26/2010 at 1:16 p.m. The north east stairway gate preventing patients, staff, and members of the public from going to the lower level was permanently open. The cam mechanism, which mechanically closes the gate every time someone goes through it when exiting from the lower level, was out of adjustment and thus the gate was in an open position at all times.

Based on observations made on 5/25/2010, the facility failed to identify the two exits required from a gymnasium.

The findings include;

Any room or any suite of rooms, other than patient sleeping rooms, of more than 2500 square feet shall have not less than two exit access doors remotely located from each other per section 19.2.5.3 of the Life Safety Code.

The gymnasium of the Psychology Center was reviewed for exiting at 9:34 a.m. on 5/25/2010. The gymnasium is approximately 4000 square feet in size. There are two sets of double doors which exit back into the corridor space and an alternating exit door which does exit to the outside of the building. The alternating exit door had the exit sign removed from above the door and the door leaf was signed with a Not an Exit sign. The east exit door is one of the doors which makes up the two access doors remotely located from each other required for exiting from the gymnasium. One additional marked exit is required in the gymnasium.

Based on observations from 5/24 - 5/26/2010, the facility failed to ensure that all exit signs were illuminated so as not to leave the exit discharge in darkness.

As required under Section 7.10.1.4 of NFPA 101 Life Safety Code; "means of egress" has to be apparent and be identified by visible exit signs.

Findings include:

On 5/24/2010 at 2:40 p.m., the "convenience stairwell" which adjoins the construction at the imaging storage room was reviewed. There was no illumination for this stairwell. There was a manual light switch at the bottom of the stairwell which did not work. The battery back-up lighting on the wall of the stairwell did not operate when tested.

Based on review of battery powered emergency light fixture testing logs and a staff interview on 5/26/2010, the facility failed to ensure that the required battery-powered emergency lights were tested on a monthly basis. The facility had several battery powered lights for exiting due to the lack of an emergency generator for this building.

In accordance with Section 39.2.9.1 emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Section 7.9.3 of NFPA 101 states that a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Although emergency lights are not required per Section 39.2.9.1 of NFPA 101 LSC; Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings include:

The battery powered emergency lighting test logs were reviewed during the survey from 5/24 to 5/27/2010. The logs lacked documentation for the required testing of the emergency lights (two were located in the stairwell) for exiting as mentioned above.

On 5/26/2010 at 11:15 a.m., the building's maintenance staff validated that the monthly and annual tests were not conducted on the emergency lights.

Based on review of battery powered emergency light fixture testing logs and a staff interview on 5/25/2010, the facility failed to ensure that the required battery-powered emergency lights were tested on a monthly basis. The facility had several battery powered lights for exiting due to the lack of an emergency generator at this building.

In accordance with Section 39.2.9.1 emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Section 7.9.3 of NFPA 101 states that a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Although emergency lighting is not required per Section 39.2.9.1 of NFPA 101 code, Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings include:

The battery powered emergency lighting test logs were reviewed during the survey from 5/24 to 5/27/2010. The logs lacked documentation for the required testing of the emergency lights for exiting as mentioned above.

On 5/25/2010 at 8:05 a.m. , the safety specialist validated that the monthly and annual tests were not conducted on the emergency lights in this building.

Based on observations from 5/24 - 5/26/2010, the facility failed to ensure that all exit and directional signs were continuously illuminated.

Findings include:

As required under Section 7.10.1.4 of NFPA 101 Life Safety Code; "means of egress" has to be apparent and be identified by visible exit signs.

1. On 5/25/2010 at 3:42 p.m., the corridor location where the third floor north "level " connects to the trauma unit was reviewed. At this juncture, there is a stairway identified as an exit stairway by an exit sign located directly above the stairway door in the corridor. The exit sign is not readily visible since the occupants of the building would use the corridor with its "north-south" orientation between the third floor north level and the trauma center.


27244

2. The conference center conference rooms exiting was evaluated on 5/26/2010 at 10:26 a.m. An exit light in the confrence room stairwell was not iluminated.

Note: The maintenance staff replaced the exit sign lights at the time of survey.

Based on observations made on 5/27/2010, the facility failed to ensure that all illuminated exit signs had been installed in such a manner to allow them to be easily seen. This is required per Section 39.2.10 Marking of Means of Egress of NFPA 101 which indicates means of egress shall have signs in accordance with Section 7.10.

Section 7.10.1.7 Visibility of NFPA 101 indicates that every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.

Section 7.10.2 Directional Signs of NFPA 101 indicates that a sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Findings include:

At approximately 8:10 a.m., the Family Medicine, Radiology, and Family Practices office space on the second level was reviewed. An exit sign was located above the east exit door at the same angle as the corridor wall. The exit sign can only be clearly seen when viewed from a location directly in front of the exit door. The exit sign was not visible from either the left or right side corridor locations.


27244

2. The east hall way common to Family Medicine, Radiology, and Family Practices was reviewed for exit signage on 5/27/2010 at 8:15 a.m. There were two issues noted with exiting signage in this hallway.

a) There is no exit sign at the south, east to west hall way indicating the proper exiting for patients and staff in Family Practice.

b) The exit sign located at the north east to west hall way in the Family Medicine was blocked by a facility sign and the sign did not have an indicator indicating the direction of egress.

Based on observations on 5/25/2010, the facility failed to maintain the continuous illumination of exit signs during emergencies.

Findings include:

Exit signs in accordance with 39.2.10 and 7.10.5.2 of the NFPA 101 Life Safety Code, 2000 edition, shall be continuously illuminated. Exit signs that are internally illuminated must meet UL 924 standards and are listed for use only with all bulbs evenly and uniformly illuminating the letters.

The exit signs operated by battery power (in case of an emergency) near the entrance to the nurses station and above the south side of the reception area would not illuminate when they were tested at 8:25 a.m. on 5/25/2010. The batteries were dead.

The facility did not have a generator; and in case of a power outage, the exit sign lights would use battery power to illuminate the exit corridors in the building.

Note: The maintenance staff corrected these violations during the survey.

Based on review of the fire alarm service and inspection reports on 5/24 - 5/27/2010, the facility failed to provide documentation to show that any testing of the fire alarm system was performed in 2009 or 2010.

In accordance with Section 39.3.4.1 of NFPA 101 a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Although this building is not required to have an alarm system per Section 39.3.4.1 of NFPA 101, Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed

Findings include:

In accordance with 7-3.2 of NFPA 72 (1999 edition) testing of the fire alarm system shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. Table 7-3.2 requires annual testing of such components as all control equipment, battery charger test, trouble signals within the control unit, remote annunciators, initiating devices including duct detectors, fire alarm boxes and smoke detectors (sensitivity testing to be in accordance with 7-3.2.1 of NFPA 72).

The fire alarm service and inspection reports were reviewed at the facility between 5/24/10 and 5/27/10. There was no evidence that the fire alarm system was inspected on an annual basis in 2009 and 2010, including sensitivity testing of the smoke detectors.

Based on observation and staff interview on 5/25/2010, the facility failed to ensure that the location of the electrical circuit breaker servicing the fire alarm panel was posted on the alarm panel itself and the circuit breaker had a red marking in the designated panel identifying the fire alarm panel.

In accordance with Section 39.3.4.1 of NFPA 101 a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Although this building is not required to have an alarm system per Section 39.3.4.1 of NFPA 101, Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed

Findings include:

1. In accordance with 1-5.2.5.2 of NFPA 72, 1999 edition, the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

On 5/25/2010 at 1:45 p.m., the location of the electrical circuit serving the fire alarm panel was not posted/marked on the fire alarm panel.

2. The breaker (#34) in the electrical panel PA was not marked in red.

Note: The items were corrected by the maintenance staff during the survey.

Based on observations made on 5/26/2010, the facility failed to maintain the smoke detectors as required in NFPA 72.

Findings include:

A smoke detector outside of the two hour fire barrier of the Family Birthing Center (FBC) atrium was hanging from the wires of the device.

Note: The device was adjusted to fit snuggly to the ceiling tile at the time of survey.

Based on observations and review of records made on 5/24/2010, the facility failed to provide for complete sprinkler protection of all portions or areas of the building.

Findings include:

The building is of construction Type II (111) protected two story with noncombustible construction which requires that the facility be protected throughout by an automatic sprinkler system that meets NFPA 13 standards. In accordance with Section 19.3.5.1 of NFPA 101, LSC, (2000 edition); where required by Section 19.1.6 of NFPA 101, LSC, (2000 edition); health care facilities shall be protected by an approved, supervised automatic sprinkler system in accordance with Section 9.7 of NFPA 101, LSC.

The cafeteria of the Psychology Center was observed at 2:30 p.m. on 5/24/2010. There is a roll cage door separating the kitchen from the cafeteria. There is an open space in the ceiling tile where the roll cage door is allowed to open above the ceiling tile. This open space could allow smoke to accumulate above the ceiling tile and not set off the sprinkler system as there is no protection above the ceiling tiles. The space above the kitchen must be protected by the installed sprinkler system or the area must be closed off near the roll cage door to not allow smoke above the level of protection.

Based on observations made on 5/26/2010, the facility lacked complete sprinkler coverage.


Findings include:

The Automated Teller Machine (ATM) room located inside the conference center was reviewed on 5/26/2010 at 2:20 p.m. The room, which was not accessible to hospital staff, was open because a technician was working on the ATM. The hard pan ceiling of the room had an approximately two foot square hole cut through both layers of sheet rock and lacked sprinkler protection.

Based on observations from 5/24 - 5/26/2010, the facility failed to ensure that the sprinkler system was being properly maintained in accordance with NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition).

Findings include:

The clearance between the deflector of standard pendent and upright spray sprinklers and the top of storage shall be 18 inches or greater per section 5-6.6 of NFPA 13.

1. On 5/24/2010 at 2:25 p.m. on the lower hospital level, the "bio med" department and the imaging storage room were inspected. In the imaging storage room, there were five plastic relay boxes stored above the discharge plane of the nearest ceiling sprinkler head.

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 edition.

2. On 5/24/2010 at 2:50 p.m. in the kitchen, there was an escutcheon ring missing at the sprinkler located above the "pop area" of kitchen storage location.


27244


3. The locker room next to the PBX was reviewed on 5/25/2010 at 1:15 p.m. An escutcheon ring was found missing inside the locker room.

4. An escutcheon ring was missing and one loosely fitted to the ceiling in Jennifer Deibele's office on 5/25/2010 at 11:20 a.m.

Note: Both issues were resolved at the time of survey.

5. The Medical Records area was inspected on 5/26/2010 at 11:16 a.m. There was a gap around two escutcheon rings.

Note: The openings around the escutcheon rings were filled with fire rated material at the time of survey.

Based on observation on 5/24 - 5/25/2010, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13 and NFPA 25.

Although fire sprinkler systems are not required per Section 39.3.5 for existing business occupancies; Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings include:

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 edition.

1. An escutcheon ring was missing from a ceiling sprinkler near the south exit door at 8:25 a.m. on 5/25/2010.

2. The sprinkler risers were observed on 5/24/2010. The control valve and the drain valve lacked signage (plates) identifying them at 2:40 p.m.

Based on observations 5/25 - 5/26/2010, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13.

Although fire sprinkler systems are not required per Section 39.3.5 for existing business occupancies, Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings include:

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 edition.

1. The escutcheon plate fell off the sprinkler head during the observation at 11:15 a.m. on 5/25/2010 in Administration bathroom in the basement. The escutcheon plate was previously duct taped to the sprinkler head and fell off while the maintenance staff was trying to fix the loose plate.

2. A missing ceiling tile was observed at 1:00 p.m. on 5/25/2010 in the data room on the forth floor. The room was sprinklered.

3. A missing ceiling tile was observed at 2:10 p.m. on 5/25/2010 in the sleep lab data room above the phone terminal. The room was sprinklered.

4. Missing ceiling tiles were observed in the electrical/data room of OBGYN at 8:07 a.m. on 5/26/2010. The room was sprinklered.

5. A missing ceiling tile was also observed in the Maternal and Fetal Medicine at 8:14 a.m. on 5/26/2010. The room was sprinklered.

6. The sprinkler head a missing escutcheon plate in the audiology testing room at 8:50 a.m. on 5/26/2010.

Note: All these items were corrected by the maintenance staff during the survey.

Based on observation on 5/27/2010, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13.

Although fire sprinkler systems are not required per Section 39.3.5 for existing business occupancies; Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 edition.

Findings include:

The Family Practice area was reviewed at 7:50 a.m. on 5/27/2010. The south west exam room immediately north of the south exit to the mezzanine had an escutcheon ring missing for the sprinkler located in that room.

Based on observations from 5/24 - 5/26/2010, fire extinguishers were not properly maintained in accordance with NFPA 10.

Findings include:

In accordance with Section 4-3.2 (b) of NFPA 10 (1998 edition), there shall be "no obstructions to access or visibility" of portable fire extinguishers.

In accordance with Section 2-3.2 of NFPA 10, "Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires." In addition, Section 2-3.2.1 of NFPA 10 requires the following: "A placard shall be conspicuously placed near the extinguisher that states that the fire protection system of the kitchen hood shall be activated prior to using the fire extinguisher."

In accordance with 1-6.7 and 1-6.10 of NFPA 10 portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

In accordance with Section 4-4.3 of NFPA 10, 1998 edition; every six years, stored-pressure fire extinguishers that require a hydrostatic test shall be emptied and subjected to the applicable maintenance procedures.

1. On 5/25/2010 at 8:51 a.m. on the lower hospital level in the "Gray Water Storage Room", access to a fire "wall mounted" extinguisher was blocked by a UPS backup unit and a large cardboard box.

2. On 5/25/2010 at 3:05 p.m., no placard as described above in Section 2-3.2.1 had been placed in the vicinity of the "K" cylinder in the basement kitchen.

3. On 5/25/2010 at 9:00 a.m. in the Gray Water Storage Room, there was a fire extinguisher which had been placed on the floor, it was "free standing", and had not been properly secured.


20343


4. The portable fire extinguisher located in the Intensive Care Unit was reviewed at 1:30 p.m. on 5/25/2010. The extinguisher was placed in service in 1992, had received a 6 year maintenance in 1998, but failed to get a 6 year maintenance test in 2004. The extinguisher also did not receive a hydro test in April of 2009.

Based on observation on 5/27/2010, the facility failed to ensure that portable fire extinguishers were readily available in accordance with the standards of NFPA 10 Section 39.3.5 of NFPA 101.

Findings include:

In accordance with 1-6.3 of NFPA 10 (1999 edition) fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire.

No fire extinguisher was observed in the elevator mechanical room or in the area within 5 feet of the elevator mechanical room at 7:56 a.m. on 5/27/2010 at the basement level.

Based on observations made 5/24/2010, the facility failed to ensure that portable fire extinguishers were readily available in accordance with the standards of NFPA 10 and Section 39.3.5 of NFPA 101.

Findings include:

In accordance with 1-6.6 and 4-3.2 of NFPA 10, 1998 edition fire extinguishers shall not be obstructed or obscured from view and no obstruction to access or visibility will impair the periodic inspection of fire extinguishers. In addition, in accordance with 1-6.3 of NFPA 10 (1999 edition) fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire.

The office adjacent to the library in human resources was observed at 3:49 p.m. on 5/24/2010. The fire extinguisher was hanging on the wall behind a panel near the exit door and was not visible to all occupants in the room at all times.

Note: The signage for the fire extinguisher was relocated during the survey.

Based on observations made on 5/24 - 5/26/2010, the facility failed to assure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Findings include:

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

In accordance with Section 4-4.3 of NFPA 10, 1998 edition; every six years, stored-pressure fire extinguishers that require a hydrostatic test shall be emptied and subjected to the applicable maintenance procedures.

In accordance with 1-6.3 of NFPA 10 (1999 edition) fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire.

1. The portable fire extinguisher located in the center corridor hall of the Psychology Center was observed at 3:30 p.m. on 5/24/2010. The extinguisher had received a hydrotest in April of 1998 and was due for the next hydrotest in April of 2010, but had been missed when the extinguishers received the annual service in April of 2010.

2. The penthouse D-4 of the Psychology Center was observed at 9:20 a.m. on 5/25/2010. The portable fire extinguisher located in the penthouse had not received its annual inspection in April of 2010. The extinguisher had a service tag dated April 2009.

3. The Carbon Dioxide type portable fire extinguisher located in the Psychology Center Penthouse C-3 was observed at 9:30 a.m. on 5/25/2010. The extinguisher had been placed in service in 1992 and received its first 6 year maintenance service in 1998 and a following 6 year service in 2007. There was a required 6 year maintenance service in 2004 which was not documented by proof of the service tags on the extinguisher.

Note: All of the above fire extinguishers were replaced with ones which were current with all maintenance and service tags at the time of the survey process.

4. The basement of the Psychology Center was inspected at 9:25 a.m. on 5/26/2010. The following locations were discovered without portable fire extinguisher protection.
a) There was no portable fire extinguisher in the pool mechanical room or within five feet of the room.
b) There was no portable fire extinguisher in the elevator mechanical room or within five feet of the room.

Note: Two portable extinguishers were installed at these locations which were current for service and maintenance during the survey process.

Based on observations made on 5/24/2010, the facility failed to maintain the means of egress, including exit corridors, free from obstructions and from being used for storage purposes.

Findings include:

Items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor per Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 04-41 effective August 12, 2004.

The east service hall to the Psychology Center was observed at 2:35 p.m. on 5/24/2010. There were numerous items blocking the exit discharge path through the service corridor. This corridor serves as a main escape route to the outside from the northeast side of the building.

Note: The items which had been stored in the exit corridor were removed during the time of the survey process.

Based on observations made on 5/26/2010, the facility failed to maintain the means of egress, including exit corridors, free from obstructions and from being used for storage purposes.

Findings include:

Items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor per Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 04-41 effective August 12, 2004.

The exit corridor common to the Conference Center and directly outside of the Security Office was observed at 10:40 a.m. on 5/26/2010. There were two living room type sofas stored in the exit corridor. This corridor serves as an escape route to the outside.

Note: The sofas which had been stored in the exit corridor were removed during the time of the survey process.

Based on observations 5/25 - 5/26/2010, the facility failed to limit the amount of oxygen that can be stored outside of a dedicated oxygen storage room and failed to ensure all oxygen cylinders were secured properly in storage.

Findings include:

Up to 300 cubic feet of nonflammable medical gas (12 "E" size cylinders) associated with patient care may be located outside of a dedicated oxygen enclosure room in a single smoke compartment as long as they are properly secured per CMS Survey and Certification letter 07-10 dated January 12, 2007. If placed in a corridor, they shall be placed so as not to obstruct the use of the corridor.

In accordance with 4-3.1.1.1 and 4-3.5.2.1(b) #13, 24 and 27 of NFPA 99, 1999 edition, all oxygen cylinders in storage shall be individually secured and located to prevent falling or being knocked over, free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart, the cylinders shall never be used as supports for other items and shall be protected against mechanical damage due to objects striking them or falling on them.

1. a)Eleven E size oxygen cylinders were placed in an alcove on the exit corridor between the sleep lab and Pulmonary at 2:37 p.m. on 5/25/2010.

b) At 2:40 p.m. on 5/25/2010, two additional E size oxygen cylinders were observed in storage in the Pulmonary nurses station giving a total of thirteen E size oxygen cylinders being stored in this compartment on the third floor of the clinic (exceeding the 3000 cubic feet limit).

2. An E size oxygen cylinder was observed lying on the floor in supply room of Same Day Care at 8:45 a.m. on 5/26/2010.

Note: The maintenance staff corrected these violations during the survey.

Based on observations made 5/26/2010, the facility failed to ensure that a cylinder of oxygen was properly secured from falling over or being knocked down.

Findings include:

In accordance with 4-3.1.1.1 and 4-3.5.2.1(b) #13, 24 and 27 of NFPA 99, 1999 edition, all oxygen cylinders in storage shall be individually secured and located to prevent falling or being knocked over, free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart, the cylinders shall never be used as supports for other items and shall be protected against mechanical damage due to objects striking them or falling on them.

An E size oxygen cylinder was observed free standing at 10:40 a.m. on 5/26/2010 in the printer room behind the main reception area.

Note: This violation was corrected at the time of the survey.

Based on observations made on 5/25/2010, the facility failed to assure that a cylinder of oxygen was properly secured from falling over or being knocked down.

Freestanding cylinders of nonflammable gases such as oxygen, shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down in accordance with Sections 8-3.1.11.2(h) and 4-3.5.2.1(b) 27 of NFPA 99, 1999 edition).

Findings include:

Several "E" size cylinders of oxygen were found to be freestanding in the medical supply room on the Adult Psychology Unit of the Psychology Center as observed at 8:45 a.m. on 5/25/2010.

Note: The cylinders were returned to the main oxygen storage room as confirmed by the surveyor while on-site.

Based on observations made on 5/26/2010, the facility failed to assure that combustilbes were being stored in oxygen storage room at least five feet away and that a cylinder of oxygen was properly secured from falling over or being knocked down.

Findings include:

In accordance with Section 8-3.1.11.2 of NFPA 99, 1999 edition, Storage for nonflammable gases less than 3000 ft3 (85 m3). (c)Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
a) A minimum distance of 20 ft (6.1 m), or
b) A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
c) 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.

Freestanding cylinders of nonflammable gases such as oxygen, shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down in accordance with Sections 8-3.1.11.2(h) and 4-3.5.2.1(b) 27 of NFPA 99, 1999 edition).

1. The Hospital Surgery Oxygen Storage Room was observed on 5/26/2010 at 9:33 a.m. A total of 13 "E" size cylinders of oxygen were found in the storage area and cardboard boxes containing medical equipment were within three feet of the cylinders.

2. The Pediatric area of the first floor was reviewed on 5/26/2010 at 12:43 a.m. A freestanding "E" size oxygen cylinder was found standing not in a rack or protected from accidental being knocked over in the "Procedure Treatment Room across from Exam Room #2.

Based on observationon 5/27/2010, the facility failed to ensure that a cylinder of oxygen was properly secured from falling over or being knocked down.

Findings include:

In accordance with 4-3.1.1.1 and 4-3.5.2.1(b) #13, 24 and 27 of NFPA 99, 1999 edition, all oxygen cylinders in storage shall be individually secured and located to prevent falling or being knocked over, free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart, the cylinders shall never be used as supports for other items and shall be protected against mechanical damage due to objects striking them or falling on them.

An E size oxygen cylinder was observed free standing at 7:45 a.m. on 5/27/2010 in the storage room of the Internal Medicine Suite.

Note: This violation was corrected at the time of the survey.

Based on observations made by the surveyor from 5/24 - 5/26/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with Article 110-26 of NFPA 70 (1999 edition) sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

In accordance with 370.28(c) of NFPA 70 (1999 edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110.

1. On 5/25/2010 at 8:22 a.m. on the lower hospital level, the "old Joslyn Room" was inspected. There were five pieces of wood in front of electrical panel (BC3L) which blocked access to the panel.

2. On 5/25/29010 at 10:54 a.m. on the lower hospital level, the telephone dialer room was inspected. In this room there was a electrical junction box which was missing a cover. The junction box contained at least three exposed wired connections.


27244


3. The emergency department first floor electrical room in A Pod was reviewed on 5/24/2010 at 2:10 p.m. Two electrical issues were identified:

a) a splice box for the fire alarm lacked a junction box cover, and
b) the fire alarm TIR was hanging loosely from the electrical box it was supposed to be mounted in.

Note: Both of these items were corrected at the time of survey.

4. The ambulance entry location was reviewed on 5/25/2010 at 9:00 a.m. Several portable radios were sitting in their charging units which were all plugged into surge protectors that were "daisy chained" together. A total of three surge protectors were hooked in series.

Note: One surge protector was removed and the other two plugged directly into the facility electrical at the time of survey.

5. The PBX Call Center was reviewed on 5/25/2010 at 11:00 a.m. A surge protector was plugged in series with another.

Note: The additional surge protector was removed at the time of survey.

6. The Endoscopy area was reviewed on 5/25/2010 at 1:15 p.m. Two electrical panel schedules require updating as follows:

a) panel 1C7L, and

b) panel 1N10L.

7. The "Admitting" area was observed on 5/26/2010 at 7:45 a.m. Two electrical issues were found in the area of Joelynn Summers office area:

a) a white household extension cord was in use, and

b) a small refrigerator was plugged into a surge protector.

Note: Both of these items were corrected at the time of survey.

8. The staff breakroom in "Admitting" was observed at 7:50 a.m. on 5/26/2010. A white household extension cord was in use.

Note: The extension cord was removed at the time of the survey.

9. A photocopier labeled #39 was plugged into a surge protector in the "Admitting" area at 7:55 a.m. on 5/26/2010.

Note: The copier was plugged directly into the facility wiring at the time of survey.

10. Two small refrigerators, one brown and one white, were found to be plugged directly into surge protectors in "Admitting" on 5/26/2010 at 8:03 a.m.

11. The Operation Excellence (OPX) area was reviewed at 8:15 a.m on 5/26/2010. Two electrical issues were noted in the same area:

a) An orange electrical extension cord was in use to provide power for a refrigerator, and

b) a microwave was plugged into a surge protector.

Note: The orange extension cord was removed and the microwave was unplugged and connected directly to the facility outlet at the time of survey.

12. The out patient surgery area was reviewed on 5/26/2010 at 8:35 a.m. Two electrical panels were in need of updating inside the electrical room and marked as follows:

a) panel 1N2H had circuit #8 marked as a spare but circuit # 8 was on, and

b) panel 1S2H had circuit #8 marked as a spare but circuit # 8 was on.

13. The Conference Center electrical room 10 East was reviewed on 5/26/2010 at 10:45 a.m. Two electrical panels were found in need of updating to the panel schedule.

a) panel 1N7L had circuit #11 marked as spare but circuit #11 was on, and

b) panel 1S3H had circuit #11 marked as a spare but circuit # 11 was on.

14. The Conference Center catering office was reviewed on 5/26/2010 at 10:47 a.m. There were two issues identified with electrical cords or surge protectors:

a) one surge protector was plugged into another or daisy chained, and

b) a thick black extension cord was in use.

15. An electrical room in "PEDS" was reviewed on 5/26/2010 at 12:50 p.m. Three panel schedules were in need of updating as follows:

a) panel L1SH1H had circuit #19 marked as a spare but circuit #19 was on,

b) panel L1N1H had circuit #2 marked as a spare but circuit #2 was on, and

c) panel LIN1L had circuits #5, 6, 8 , 10, 11, 12, 13 & 14 as spare but all were on.

16. The "PEDS" area of the first floor was reviewed at 12:30 a.m. on 5/26/2010. A green extension cord was found to be plugged into a paper shredder.

Note: The extension cord was removed at the time of survey.

17. The Family Birthing Center (FBC) atrium was reviewed on 5/26/2010 at 2:00 p.m. The security desk was reviewed and it was found that two surge protectors were plugged into each other. One of the surge protectors also had a damaged cord.

Based on observation on 5/24/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. Tthese items must be directly connected to an appropriate receptacle.

An extension cord was found under the desk in the northwest corner of the nurses station on 5/24/2010 at 2:00 p.m.

Note: The extension cord was removed and discarded by the maintenance staff after the observation was made during the survey.

Based on observations 5/24 - 5/26/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use per Article 370.28(c) of NFPA 70.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

1. The patient financial services and risk management break room was observed on at 3:16 p.m. on 5/24/2010. A microwave was plugged into a surge protector on the south east corner of the room.

2. The human resources employee file room was observed at 3:32 p.m. on 5/24/2010. The upright refrigerator was plugged into a surge protector.

3. The mechanical room in human resources was observed at 3:36 p.m. on 5/24/2010. An electrical junction box located on the ceiling was missing its cover plate.

4. The electrical panel BN4L (LL04) in mechanical room of human resources was observed at 3:40 p.m. on 5/24/2010. The circuit breakers 31, 33, and 35 were not numbered on the panel. They were in on positions. The circuit breaker 37 was in off position and this was not marked on the panel directory as spare.

5. A microwave was plugged into a surge protector in Release Information at 9:40 a.m. on 5/25/2010.

6. A coffee maker was plugged into an extension cord, then the extension cord was plugged into a surge protector in Transcription at 9:35 a.m. on 5/25/2010.

7. The circuit breaker 5 located in electrical panel 4NIL found in the forth floor penthouse was in on position but it was not listed on the panel directory. Breakers 1-3 and 2-6 were in off positions but they were not marked as spares on the panel directory. These observations were made at 1:15 p.m. on 5/25/2010.

8. A microwave was plugged into a surge protector in the sleep lab control room at 2:17 p.m. on 5/25/2010.

9. A microwave was plugged into a three receptacle splitter in the general surgery employee lounge at 2:52 p.m. on 5/25/2010.

10. A microwave was plugged into a surge protector in the general surgery conference room at 2:58 p.m. on 5/25/2010.

11. A microwave was plugged into a surge protector in room 4 in Maternal and Fetal Medicine at 8:19 a.m. on 5/26/2010.

12. A refrigerator was plugged into a surge protector in the Same Day Care nurses station at 8:40 a.m. on 5/26/2010.

13. Breakers 17 and 18 of the electrical panel (not identified) at the south end of the Physical Medicine and Rehab hallway were in on positions, but they were not identified on the panel directory. Some of the breaker numbers on the panel were pencilled in and were illegible. The panel numbers did not coincide with the breaker numbers on the panel directory.

Note: These violations were corrected by the maintenance staff during the survey.

Based on observations made 5/26/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

1. A refrigerator was plugged into a surgery protector in room 235 at 11:10 a.m. on 5/26/2010.

2. Circuit breakers 22 through 28 in electrical panel LS were in on positions, but they were not addressed on the panel directory at 10:50 a.m. on 5/26/2010.

Note: These violations were corrected at the time of the survey.

Based on observations made on 5/24 - 5/25/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

1. The Coke dispensing machine in the east service corridor was observed at 2:40 p.m. on 5/24/2010. There was a large black extension cord in use to power the Coke machine.

Note: The extension cord was removed at the time of the survey process by maintenance staff.

2. The conference room in the Psychology Center was observed at 3:15 p.m. on 5/24/2010. An electrical outlet cover was missing in the conference room cubby space.

Note: The electrical cover was replaced during the survey process by maintenance staff.

3. The Youth Case Manager's Office was observed at 8:30 a.m. on 5/25/2010. An extension cord was in-use along the south wall of this office.

Note: The extension cord was removed at the time of the survey process by maintenance staff.

Based on observations made on 5/27/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with Article 410-56(d) of NFPA 70, faceplates on receptacles shall be installed so as to completely cover the opening and seat against the mounting surface.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

1. The mechanical room on the east wing of Billings Clinic West was observed at 8:10 a.m. on 5/27/2010. An electrical cover was missing on the north wall of the mechanical room on the main level of the clinic.


18076


2. A refrigerator was plugged into a surge protector in the nurse practitioners's office near the "Check Out" sign at 8:00 a.m. on 5/27/2010.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

3. Circuit breakers 31, 33, 35, 37, 39, and 41 were addressed in the electrical panel (7-8L) directory, however, these circuits were not numbered on the panel at 7:54 a.m. on 5/27/10 in the main floor of the Billings Clinic West.

Based on observations made on 5/25/2010, the facility failed to maintain the two-hour resistance rating of fire barriers and their communicating openings in the building.

In accordance with Section 19.1.2.3 of NFPA 101, LSC, 2000 edition; buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two hours as provided of additions in Section 19.1.1.4.

Findings include:

1. The two-hour fire barrier at the Clinical Educator's office in the Pulmonary Center was reviewed at 1:00 p.m. on 5/25/2010. There was a six inch by six inch hole in the fire barrier wall above the ceiling tile in the Clinical Educator's office.

2. The two-hour fire barrier near the east hospital waiting area was reviewed at 2:40 p.m. on 5/25/2010. The two-hour barrier was incomplete near the LDRP fire doors.


27244


3. The first floor two hour egress corridor was observed at 1:50 p.m. on 5/24/2010. A portion of the two hour barrier was incomplete to the floor/ceiling assembly above near the west exit.

4. The east two hour fire barrier in the large atrium was observed on 5/26/2010 at 8:45 a.m. The two hour wall above the northeast doors going to Same Day Surgery was observed and two penetrations were found as follows:

a) a 1/2 inch water pipe was not sealed around as it entered the barrier, and

b) there was also a sleeve through the two hour barrier that held one blue wire and four red wires was that was not sealed on the end of the sleeve.

Note: Both of these items were sealed at the time of survey.

5. The two hour fire barrier in the large atrium was reviewed on 5/26/2010 at 8:54 a.m. A sleeve passed through the barrier that was unsealed on the end and contained five blue wires passing through it.

Note: The end of the sleeve was filled with fire rated material at the time of survey.

Based on observations made on 5/25/2010, the facility failed to maintain the two-hour resistance rating of fire barriers and their communicating openings in the building.

In accordance with Section 19.1.2.3 of NFPA 101, LSC, 2000 edition; buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two hours as provided of additions in Section 19.1.1.4.

Findings include:

The fire barrier wall between the corridor and the north entrance to Adult Patient Psychology Center was observed at 8:20 a.m. on 5/25/2010. One Sheetrock seam along the east outside corner wall at the entrance to the Adult Patient Psych Center was not sealed with fire tape.

Note: The seam was sealed at the time of the survey process by maintenance staff.

Based on observations from 5/24 - 5/26/2010, the facility failed to maintain the fire and smoke resistance rating of wall assemblies.

Findings include:

In accordance with Section 19.1.6.1 of NFPA 101, 2000 edition, building construction type and height shall meet one of the following: 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1.

1. On 5/24/2010 at 3:10 p.m. on the hospital lower level, the dietary storage room was reviewed and at least two holes three inches in diameter in the ceiling tile were found to not be sealed.

2. On 5/24/2010 at 4:25 p.m. on the hospital lower level, there were two pipe penetrations approximately two inches in diameter which needed to be sealed. The penetrations were located at the wall above electrical panel EMCC-B.

3. On 5/25/2010 between 8:40 a.m. and 8:45 a.m. in the garage, there was a two inch unsealed hole in the exterior wall of the garage. Also, at another location in the garage there were three pipes passing through four inch penetrations in the exterior wall. These unsealed penetrations were located in the northeast corner of the garage.


27244

4. Room 5 in Endoscopy was reviewed on 5/25/2010 at 11:00 a.m. A ceiling tile was missing within the lay in tile ceiling.

Note: The ceiling tile was replaced at the time of survey.

5. The two hour fire barrier outside of the pharmacy was observed on 5/25/2010 at 11:05 a.m. Two violations were identified as follows:

a) there was a sleeve through the barrier that contained several wires that was not sealed, and

b) the barrier was not complete to the ceiling pan above.

6. The two hour fire barrier outside of the Chapel was reviewed on 5/26/2010 at 9:18 a.m. There were some security wires as described by staff that entered the barrier that were not sealed.

Note: The wires were sealed at the time of survey.

7. The Conference Center media room was reviewed on 5/26/2010 at 10:59 a.m. Two ceiling tiles were not in place in two different locations where several conduits and or wires passed through the ceiling.

Note: The ceiling tiles were replaces at the time of survey.

8. The two hour fire barrier within the Family Berthing Center atrium was examined on 5/26/2010 at 2:00 p.m. The barrier was incomplete between the floor/ceiling assembly and the two layers of sheet rock.

Note: The empty space was completed to the floor/ceiling assembly at the time of survey.

9. The Automated Teller Machine (ATM) room located inside the conference center was reviewed on 5/26/2010 at 2:20 p.m. The room which was not accessible to hospital staff was open because a technician was working on the ATM. The hard pan ceiling of the room had an approximately two foot square hole cut through both layers of sheet rock.

Based on observation on 5/25/2010, the facility failed to maintain flame spread rating for all interior finishes on ceiling spaces in a penthouse.

Findings include:

In accordance with Section 19.3.3.1 and 2 of NFPA 101, interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings shall have a flame spread rating of Class A or Class B.

Penthouse B2 of the Psychology Center was observed at 10:00 a.m. on 5/25/2010. The sprayed on flame spread material which had been applied to beams and portions of the ceiling was coming down in one corner of the penthouse. It appeared that the facility knew about a leak in the ceiling which had caused the damaged flame spread material to come down as there were work lights and tools near the area.

Note: The area was re-applied with new flame spread material and repaired at the time of the survey process.

Based on observations made on 5/26/2010, the facility failed to assure that there were no impediments to closing of corridor doors.

In accordance with section 19.6.6.3.3 of NFPA 101, 2000 edition; doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close.

Findings include:

The Medication Assistance Program office was observed at 9:25 a.m. on 5/26/2010. The corridor door to the office was being held open with a rubber wedge.

Note: The wedge was removed at the time of survey by facility staff.

Based on observations from 5/24 - 5/26/2010, the facility did not ensure all vertical openings in ceiling/floor assemblies were maintained and resistant to the passage of smoke.

Findings include:

1. On 5/26/2010 at 12:36 p.m., Penthouse #5 ws inspected. In the "5 West Control Room", there were three holes each being one inch in diameter which had been drilled in the floor and left open.

2. On 5/26/2010 at approximately 12:45 p.m. in the former air handling room in a penthouse for the surgery department, there was a three to four inch pipe located vertically in the floor of the penthouse. The "plug" being used to seal the open end of the pipe had not maintained the sealed penetration at the end of the pipe.

3. On 5/26/2010 at approximately 12:50 p.m. in the penthouse for elevators "#7 and #8", there were five holes in the floor of the penthouse. The holes were at least one inch in diameter and were unsealed.


27244


4. The Intensive Care Unit was observed on 5/26/2010 at 9:00 a.m. The locker room from surgery contained a vertical penetration of electrical to the floor above that was not sealed.

Based on observations made 5/25/2010, the facility failed to ensure that vertical openings between floors were sealed and/or enclosed by fire-resistive construction.

Findings include:

In accordance with Section 39.3.1.1 of NFPA 101 Life Safety Code, 2000 edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101 Life Safety Code, 2000 edition, 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/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. There were missing ceiling tiles and several unsealed pipe and conduit penetrations observed in the Communications closet on the east side of Coding next to the Fire Alarm Control Panel (FACP) room at 9:22 a.m. on 5/25/2010 in the basement. On 5/26/10 at 9:07 a.m., these penetrations were also observed to be not sealed at the first floor level.

2. An unsealed ceiling penetration measuring two inches by three inches was observed in the stairwell north from Transcription at 9:57 a.m. on 5/25/2010.

Note: These items were corrected by the maintenance staff during the survey.

Based on observations made on 5/25/2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 19.3.1.1 of NFPA 101, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 edition, 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/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The nurse's station at 1 South of the Psychology Center was observed at 9:15 a.m. on 5/25/2010. There were five conduits extending through the floor below the administrative desk which were not sealed to prevent the passage of fire/smoke.

Note: The conduits were sealed by maintenance staff at the time of the survey process.

2. Penthouse B-2 of the Psychology Center was observed at 10:05 a.m. on 5/25/2010. One cabinet door was missing on Unit 2 North data closet along the south wall of the penthouse. There was a two inch exposed conduit extending through the floor of the penthouse which was not sealed either at the conduit or by proper door closure.

Note: The cabinet door was replaced at the time of the survey process.

Based on observations during a tour of the hospital from 5/24 - 5/26/2010, not all doors serving fire rated barriers or hazardous area enclosures were being properly maintained.

Findings include:

1. On 5/25/2010 at 9:15 a.m. on the lower hospital level, the pair of corridor doors were open at the "Repair Shop" location. Both doors are self closing. However, one of the doors would not automatically close since a large cart on wheels had been put in the swing path of one of the doors.

2. On 5/25/2010 at 10:50 a.m. on the lower hospital level, there was no self closing device installed on the corridor door which opened into the Medical Record Storage Room which contained large quantities of combustible materials.

3. On 5/26/2010 at 7:45 a.m., a smoke barrier which separates the 300 North Wing from the Trauma Center was observed. The rated cross corridor doors at this smoke barrier were tested. When the doors were released from their magnetic "hold open"devices, one of the two doors did not close to a smoke tight seal.


27244

4. The soiled linen door for hospital surgery was observed on 5/26/2010 at 9:33 a.m. Upon three attempts to allow the door to close and latch, the door would close but would not positively latch.

Note: The maintenance staff did adjust the door handle hardware and were able to get the door to latch at the time of survey.

Based on observations made 5/25/2010, the facility failed to ensure that all smoke-rated enclosures were protected by doors that were capable of closing to positive latching.

In accordance with 39.2.2.2.1, doors complying with 7.2.1 shall be permitted. Specifically, section 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 include:

1. The west exit stairwell basement door did not latch when exercised three times at 10:40 a.m. on 5/25/2010. The door had a self closure device. The stairwell traveled between the basement and the 4th floor of the clinic.

2. The door to the west building mechanical room (located in the basement) with self closure device was exercised three times at 10:55 a.m. on 5/25/2010. The door failed to latch. The room stored boilers. The room opened into the medical record storage room in the basement. The door was held open with a paint brush. The door had a 1.5 hour fire rating.

Note: These items were corrected by the maintenance staff during the survey.

Based on observations made 5/26/2010, the facility failed to ensure that all smoke-rated enclosures were protected by doors that were capable of closing to positive latching.

In accordance with 39.2.2.2.1 Doors complying with 7.2.1 shall be permitted. Specifically, section 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 include:

The north exit stairwell door on the first floor did not latch when exercised three times at 11:17 a.m. on 5/26/2010. The the door had a self closure device. The stairwell traveled between the first and the 4th floor.

Note: This violation was corrected during the survey.

Based on observations on 5/27/2010, the facility failed to ensure that all hazardous areas and rated enclosures were protected by doors that were capable of closing to positive latching.

In accordance with 39.2.2.2.1 Doors complying with 7.2.1 shall be permitted. Specifically, section 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 include:

The door to the elevator mechanical room failed to latch at 7:58 a.m. on 5/27/10 at the basement level. The raised carpet at the threshold kept the door from closing on its own. The door had a self closure device.

Based on observations made 5/25/2010, the facility failed to ensure that doors opening into enclosed courtyards were properly identified as not being an exit way and to use exit signs with arrows to identify direction of exit to exit doors.

Findings include:

Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT or similar language per the 2000 edition of NFPA 101 Life Safety Code Section 7.10.8.1 Marking of Means of Egress.

There was not a "NO EXIT" or "Not an Exit" sign on the interior court yard door located on the east side of Coding at 8:55 a.m. on 5/25/2010.

Based on observations made on 5/24/2010; the facility failed to assure that doors opening into enclosed courtyards were properly identified as not being an exit way and to use exit signs with arrows to identify direction of exit to exit doors.

Findings include:

Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT or similar language per Section 7.10.8.1 Marking of Means of Egress of NFPA 101.

The south and east corridor doors which open into the enclosed courtyard were reviewed at 3:20 p.m. on 5/24/2010. The doors are not marked as NOT an EXIT and could be confused as an exit as one can see daylight to the outside. These corridor doors must be marked by a sign that reads NO EXIT or NOT an EXIT per Section 7.10.8.1.

Based on observations made on 5/24/2010; the facility failed to assure that doors opening into the Trauma Center Stair tower were properly identified as not being an exit.

Findings include:

Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT or similar language per the 2000 edition of NFPA 101 Section 7.10.8.1 Marking of Means of Egress.

The two hour Trauma Center stair tower leads to the first floor and is tied into a set of stairs coming from the lower level. The door to the stairs from the lower level should be labeled with a sign not an exit to avoid staff and the public from continuing to exit down the lower level.

Based on observations made on 5/24 - 5/26/2010, the facility failed to maintain the fire resistive rating of smoke barrier walls.

Findings include:

In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).

1. The smoke barrier wall in the exit stairway between the Intensive Care Unit and Pulmonary was reviewed at 1:20 p.m. on 5/25/2010. There was one penetration of the smoke wall where a communication wire extended through the wall near a sprinkler valve which was not properly sealed.

Note: The penetration was sealed at the time of the survey process.


27244

2. The Emergency Department (ED) was reviewed on 5/24/2010 at 2:30 p.m. Four penetrations were found at the center smoke barrier doors in the A Pod entrance from registration.

3. The smoke barrier for ED was reviewed on 5/24/2010 at 2:40 p.m. Three conduits entered the smoke barrier wall near the east fire corridor smoke barrier doors.

Note: The penetrations were filled at the time of survey.

4. The smoke barrier next to the Cafeteria on the east wall of Out Patient Surgery was observed on 5/26/2010 at 8:32 a.m. Several wires passed through the barrier and were previously sealed with fire rated material which had been pulled out of the barrier.

Note: The penetration was filled at the time of survey.

Based on observations made on 5/24-5/25/2010, the facility failed to maintain the fire resistive rating of smoke barrier walls.

Findings include:

In accordance with Section 8.3 of NFPA 101 LSC, smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 edition).

1. The smoke barrier wall between the south wall of the conference room and the exit corridor was observed at 3:15 p.m. on 5/24/2010. The wall was incomplete along the south wall of the conference room.

Note: The wall was repaired to be smoke tight during the survey process.

2. The smoke barrier wall between the entrance to the Youth Inpatient Unit and the corridor was observed at 8:00 a.m. on 5/25/2010. There was a penetration through the smoke barrier wall around an electrical conduit which was not sealed properly.

Note: The penetration at the smoke barrier wall was sealed by maintenance staff at the time of the survey process.

Based on observations 5/25/2010, the facility failed to maintain or establish the fire-rated protection for hazardous areas.

Findings include:

In accordance with Section 8.4 of NFPA 101, Life Safety Code, 2000 edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 39.3.2.1 of NFPA 101 LSC.

On 5/25/2010 at 9:47 a.m., the boiler room was reviewed. There were unsealed pipe penetrations above the old boiler room doors (west side of boiler room B) extending into the stairwell located north of Transcription in the basement.

Based on observations made on 5/25 - 5/26/2010, the facility failed to maintain or establish the fire-rated protection for hazardous areas.

Findings include:

In accordance with Section 8.4 of NFPA 101, Life Safety Code, 2000 edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

1. The storage room in B Pod was observed on 5/25/2010 at 9:30 a.m. A open penetration around some wiring passing through the wall was observed. The penetration was repaired at the time of survey.

2. An unfinished room in the Emergency Department Atrium was reviewed on 5/25/2010 at 12:40 p.m. The room contained combustible items and is considered a storage area. The door to the room lacked a self closure device.

Note: A self closure device was installed by maintenance staff at the time of survey.

3. On 5/26/2010 at 8:01 a.m, the Admitting area was reviewed. Storage of cardboard boxes and other materials were noted behind the modular wall and between the black construction plastic in place for an ongoing project in Pharmacy. These items should be in a designated storage area as to not increase the fireload for staff and patients in the Admitting area.

Based on observations made on 5/27/2010, the facility failed to prevent the use of exit stairways as storage areas.

Findings include:

In accordance with 39.2.2.3.1 of NFPA 101 LSC, exit stairs shall comply with 7.2.2. In accordance with 7.2.2.5.1 of NFPA 101 LSC, all inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. In accordance with 7.1.3.2.3 of NFPA 101 LSC, an exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit.

On 8:00 a.m. on 5/27/2010, the northwest exit stairway from the Physical Therapy suite had items stored at the basement level. There was a painted sign in this area with the words "NO STORAGE".

Based on observations made on 5/25/2010, the facility failed to maintain the rating of a stair well.

Findings include:

In accordance with 19.3.1.1 of the Life Safety Code exit stairs shall comply with 8.2.5 of the Life Safety Code. In accordance with 8.2.5.2 of NFPA 101 openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

The Emergency Department east stairwell wall was observed on 5/25/2010 at 2:51 p.m. A penetration where an electrical conduit had been removed was not sealed and other areas on the barrier were in need of complete coverage with fire rated material.

Note: The one hour fire wall was repaired at the time of survey.

Based on observations made on 5/26/2010, the facility failed to maintain exit stair gates to prevent patients, staff, and members of the public from going to the lower level in an exit stairway.

According to Section 7.7.3 of NFPA 101, stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

Findings include:

The north east exit stair way in Pediatrics was reviewed on 5/26/2010 at 1:16 p.m. The north east stairway gate preventing patients, staff, and members of the public from going to the lower level was permanently open. The cam mechanism, which mechanically closes the gate every time someone goes through it when exiting from the lower level, was out of adjustment and thus the gate was in an open position at all times.

Based on observations made on 5/25/2010, the facility failed to identify the two exits required from a gymnasium.

The findings include;

Any room or any suite of rooms, other than patient sleeping rooms, of more than 2500 square feet shall have not less than two exit access doors remotely located from each other per section 19.2.5.3 of the Life Safety Code.

The gymnasium of the Psychology Center was reviewed for exiting at 9:34 a.m. on 5/25/2010. The gymnasium is approximately 4000 square feet in size. There are two sets of double doors which exit back into the corridor space and an alternating exit door which does exit to the outside of the building. The alternating exit door had the exit sign removed from above the door and the door leaf was signed with a Not an Exit sign. The east exit door is one of the doors which makes up the two access doors remotely located from each other required for exiting from the gymnasium. One additional marked exit is required in the gymnasium.

Based on observations from 5/24 - 5/26/2010, the facility failed to ensure that all exit signs were illuminated so as not to leave the exit discharge in darkness.

As required under Section 7.10.1.4 of NFPA 101 Life Safety Code; "means of egress" has to be apparent and be identified by visible exit signs.

Findings include:

On 5/24/2010 at 2:40 p.m., the "convenience stairwell" which adjoins the construction at the imaging storage room was reviewed. There was no illumination for this stairwell. There was a manual light switch at the bottom of the stairwell which did not work. The battery back-up lighting on the wall of the stairwell did not operate when tested.

Based on review of battery powered emergency light fixture testing logs and a staff interview on 5/26/2010, the facility failed to ensure that the required battery-powered emergency lights were tested on a monthly basis. The facility had several battery powered lights for exiting due to the lack of an emergency generator for this building.

In accordance with Section 39.2.9.1 emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Section 7.9.3 of NFPA 101 states that a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Although emergency lights are not required per Section 39.2.9.1 of NFPA 101 LSC; Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings include:

The battery powered emergency lighting test logs were reviewed during the survey from 5/24 to 5/27/2010. The logs lacked documentation for the required testing of the emergency lights (two were located in the stairwell) for exiting as mentioned above.

On 5/26/2010 at 11:15 a.m., the building's maintenance staff validated that the monthly and annual tests were not conducted on the emergency lights.

Based on review of battery powered emergency light fixture testing logs and a staff interview on 5/25/2010, the facility failed to ensure that the required battery-powered emergency lights were tested on a monthly basis. The facility had several battery powered lights for exiting due to the lack of an emergency generator at this building.

In accordance with Section 39.2.9.1 emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Section 7.9.3 of NFPA 101 states that a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Although emergency lighting is not required per Section 39.2.9.1 of NFPA 101 code, Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings include:

The battery powered emergency lighting test logs were reviewed during the survey from 5/24 to 5/27/2010. The logs lacked documentation for the required testing of the emergency lights for exiting as mentioned above.

On 5/25/2010 at 8:05 a.m. , the safety specialist validated that the monthly and annual tests were not conducted on the emergency lights in this building.

Based on observations from 5/24 - 5/26/2010, the facility failed to ensure that all exit and directional signs were continuously illuminated.

Findings include:

As required under Section 7.10.1.4 of NFPA 101 Life Safety Code; "means of egress" has to be apparent and be identified by visible exit signs.

1. On 5/25/2010 at 3:42 p.m., the corridor location where the third floor north "level " connects to the trauma unit was reviewed. At this juncture, there is a stairway identified as an exit stairway by an exit sign located directly above the stairway door in the corridor. The exit sign is not readily visible since the occupants of the building would use the corridor with its "north-south" orientation between the third floor north level and the trauma center.


27244

2. The conference center conference rooms exiting was evaluated on 5/26/2010 at 10:26 a.m. An exit light in the confrence room stairwell was not iluminated.

Note: The maintenance staff replaced the exit sign lights at the time of survey.

Based on observations made on 5/27/2010, the facility failed to ensure that all illuminated exit signs had been installed in such a manner to allow them to be easily seen. This is required per Section 39.2.10 Marking of Means of Egress of NFPA 101 which indicates means of egress shall have signs in accordance with Section 7.10.

Section 7.10.1.7 Visibility of NFPA 101 indicates that every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.

Section 7.10.2 Directional Signs of NFPA 101 indicates that a sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Findings include:

At approximately 8:10 a.m., the Family Medicine, Radiology, and Family Practices office space on the second level was reviewed. An exit sign was located above the east exit door at the same angle as the corridor wall. The exit sign can only be clearly seen when viewed from a location directly in front of the exit door. The exit sign was not visible from either the left or right side corridor locations.


27244

2. The east hall way common to Family Medicine, Radiology, and Family Practices was reviewed for exit signage on 5/27/2010 at 8:15 a.m. There were two issues noted with exiting signage in this hallway.

a) There is no exit sign at the south, east to west hall way indicating the proper exiting for patients and staff in Family Practice.

b) The exit sign located at the north east to west hall way in the Family Medicine was blocked by a facility sign and the sign did not have an indicator indicating the direction of egress.

Based on observations on 5/25/2010, the facility failed to maintain the continuous illumination of exit signs during emergencies.

Findings include:

Exit signs in accordance with 39.2.10 and 7.10.5.2 of the NFPA 101 Life Safety Code, 2000 edition, shall be continuously illuminated. Exit signs that are internally illuminated must meet UL 924 standards and are listed for use only with all bulbs evenly and uniformly illuminating the letters.

The exit signs operated by battery power (in case of an emergency) near the entrance to the nurses station and above the south side of the reception area would not illuminate when they were tested at 8:25 a.m. on 5/25/2010. The batteries were dead.

The facility did not have a generator; and in case of a power outage, the exit sign lights would use battery power to illuminate the exit corridors in the building.

Note: The maintenance staff corrected these violations during the survey.

Based on review of the fire alarm service and inspection reports on 5/24 - 5/27/2010, the facility failed to provide documentation to show that any testing of the fire alarm system was performed in 2009 or 2010.

In accordance with Section 39.3.4.1 of NFPA 101 a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Although this building is not required to have an alarm system per Section 39.3.4.1 of NFPA 101, Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed

Findings include:

In accordance with 7-3.2 of NFPA 72 (1999 edition) testing of the fire alarm system shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. Table 7-3.2 requires annual testing of such components as all control equipment, battery charger test, trouble signals within the control unit, remote annunciators, initiating devices including duct detectors, fire alarm boxes and smoke detectors (sensitivity testing to be in accordance with 7-3.2.1 of NFPA 72).

The fire alarm service and inspection reports were reviewed at the facility between 5/24/10 and 5/27/10. There was no evidence that the fire alarm system was inspected on an annual basis in 2009 and 2010, including sensitivity testing of the smoke detectors.

Based on observation and staff interview on 5/25/2010, the facility failed to ensure that the location of the electrical circuit breaker servicing the fire alarm panel was posted on the alarm panel itself and the circuit breaker had a red marking in the designated panel identifying the fire alarm panel.

In accordance with Section 39.3.4.1 of NFPA 101 a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Although this building is not required to have an alarm system per Section 39.3.4.1 of NFPA 101, Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed

Findings include:

1. In accordance with 1-5.2.5.2 of NFPA 72, 1999 edition, the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

On 5/25/2010 at 1:45 p.m., the location of the electrical circuit serving the fire alarm panel was not posted/marked on the fire alarm panel.

2. The breaker (#34) in the electrical panel PA was not marked in red.

Note: The items were corrected by the maintenance staff during the survey.

Based on observations made on 5/26/2010, the facility failed to maintain the smoke detectors as required in NFPA 72.

Findings include:

A smoke detector outside of the two hour fire barrier of the Family Birthing Center (FBC) atrium was hanging from the wires of the device.

Note: The device was adjusted to fit snuggly to the ceiling tile at the time of survey.

Based on observations and review of records made on 5/24/2010, the facility failed to provide for complete sprinkler protection of all portions or areas of the building.

Findings include:

The building is of construction Type II (111) protected two story with noncombustible construction which requires that the facility be protected throughout by an automatic sprinkler system that meets NFPA 13 standards. In accordance with Section 19.3.5.1 of NFPA 101, LSC, (2000 edition); where required by Section 19.1.6 of NFPA 101, LSC, (2000 edition); health care facilities shall be protected by an approved, supervised automatic sprinkler system in accordance with Section 9.7 of NFPA 101, LSC.

The cafeteria of the Psychology Center was observed at 2:30 p.m. on 5/24/2010. There is a roll cage door separating the kitchen from the cafeteria. There is an open space in the ceiling tile where the roll cage door is allowed to open above the ceiling tile. This open space could allow smoke to accumulate above the ceiling tile and not set off the sprinkler system as there is no protection above the ceiling tiles. The space above the kitchen must be protected by the installed sprinkler system or the area must be closed off near the roll cage door to not allow smoke above the level of protection.

Based on observations made on 5/26/2010, the facility lacked complete sprinkler coverage.


Findings include:

The Automated Teller Machine (ATM) room located inside the conference center was reviewed on 5/26/2010 at 2:20 p.m. The room, which was not accessible to hospital staff, was open because a technician was working on the ATM. The hard pan ceiling of the room had an approximately two foot square hole cut through both layers of sheet rock and lacked sprinkler protection.

Based on observations from 5/24 - 5/26/2010, the facility failed to ensure that the sprinkler system was being properly maintained in accordance with NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition).

Findings include:

The clearance between the deflector of standard pendent and upright spray sprinklers and the top of storage shall be 18 inches or greater per section 5-6.6 of NFPA 13.

1. On 5/24/2010 at 2:25 p.m. on the lower hospital level, the "bio med" department and the imaging storage room were inspected. In the imaging storage room, there were five plastic relay boxes stored above the discharge plane of the nearest ceiling sprinkler head.

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 edition.

2. On 5/24/2010 at 2:50 p.m. in the kitchen, there was an escutcheon ring missing at the sprinkler located above the "pop area" of kitchen storage location.


27244


3. The locker room next to the PBX was reviewed on 5/25/2010 at 1:15 p.m. An escutcheon ring was found missing inside the locker room.

4. An escutcheon ring was missing and one loosely fitted to the ceiling in Jennifer Deibele's office on 5/25/2010 at 11:20 a.m.

Note: Both issues were resolved at the time of survey.

5. The Medical Records area was inspected on 5/26/2010 at 11:16 a.m. There was a gap around two escutcheon rings.

Note: The openings around the escutcheon rings were filled with fire rated material at the time of survey.

Based on observation on 5/24 - 5/25/2010, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13 and NFPA 25.

Although fire sprinkler systems are not required per Section 39.3.5 for existing business occupancies; Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings include:

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 edition.

1. An escutcheon ring was missing from a ceiling sprinkler near the south exit door at 8:25 a.m. on 5/25/2010.

2. The sprinkler risers were observed on 5/24/2010. The control valve and the drain valve lacked signage (plates) identifying them at 2:40 p.m.

Based on observations 5/25 - 5/26/2010, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13.

Although fire sprinkler systems are not required per Section 39.3.5 for existing business occupancies, Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings include:

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 edition.

1. The escutcheon plate fell off the sprinkler head during the observation at 11:15 a.m. on 5/25/2010 in Administration bathroom in the basement. The escutcheon plate was previously duct taped to the sprinkler head and fell off while the maintenance staff was trying to fix the loose plate.

2. A missing ceiling tile was observed at 1:00 p.m. on 5/25/2010 in the data room on the forth floor. The room was sprinklered.

3. A missing ceiling tile was observed at 2:10 p.m. on 5/25/2010 in the sleep lab data room above the phone terminal. The room was sprinklered.

4. Missing ceiling tiles were observed in the electrical/data room of OBGYN at 8:07 a.m. on 5/26/2010. The room was sprinklered.

5. A missing ceiling tile was also observed in the Maternal and Fetal Medicine at 8:14 a.m. on 5/26/2010. The room was sprinklered.

6. The sprinkler head a missing escutcheon plate in the audiology testing room at 8:50 a.m. on 5/26/2010.

Note: All these items were corrected by the maintenance staff during the survey.

Based on observation on 5/27/2010, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13.

Although fire sprinkler systems are not required per Section 39.3.5 for existing business occupancies; Section 4.6.1.2 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 edition.

Findings include:

The Family Practice area was reviewed at 7:50 a.m. on 5/27/2010. The south west exam room immediately north of the south exit to the mezzanine had an escutcheon ring missing for the sprinkler located in that room.

Based on observations from 5/24 - 5/26/2010, fire extinguishers were not properly maintained in accordance with NFPA 10.

Findings include:

In accordance with Section 4-3.2 (b) of NFPA 10 (1998 edition), there shall be "no obstructions to access or visibility" of portable fire extinguishers.

In accordance with Section 2-3.2 of NFPA 10, "Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires." In addition, Section 2-3.2.1 of NFPA 10 requires the following: "A placard shall be conspicuously placed near the extinguisher that states that the fire protection system of the kitchen hood shall be activated prior to using the fire extinguisher."

In accordance with 1-6.7 and 1-6.10 of NFPA 10 portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

In accordance with Section 4-4.3 of NFPA 10, 1998 edition; every six years, stored-pressure fire extinguishers that require a hydrostatic test shall be emptied and subjected to the applicable maintenance procedures.

1. On 5/25/2010 at 8:51 a.m. on the lower hospital level in the "Gray Water Storage Room", access to a fire "wall mounted" extinguisher was blocked by a UPS backup unit and a large cardboard box.

2. On 5/25/2010 at 3:05 p.m., no placard as described above in Section 2-3.2.1 had been placed in the vicinity of the "K" cylinder in the basement kitchen.

3. On 5/25/2010 at 9:00 a.m. in the Gray Water Storage Room, there was a fire extinguisher which had been placed on the floor, it was "free standing", and had not been properly secured.


20343


4. The portable fire extinguisher located in the Intensive Care Unit was reviewed at 1:30 p.m. on 5/25/2010. The extinguisher was placed in service in 1992, had received a 6 year maintenance in 1998, but failed to get a 6 year maintenance test in 2004. The extinguisher also did not receive a hydro test in April of 2009.

Based on observation on 5/27/2010, the facility failed to ensure that portable fire extinguishers were readily available in accordance with the standards of NFPA 10 Section 39.3.5 of NFPA 101.

Findings include:

In accordance with 1-6.3 of NFPA 10 (1999 edition) fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire.

No fire extinguisher was observed in the elevator mechanical room or in the area within 5 feet of the elevator mechanical room at 7:56 a.m. on 5/27/2010 at the basement level.

Based on observations made 5/24/2010, the facility failed to ensure that portable fire extinguishers were readily available in accordance with the standards of NFPA 10 and Section 39.3.5 of NFPA 101.

Findings include:

In accordance with 1-6.6 and 4-3.2 of NFPA 10, 1998 edition fire extinguishers shall not be obstructed or obscured from view and no obstruction to access or visibility will impair the periodic inspection of fire extinguishers. In addition, in accordance with 1-6.3 of NFPA 10 (1999 edition) fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire.

The office adjacent to the library in human resources was observed at 3:49 p.m. on 5/24/2010. The fire extinguisher was hanging on the wall behind a panel near the exit door and was not visible to all occupants in the room at all times.

Note: The signage for the fire extinguisher was relocated during the survey.

Based on observations made on 5/24 - 5/26/2010, the facility failed to assure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Findings include:

Fire extinguishers shall be hydrostatically tested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

In accordance with Section 4-4.3 of NFPA 10, 1998 edition; every six years, stored-pressure fire extinguishers that require a hydrostatic test shall be emptied and subjected to the applicable maintenance procedures.

In accordance with 1-6.3 of NFPA 10 (1999 edition) fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire.

1. The portable fire extinguisher located in the center corridor hall of the Psychology Center was observed at 3:30 p.m. on 5/24/2010. The extinguisher had received a hydrotest in April of 1998 and was due for the next hydrotest in April of 2010, but had been missed when the extinguishers received the annual service in April of 2010.

2. The penthouse D-4 of the Psychology Center was observed at 9:20 a.m. on 5/25/2010. The portable fire extinguisher located in the penthouse had not received its annual inspection in April of 2010. The extinguisher had a service tag dated April 2009.

3. The Carbon Dioxide type portable fire extinguisher located in the Psychology Center Penthouse C-3 was observed at 9:30 a.m. on 5/25/2010. The extinguisher had been placed in service in 1992 and received its first 6 year maintenance service in 1998 and a following 6 year service in 2007. There was a required 6 year maintenance service in 2004 which was not documented by proof of the service tags on the extinguisher.

Note: All of the above fire extinguishers were replaced with ones which were current with all maintenance and service tags at the time of the survey process.

4. The basement of the Psychology Center was inspected at 9:25 a.m. on 5/26/2010. The following locations were discovered without portable fire extinguisher protection.
a) There was no portable fire extinguisher in the pool mechanical room or within five feet of the room.
b) There was no portable fire extinguisher in the elevator mechanical room or within five feet of the room.

Note: Two portable extinguishers were installed at these locations which were current for service and maintenance during the survey process.

Based on observations made on 5/24/2010, the facility failed to maintain the means of egress, including exit corridors, free from obstructions and from being used for storage purposes.

Findings include:

Items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor per Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 04-41 effective August 12, 2004.

The east service hall to the Psychology Center was observed at 2:35 p.m. on 5/24/2010. There were numerous items blocking the exit discharge path through the service corridor. This corridor serves as a main escape route to the outside from the northeast side of the building.

Note: The items which had been stored in the exit corridor were removed during the time of the survey process.

Based on observations made on 5/26/2010, the facility failed to maintain the means of egress, including exit corridors, free from obstructions and from being used for storage purposes.

Findings include:

Items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery items and other similar items must be stored properly or removed from the corridor per Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 04-41 effective August 12, 2004.

The exit corridor common to the Conference Center and directly outside of the Security Office was observed at 10:40 a.m. on 5/26/2010. There were two living room type sofas stored in the exit corridor. This corridor serves as an escape route to the outside.

Note: The sofas which had been stored in the exit corridor were removed during the time of the survey process.

Based on observations 5/25 - 5/26/2010, the facility failed to limit the amount of oxygen that can be stored outside of a dedicated oxygen storage room and failed to ensure all oxygen cylinders were secured properly in storage.

Findings include:

Up to 300 cubic feet of nonflammable medical gas (12 "E" size cylinders) associated with patient care may be located outside of a dedicated oxygen enclosure room in a single smoke compartment as long as they are properly secured per CMS Survey and Certification letter 07-10 dated January 12, 2007. If placed in a corridor, they shall be placed so as not to obstruct the use of the corridor.

In accordance with 4-3.1.1.1 and 4-3.5.2.1(b) #13, 24 and 27 of NFPA 99, 1999 edition, all oxygen cylinders in storage shall be individually secured and located to prevent falling or being knocked over, free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart, the cylinders shall never be used as supports for other items and shall be protected against mechanical damage due to objects striking them or falling on them.

1. a)Eleven E size oxygen cylinders were placed in an alcove on the exit corridor between the sleep lab and Pulmonary at 2:37 p.m. on 5/25/2010.

b) At 2:40 p.m. on 5/25/2010, two additional E size oxygen cylinders were observed in storage in the Pulmonary nurses station giving a total of thirteen E size oxygen cylinders being stored in this compartment on the third floor of the clinic (exceeding the 3000 cubic feet limit).

2. An E size oxygen cylinder was observed lying on the floor in supply room of Same Day Care at 8:45 a.m. on 5/26/2010.

Note: The maintenance staff corrected these violations during the survey.

Based on observations made 5/26/2010, the facility failed to ensure that a cylinder of oxygen was properly secured from falling over or being knocked down.

Findings include:

In accordance with 4-3.1.1.1 and 4-3.5.2.1(b) #13, 24 and 27 of NFPA 99, 1999 edition, all oxygen cylinders in storage shall be individually secured and located to prevent falling or being knocked over, free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart, the cylinders shall never be used as supports for other items and shall be protected against mechanical damage due to objects striking them or falling on them.

An E size oxygen cylinder was observed free standing at 10:40 a.m. on 5/26/2010 in the printer room behind the main reception area.

Note: This violation was corrected at the time of the survey.

Based on observations made on 5/25/2010, the facility failed to assure that a cylinder of oxygen was properly secured from falling over or being knocked down.

Freestanding cylinders of nonflammable gases such as oxygen, shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down in accordance with Sections 8-3.1.11.2(h) and 4-3.5.2.1(b) 27 of NFPA 99, 1999 edition).

Findings include:

Several "E" size cylinders of oxygen were found to be freestanding in the medical supply room on the Adult Psychology Unit of the Psychology Center as observed at 8:45 a.m. on 5/25/2010.

Note: The cylinders were returned to the main oxygen storage room as confirmed by the surveyor while on-site.

Based on observations made on 5/26/2010, the facility failed to assure that combustilbes were being stored in oxygen storage room at least five feet away and that a cylinder of oxygen was properly secured from falling over or being knocked down.

Findings include:

In accordance with Section 8-3.1.11.2 of NFPA 99, 1999 edition, Storage for nonflammable gases less than 3000 ft3 (85 m3). (c)Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
a) A minimum distance of 20 ft (6.1 m), or
b) A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
c) 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.

Freestanding cylinders of nonflammable gases such as oxygen, shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down in accordance with Sections 8-3.1.11.2(h) and 4-3.5.2.1(b) 27 of NFPA 99, 1999 edition).

1. The Hospital Surgery Oxygen Storage Room was observed on 5/26/2010 at 9:33 a.m. A total of 13 "E" size cylinders of oxygen were found in the storage area and cardboard boxes containing medical equipment were within three feet of the cylinders.

2. The Pediatric area of the first floor was reviewed on 5/26/2010 at 12:43 a.m. A freestanding "E" size oxygen cylinder was found standing not in a rack or protected from accidental being knocked over in the "Procedure Treatment Room across from Exam Room #2.

Based on observationon 5/27/2010, the facility failed to ensure that a cylinder of oxygen was properly secured from falling over or being knocked down.

Findings include:

In accordance with 4-3.1.1.1 and 4-3.5.2.1(b) #13, 24 and 27 of NFPA 99, 1999 edition, all oxygen cylinders in storage shall be individually secured and located to prevent falling or being knocked over, free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart, the cylinders shall never be used as supports for other items and shall be protected against mechanical damage due to objects striking them or falling on them.

An E size oxygen cylinder was observed free standing at 7:45 a.m. on 5/27/2010 in the storage room of the Internal Medicine Suite.

Note: This violation was corrected at the time of the survey.

Based on observations made by the surveyor from 5/24 - 5/26/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with Article 110-26 of NFPA 70 (1999 edition) sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

In accordance with 370.28(c) of NFPA 70 (1999 edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110.

1. On 5/25/2010 at 8:22 a.m. on the lower hospital level, the "old Joslyn Room" was inspected. There were five pieces of wood in front of electrical panel (BC3L) which blocked access to the panel.

2. On 5/25/29010 at 10:54 a.m. on the lower hospital level, the telephone dialer room was inspected. In this room there was a electrical junction box which was missing a cover. The junction box contained at least three exposed wired connections.


27244


3. The emergency department first floor electrical room in A Pod was reviewed on 5/24/2010 at 2:10 p.m. Two electrical issues were identified:

a) a splice box for the fire alarm lacked a junction box cover, and
b) the fire alarm TIR was hanging loosely from the electrical box it was supposed to be mounted in.

Note: Both of these items were corrected at the time of survey.

4. The ambulance entry location was reviewed on 5/25/2010 at 9:00 a.m. Several portable radios were sitting in their charging units which were all plugged into surge protectors that were "daisy chained" together. A total of three surge protectors were hooked in series.

Note: One surge protector was removed and the other two plugged directly into the facility electrical at the time of survey.

5. The PBX Call Center was reviewed on 5/25/2010 at 11:00 a.m. A surge protector was plugged in series with another.

Note: The additional surge protector was removed at the time of survey.

6. The Endoscopy area was reviewed on 5/25/2010 at 1:15 p.m. Two electrical panel schedules require updating as follows:

a) panel 1C7L, and

b) panel 1N10L.

7. The "Admitting" area was observed on 5/26/2010 at 7:45 a.m. Two electrical issues were found in the area of Joelynn Summers office area:

a) a white household extension cord was in use, and

b) a small refrigerator was plugged into a surge protector.

Note: Both of these items were corrected at the time of survey.

8. The staff breakroom in "Admitting" was observed at 7:50 a.m. on 5/26/2010. A white household extension cord was in use.

Note: The extension cord was removed at the time of the survey.

9. A photocopier labeled #39 was plugged into a surge protector in the "Admitting" area at 7:55 a.m. on 5/26/2010.

Note: The copier was plugged directly into the facility wiring at the time of survey.

10. Two small refrigerators, one brown and one white, were found to be plugged directly into surge protectors in "Admitting" on 5/26/2010 at 8:03 a.m.

11. The Operation Excellence (OPX) area was reviewed at 8:15 a.m on 5/26/2010. Two electrical issues were noted in the same area:

a) An orange electrical extension cord was in use to provide power for a refrigerator, and

b) a microwave was plugged into a surge protector.

Note: The orange extension cord was removed and the microwave was unplugged and connected directly to the facility outlet at the time of survey.

12. The out patient surgery area was reviewed on 5/26/2010 at 8:35 a.m. Two electrical panels were in need of updating inside the electrical room and marked as follows:

a) panel 1N2H had circuit #8 marked as a spare but circuit # 8 was on, and

b) panel 1S2H had circuit #8 marked as a spare but circuit # 8 was on.

13. The Conference Center electrical room 10 East was reviewed on 5/26/2010 at 10:45 a.m. Two electrical panels were found in need of updating to the panel schedule.

a) panel 1N7L had circuit #11 marked as spare but circuit #11 was on, and

b) panel 1S3H had circuit #11 marked as a spare but circuit # 11 was on.

14. The Conference Center catering office was reviewed on 5/26/2010 at 10:47 a.m. There were two issues identified with electrical cords or surge protectors:

a) one surge protector was plugged into another or daisy chained, and

b) a thick black extension cord was in use.

15. An electrical room in "PEDS" was reviewed on 5/26/2010 at 12:50 p.m. Three panel schedules were in need of updating as follows:

a) panel L1SH1H had circuit #19 marked as a spare but circuit #19 was on,

b) panel L1N1H had circuit #2 marked as a spare but circuit #2 was on, and

c) panel LIN1L had circuits #5, 6, 8 , 10, 11, 12, 13 & 14 as spare but all were on.

16. The "PEDS" area of the first floor was reviewed at 12:30 a.m. on 5/26/2010. A green extension cord was found to be plugged into a paper shredder.

Note: The extension cord was removed at the time of survey.

17. The Family Birthing Center (FBC) atrium was reviewed on 5/26/2010 at 2:00 p.m. The security desk was reviewed and it was found that two surge protectors were plugged into each other. One of the surge protectors also had a damaged cord.

Based on observation on 5/24/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. Tthese items must be directly connected to an appropriate receptacle.

An extension cord was found under the desk in the northwest corner of the nurses station on 5/24/2010 at 2:00 p.m.

Note: The extension cord was removed and discarded by the maintenance staff after the observation was made during the survey.

Based on observations 5/24 - 5/26/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use per Article 370.28(c) of NFPA 70.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

1. The patient financial services and risk management break room was observed on at 3:16 p.m. on 5/24/2010. A microwave was plugged into a surge protector on the south east corner of the room.

2. The human resources employee file room was observed at 3:32 p.m. on 5/24/2010. The upright refrigerator was plugged into a surge protector.

3. The mechanical room in human resources was observed at 3:36 p.m. on 5/24/2010. An electrical junction box located on the ceiling was missing its cover plate.

4. The electrical panel BN4L (LL04) in mechanical room of human resources was observed at 3:40 p.m. on 5/24/2010. The circuit breakers 31, 33, and 35 were not numbered on the panel. They were in on positions. The circuit breaker 37 was in off position and this was not marked on the panel directory as spare.

5. A microwave was plugged into a surge protector in Release Information at 9:40 a.m. on 5/25/2010.

6. A coffee maker was plugged into an extension cord, then the extension cord was plugged into a surge protector in Transcription at 9:35 a.m. on 5/25/2010.

7. The circuit breaker 5 located in electrical panel 4NIL found in the forth floor penthouse was in on position but it was not listed on the panel directory. Breakers 1-3 and 2-6 were in off positions but they were not marked as spares on the panel directory. These observations were made at 1:15 p.m. on 5/25/2010.

8. A microwave was plugged into a surge protector in the sleep lab control room at 2:17 p.m. on 5/25/2010.

9. A microwave was plugged into a three receptacle splitter in the general surgery employee lounge at 2:52 p.m. on 5/25/2010.

10. A microwave was plugged into a surge protector in the general surgery conference room at 2:58 p.m. on 5/25/2010.

11. A microwave was plugged into a surge protector in room 4 in Maternal and Fetal Medicine at 8:19 a.m. on 5/26/2010.

12. A refrigerator was plugged into a surge protector in the Same Day Care nurses station at 8:40 a.m. on 5/26/2010.

13. Breakers 17 and 18 of the electrical panel (not identified) at the south end of the Physical Medicine and Rehab hallway were in on positions, but they were not identified on the panel directory. Some of the breaker numbers on the panel were pencilled in and were illegible. The panel numbers did not coincide with the breaker numbers on the panel directory.

Note: These violations were corrected by the maintenance staff during the survey.

Based on observations made 5/26/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

1. A refrigerator was plugged into a surgery protector in room 235 at 11:10 a.m. on 5/26/2010.

2. Circuit breakers 22 through 28 in electrical panel LS were in on positions, but they were not addressed on the panel directory at 10:50 a.m. on 5/26/2010.

Note: These violations were corrected at the time of the survey.

Based on observations made on 5/24 - 5/25/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

1. The Coke dispensing machine in the east service corridor was observed at 2:40 p.m. on 5/24/2010. There was a large black extension cord in use to power the Coke machine.

Note: The extension cord was removed at the time of the survey process by maintenance staff.

2. The conference room in the Psychology Center was observed at 3:15 p.m. on 5/24/2010. An electrical outlet cover was missing in the conference room cubby space.

Note: The electrical cover was replaced during the survey process by maintenance staff.

3. The Youth Case Manager's Office was observed at 8:30 a.m. on 5/25/2010. An extension cord was in-use along the south wall of this office.

Note: The extension cord was removed at the time of the survey process by maintenance staff.

Based on observations made on 5/27/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with Article 410-56(d) of NFPA 70, faceplates on receptacles shall be installed so as to completely cover the opening and seat against the mounting surface.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

1. The mechanical room on the east wing of Billings Clinic West was observed at 8:10 a.m. on 5/27/2010. An electrical cover was missing on the north wall of the mechanical room on the main level of the clinic.


18076


2. A refrigerator was plugged into a surge protector in the nurse practitioners's office near the "Check Out" sign at 8:00 a.m. on 5/27/2010.

Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident per Article 110-22 of NFPA 70.

3. Circuit breakers 31, 33, 35, 37, 39, and 41 were addressed in the electrical panel (7-8L) directory, however, these circuits were not numbered on the panel at 7:54 a.m. on 5/27/10 in the main floor of the Billings Clinic West.