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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.


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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 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.


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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.


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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 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.


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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 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 - 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.


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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 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 5/27/2010, 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 5/26/2010, 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 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.


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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 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 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 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.


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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 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.


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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 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 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 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.


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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.