HospitalInspections.org

Based on observation the facility failed to maintain corridor operating room doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed the following corridor door operating rooms had smoke seals torn in one or two places and the corridor doors were not smoke resistant when tightly closed.

1. Operating room corridor doors marked # 11, 12, 14, 15, 16, 17, 18, 19, 21, 22, and the corridor doors by MCH 2-519

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

The facility failed to fill penetrations in the smoke barriers for two of seven floors of the hospital.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed unsealed penetrations in the smoke barriers above the communication cable trays located on the two floors by the following locations:

1. Seventh floor by smoke barriers MCH 121, 123, and 125
2. Sixth floor MCH 6E 36

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients.

Based on Observation the facility failed to maintain three smoke barrier doors on a total of seven floors, the self closing/automatic-closing doors in the smoke barriers did not close or latch when tested three of three times.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. ( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3, "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Section 7.2.1.8.1 (1) "Upon release of the hold-open mechanism, the door becomes self-closing."

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed the testing of the smoke barrier doors in the following locations:

1. 2W MCH 2-153, MCH 2-432 and MCH 1-435A would not close and latch when tested three of three times.

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Failure to properly adjust or repair the smoke barrier doors could cause harm to the patients.

Based on Observation the facility did not keep exits and exit access readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft ( EXISTING not less than 48 in.) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." CMS has determined that facilities built with 8 foot corridors shall maintain these corridors clear and unobstructed at all times.

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed storage, medical equipment, maintenance equipment and non emergency medical or maintenance supplies within the maintenance shop exit corridor North and South and stored throughout the corridor thus reducing the corridor to approximately four feet in width when measured.

The basement corridor East and West had approximately 20-25 hospital beds placed directly in the path of the entire exit access from one end to the other throughout the basement corridor. This further reduced the exit access corridor from approximately eleven feet to five feet in width.

In addition, the following areas had the exit doors blocked with the following equipment, two pallets of sodium chloride and three yellow flammable cabinets, in the Pharmacy supply room marked MCH1-401A.

The main kitchen one set of exit doors had three food tray carts and a green recycle bin placed directly in front of one set of exit doors. The Environmental Services had several chairs and couches placed in the exit corridor path directly in front of the double exit doors marked MCH 1-422. The emergency department walk in entrance had five wheelchairs placed directly in front of one of the two double doors to the main entrance.

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on Observation the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, asked to see the Red Emergency Guide written manual at the following nurse's stations. The Red Emergency Guide written manual which has the fire procedures was not at the nursing station pods or could not be located during the survey by staff. The surveyor asked several hospital staff at the nurses stations for the Red Emergency Guide. The hospital staff advised the surveyor the fire procedures were online.

1. 2A Pod
2. 3B D/E Pods
2. 4E F Pod
3. 5W A/B and C Pods
4.7W A/B and C Pods
5. Pac U East
6. Emergency Department

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

In time of an emergency, an emergency policy manuals must be readily available for the staff.
Patients will be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Based on observation the facility failed to keep several automatic sprinkler heads free of lint and one of one sprinkler heads had corrosion on the sprinkler.

NFPA 101, Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the installation of Sprinkler Systems." NFPA 13, Chapter 12, Section 12-1 "General" "A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25....NFPA 25, Chapter 2, Section 2-2.1 "Sprinklers" 2-2.1.1 ...Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g.,upright, pendant, or sidewall).

Findings Include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed the following locations in the facility several sprinkler heads had lint on the entire sprinkler frame and assembly or one sprinkler was corroded.

1. 3rd floor Rehab Kitchen one of one sprinklers, lint
2. MCH 3E-C20 Staff report office one of one sprinklers, lint
3. MCH 2W-05 A pod 2nd floor one of two sprinklers, lint
4. Employee Elevator Lobby three of three sprinklers, lint
5. MCH 2-151 Resident Center one of two sprinklers, lint
6. MCH 2-425 Soiled Utility 2nd floor, one of one sprinklers, lint
7. Operating break room surgical lounge one of six sprinklers, lint
8. MCH 1-368 Tank Room one of one, corroded sprinkler green in color
9. MCH 1-520 one of two sprinklers, lint
10 Main kitchen freezers, numbers 1, 2, 3, and 6 one of one, lint

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Lint or corrosion on the sprinkler head could slow that response or disable the sprinkler head. This could cause harm to the patients and staff.

Based on Observation the facility failed to provide medical gas cylinder storage rooms free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff observed one or several oxygen storage E -type cylinders located on the following floors of the hospital being stored next to storage of plastics, paper cardboard boxes, medical equipment or medical supplies within 5 feet of the oxygen cylinders. The following rooms observed were

1. MCH 5W-116
2. MCH 5W-111
3. MCH 5W C17
3. MCH 7W A16
4. MCH 7W B17
5. MCH 3E-B13 MCH 3E-C20
6. Soiled Utility room MCH 2E-A16
7. Rehab Servcies third floor

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.

Based on Observation the facility allowed the use of a multiple outlet adapters and extension cord for appliances refridgerators and microwaves.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed the following rooms or locations had the use of a multiple outlet adapters and an extension cord in use connected to appliances in the following locations.

Refridgerators or microwaves were plugged into power strips and not directly plugged directly into the wall receptacle outlet.

1. MCH 7E E14
2.MCH 6E 42 and 47
3. MCH 2W B11 and 2W A12
4. MCH 2-264
5. MCH 1-377
6. MCH 1-436
7. MCH 1-543
8. Central Plant office
9. Extension cord 2-214 connected to a computer printer.

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accredation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

The use of multiple outlet adapters and an extension cord could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on Observation the facility failed to secure electrical receptacles to a wall mounting box or the receptacle faceplate covers were observed to be cracked/broken.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1." Section 9.1.2. "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code. " NEC, Article 410, Section 410-56 (f) Receptacle Mounting (2) "Receptacles mounted in boxes that are flush with the wall surface or project therefrom shall be installed so that the mounting yoke or strap of the receptacle is seated against the box or raised box cover."

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed electrical receptacles/faceplate covers were not secured to the wall mounting boxes or were cracked or broken in the following locations:

1. MCH 7E 72 loose receptacle
2.MCH 4W 15 receptacle faceplate cracked/broken
3. MCH 5W-10 and by stairwell 5 receptacle faceplate cracked/broken
4. MCH 3E C31A loose receptacle
5. Second floor B Pod by stairwell 5 loose receptacle
6. Missing receptacle faceplate cover MCH 1-363

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accredation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Failing to secure electrical receptacle or replace cracked/broken receptacle faceplate covers could cause electrical shocks or cause a fire. A fire could cause harm to the patients.

Based on Observation the facility failed to allow access to the electrical equipment panels.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "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. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

"(NO STORAGE ALLOWED IN THE WORKING SPACE)"

Findings include:

On February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed storage in front of the electrical panel (s) located in the following locations:

1. Central Plant PC 101A Mechanical lift device
2. Operating room marked number #14 Microscope blocking electrical panel.

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients could be harmed if a fire should start because of a delay.

Based on observation the facility failed to maintain corridor operating room doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed the following corridor door operating rooms had smoke seals torn in one or two places and the corridor doors were not smoke resistant when tightly closed.

1. Operating room corridor doors marked # 11, 12, 14, 15, 16, 17, 18, 19, 21, 22, and the corridor doors by MCH 2-519

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

The facility failed to fill penetrations in the smoke barriers for two of seven floors of the hospital.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed unsealed penetrations in the smoke barriers above the communication cable trays located on the two floors by the following locations:

1. Seventh floor by smoke barriers MCH 121, 123, and 125
2. Sixth floor MCH 6E 36

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients.

Based on Observation the facility failed to maintain three smoke barrier doors on a total of seven floors, the self closing/automatic-closing doors in the smoke barriers did not close or latch when tested three of three times.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. ( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3, "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Section 7.2.1.8.1 (1) "Upon release of the hold-open mechanism, the door becomes self-closing."

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed the testing of the smoke barrier doors in the following locations:

1. 2W MCH 2-153, MCH 2-432 and MCH 1-435A would not close and latch when tested three of three times.

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Failure to properly adjust or repair the smoke barrier doors could cause harm to the patients.

Based on Observation the facility did not keep exits and exit access readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft ( EXISTING not less than 48 in.) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." CMS has determined that facilities built with 8 foot corridors shall maintain these corridors clear and unobstructed at all times.

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed storage, medical equipment, maintenance equipment and non emergency medical or maintenance supplies within the maintenance shop exit corridor North and South and stored throughout the corridor thus reducing the corridor to approximately four feet in width when measured.

The basement corridor East and West had approximately 20-25 hospital beds placed directly in the path of the entire exit access from one end to the other throughout the basement corridor. This further reduced the exit access corridor from approximately eleven feet to five feet in width.

In addition, the following areas had the exit doors blocked with the following equipment, two pallets of sodium chloride and three yellow flammable cabinets, in the Pharmacy supply room marked MCH1-401A.

The main kitchen one set of exit doors had three food tray carts and a green recycle bin placed directly in front of one set of exit doors. The Environmental Services had several chairs and couches placed in the exit corridor path directly in front of the double exit doors marked MCH 1-422. The emergency department walk in entrance had five wheelchairs placed directly in front of one of the two double doors to the main entrance.

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on Observation the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, asked to see the Red Emergency Guide written manual at the following nurse's stations. The Red Emergency Guide written manual which has the fire procedures was not at the nursing station pods or could not be located during the survey by staff. The surveyor asked several hospital staff at the nurses stations for the Red Emergency Guide. The hospital staff advised the surveyor the fire procedures were online.

1. 2A Pod
2. 3B D/E Pods
2. 4E F Pod
3. 5W A/B and C Pods
4.7W A/B and C Pods
5. Pac U East
6. Emergency Department

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

In time of an emergency, an emergency policy manuals must be readily available for the staff.
Patients will be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Based on observation the facility failed to keep several automatic sprinkler heads free of lint and one of one sprinkler heads had corrosion on the sprinkler.

NFPA 101, Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the installation of Sprinkler Systems." NFPA 13, Chapter 12, Section 12-1 "General" "A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25....NFPA 25, Chapter 2, Section 2-2.1 "Sprinklers" 2-2.1.1 ...Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g.,upright, pendant, or sidewall).

Findings Include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed the following locations in the facility several sprinkler heads had lint on the entire sprinkler frame and assembly or one sprinkler was corroded.

1. 3rd floor Rehab Kitchen one of one sprinklers, lint
2. MCH 3E-C20 Staff report office one of one sprinklers, lint
3. MCH 2W-05 A pod 2nd floor one of two sprinklers, lint
4. Employee Elevator Lobby three of three sprinklers, lint
5. MCH 2-151 Resident Center one of two sprinklers, lint
6. MCH 2-425 Soiled Utility 2nd floor, one of one sprinklers, lint
7. Operating break room surgical lounge one of six sprinklers, lint
8. MCH 1-368 Tank Room one of one, corroded sprinkler green in color
9. MCH 1-520 one of two sprinklers, lint
10 Main kitchen freezers, numbers 1, 2, 3, and 6 one of one, lint

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Lint or corrosion on the sprinkler head could slow that response or disable the sprinkler head. This could cause harm to the patients and staff.

Based on Observation the facility failed to provide medical gas cylinder storage rooms free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff observed one or several oxygen storage E -type cylinders located on the following floors of the hospital being stored next to storage of plastics, paper cardboard boxes, medical equipment or medical supplies within 5 feet of the oxygen cylinders. The following rooms observed were

1. MCH 5W-116
2. MCH 5W-111
3. MCH 5W C17
3. MCH 7W A16
4. MCH 7W B17
5. MCH 3E-B13 MCH 3E-C20
6. Soiled Utility room MCH 2E-A16
7. Rehab Servcies third floor

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.

Based on Observation the facility allowed the use of a multiple outlet adapters and extension cord for appliances refridgerators and microwaves.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed the following rooms or locations had the use of a multiple outlet adapters and an extension cord in use connected to appliances in the following locations.

Refridgerators or microwaves were plugged into power strips and not directly plugged directly into the wall receptacle outlet.

1. MCH 7E E14
2.MCH 6E 42 and 47
3. MCH 2W B11 and 2W A12
4. MCH 2-264
5. MCH 1-377
6. MCH 1-436
7. MCH 1-543
8. Central Plant office
9. Extension cord 2-214 connected to a computer printer.

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accredation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

The use of multiple outlet adapters and an extension cord could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on Observation the facility failed to secure electrical receptacles to a wall mounting box or the receptacle faceplate covers were observed to be cracked/broken.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1." Section 9.1.2. "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code. " NEC, Article 410, Section 410-56 (f) Receptacle Mounting (2) "Receptacles mounted in boxes that are flush with the wall surface or project therefrom shall be installed so that the mounting yoke or strap of the receptacle is seated against the box or raised box cover."

Findings include:

On February 19, 2014 and February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed electrical receptacles/faceplate covers were not secured to the wall mounting boxes or were cracked or broken in the following locations:

1. MCH 7E 72 loose receptacle
2.MCH 4W 15 receptacle faceplate cracked/broken
3. MCH 5W-10 and by stairwell 5 receptacle faceplate cracked/broken
4. MCH 3E C31A loose receptacle
5. Second floor B Pod by stairwell 5 loose receptacle
6. Missing receptacle faceplate cover MCH 1-363

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accredation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Failing to secure electrical receptacle or replace cracked/broken receptacle faceplate covers could cause electrical shocks or cause a fire. A fire could cause harm to the patients.

Based on Observation the facility failed to allow access to the electrical equipment panels.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "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. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

"(NO STORAGE ALLOWED IN THE WORKING SPACE)"

Findings include:

On February 20, 2014 the surveyor, accompanied by the following hospital staff, Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering a Facility Engineer staff and Project Planning and Design staff, observed storage in front of the electrical panel (s) located in the following locations:

1. Central Plant PC 101A Mechanical lift device
2. Operating room marked number #14 Microscope blocking electrical panel.

During the exit conference the above findings were acknowledged by the Operations Administrator, two Accreditation Regulatory Specialists, Manager of Facility Engineering, Facility Engineer staff and Project Planning and Design staff, Chief Nursing Officer, Division Chair of Operations and Division Chair of Facilities.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients could be harmed if a fire should start because of a delay.