HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in ceilings and . This deficient practice affected 5 of 15 floors at the Parnassus Campus, 1 of 7 floors at the Mt. Zion campus and 1 of 1 floor at the Ambulatory Surgery Center and could result in the spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire.

Findings:

During the tour of the facility with facility staff the following observations were made:

Parnassus Campus

1. On 10/12/10, at 1:58 p.m., on the 12th floor of the Long Building in room 1232A, the damper control cover was hanging off the ceiling surface and exposed a penetration in the ceiling.
2. On 10/12/10, at 2:01 p.m., on the 12th floor of the Moffit Building across from the Nursing station in the office supply closet, two flex pipe conduits each one inch in diameter were not sealed.
3. On 10/12/10, at 2:35 p.m., on the 10th floor of the Long Building in room L1015, one of two escutcheons was hanging off the ceiling surface and exposed a two inch penetration in the ceiling surface. The damper control cover adjacent to the sprinkler head was missing.

Mount Zion Campus

1. On 10/13/10, at 10:00 a.m., on the 4th floor of Building A in room A434D, the junction box cover was missing.

Ambulatory Surgery Center
1. On 10/13/10, at 2:00 p.m., in room A42, there were two 1" penetrations along the bottom left wall.


27893

During a facility tour with staff, the walls and ceilings were observed.

Moffitt Hospital:

1. On 10/12/10 at 11:17 a.m., there was an approximately three and one half inch diameter unsealed penetration in the wall of the penthouse mechanical room 1699ML. The penetration was located on the right hand side wall when entering the room from the stairwell.

2. On 10/14/10 at 10:20 a.m., there was an approximately four inch by two and one half inch unsealed penetration in the wall of room M172. The penetration was located below the sink in that room to the right of the sink pipe.

Long Hospital:

1. On 10/13/10 at 11:53 a.m., there was an approximately twelve inch by ten inch unsealed penetration in the wall of the electrical room L5M5. The penetration was located at the base of the wall below the light switch to that room.

Based on observation, the facility failed to maintain corridor doors as evidenced by doors along the corridor that were obstructed from closing or latching. This affected eight of sixteen floors at the Parnassus Campus. This could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff, the doors in the facility were observed.

Moffitt Building:

1. On 10/13/10 at 9:07 a.m., the corridor door to the family lounge M715 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a trash receptacle positioned directly in the swing path of the door. The trash receptacle was relocated and the door was allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.

2. On 10/13/10 at 10:32 a.m., the corridor door to the staff office M691 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a rubber door wedge placed underneath the door leaf. The room was unoccupied at the time.

3. On 10/13/10 at 11:16 a.m., the corridor door to the Neuropathology office M551 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to the latching barrel that was taped over in the depressed position.

4. On 10/13/10 at 11:23 a.m., the corridor door to the staff break room M578 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a chair positioned directly in the swing path of the door. The room was unoccupied at the time.

5. On 10/13/10 at 2:52 p.m., the corridor doors to the 2nd floor kitchen were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. The doors failed to latch. The doors were obstructed from latching by the door closing delay device affixed at the top center portion of the door frame.

Long Building:

1. On 10/12/10 at 2:32 p.m., the corridor door to the pharmacy office L1126 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

2. On 10/12/10 at 4:24 p.m., the corridor door to the pharmacy office L865 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

3. On 10/12/10 at 4:36 p.m., the corridor door to the electrical closet near the 8th floor service elevators was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

4. On 10/13/10 at 9:16 a.m., the corridor door to the pantry L710 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.


27254

During a tour of the facility with staff members on 10/12/10, at 3:18 p.m., on the 9th floor of the Long Building in room L931, the corridor to the room was held open by a wood door wedge.

Based on observation, the facility failed to maintain smoke barrier doors as evidenced by smoke barrier doors that were obstructed from latching when the doors were released from their hold-open devices and by a roll down door that was obstructed by items stored on the counter top. This affected one of sixteen floors in the Moffitt Hospital and two of sixteen floors in the Long Hospital. This could result in a failure contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff, the facility's smoke barrier doors were observed.

Moffitt Hospital:

1. 10/12/10 at 4:16 p.m., the smoke barrier doors by room M815 were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of the two door leafs of the smoke barrier doors failed to latch. The door was obstructed from latching by the door frame.

Long Hospital:

1. On 10/13/10 at 1:31 p.m., the smoke barrier doors by room L399MB were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of the two door leafs of the smoke barrier doors failed to latch. The door was obstructed from latching by the other door leaf.

2. On 10/14/10 at 11:08 a.m., the smoke barrier doors across from room L121 were equipped with automatic closing devices. The doors were allowed to close. One of the two door leafs of the smoke barrier doors failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.




27254

During a tour of the facility on 10/12/10, at 1:41 p.m., on the 13th floor of the Moffitt Building, the roll down fire door at the Nursing Station of the ICU, items were placed in the path of the drop down door. The items on the counter top would prevent the full closure of the fire door in the event of a fire.

Based on observation, the facility failed to maintain a clear width of not less than 32 inches for smoke barrier doors as evidenced by one smoke barrier door that had a passage width less than thirty-two inches. This affected one of sixteen floors at the Parnassus Campus and could result in a delayed evacuation in the event of an emergency.

Findings:

During a facility tour with staff, the clear width passage through the smoke barrier doors were observed.

Moffitt Building:

1. On 10/13/10 at 2:02 p.m., the smoke barrier doors near M301 were observed. A gurney was positioned in front of the smoke barrier doors along one side of the corridor. The clear width measured from the gurney to the opposite door leaf of the closed smoke barrier door was approximately 24 inches.

Based on observation, the facility failed to maintain their hazardous areas as evidenced by doors to hazardous areas that were obstructed from latching. This deficient practice affected two of sixteen floors at the Parnassus Campus and one of seven floors at the Mount Zion Campus. This could result in a delay to contain smoke or fire to a hazardous area.

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

19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5lbf (22N) is applied at the latch edge of the door.

Findings:

During a facility tour with staff, the facility's hazardous areas were observed.

Moffitt Building:
1. On 10/13/10 at 8:51 a.m., the corridor door to the soiled utility room M702L was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Long Building:
1. On 10/14/10 at 10:57 a.m., the corridor door to compressed gas storage room L140C was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to a malfunctioning latching barrel that would not retract.


27254

During a tour of the facility with staff members on 10/13/10, at 11:22 a.m., at the Mount Zion Campus Building R, the door to the Gift Shop did not fully close during fire alarm testing. The doors were held open by magnets and released upon activation of the fire alarm system. The doors became stuck on one another and did not fully close and latch. These doors must function and latch shut during activation of the fire alarm system as required.

Based on observation, the facility failed to maintain exit access so that exits are readily accessible at all times as evidenced by the corridor behind the Intensive Care Nursery that had medical equipment stored along the right hand wall and diminished the width of the exit corridor. This condition affected one of sixteen floors in the Moffit Building and could result in a delay of egress in the event of an emergency exit.

NFPA 101, 2000 Life Safety Code
7.1.3.2.3 - An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, an area of refuge.
7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a tour of the facility wih staff members, the following observations were made:

Parnassus Campus
1. On 10/12/10, at 11:14 a.m., the 15 West Back corridor of the Moffitt Building had medical equipment stored along the right hand wall of the emergency egress pathway. The emergency exit corridor wisth had been decreased.

Ambulatory Surgery Center
1. On 10/13/10, at 2:10 p.m., a linen cart was stored in the corridor near room A57. The clean linen cart did not fit into the alcove and fully stuck out into the corridor.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by three sprinklers that were missing escutcheons and two sprinklers that did not have eighteen inches of clearance around their deflector plates. This affected three of sixteen floors at the Parnassus Campus. This could result in the passage of smoke through openings in the ceiling around the sprinkler or a delay in extinguishing a fire due to obstructions of a sprinkler.

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

NFPA 25, 1998 edition
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Findings:

During a facility tour with staff, the sprinklers in the facility were observed.

Moffitt Building:

1. On 10/12/10 at 4:08 p.m., the sprinkler in the environmental services closet M818C was missing an escutcheon.

2. On 10/13/10 at 8:17 a.m., the sprinkler in the environmental services closet adjacent to M799TA was missing an escutcheon.

Long Building:

1. On 10/12/10 at 2:25 p.m., the sprinkler in the bathroom for patient room L1116 was missing an escutcheon.

2. On 10/12/10 at 2:57 p.m., the sprinkler in the light bulb storage closet L1178 did not have eighteen inches of clearance around its deflector plate. The sprinkler was obstructed by the storage of light bulbs approximately three inches directly below the sprinkler.

3. On 10/12/10 at 3:00 p.m., the sprinkler in the storage closet L1181 did not have eighteen inches of clearance around its deflector plate. The sprinkler was obstructed by the storage of a box of paper towels approximately two inches directly below the sprinkler.

Based on observation, the facility failed to maintain the storage of medical gas cylinders as evidenced by oxygen cylinders that were stored without being secured, by eight nitrogen H tanks that were stored unsecured and one medical gas bulk storage location that had electrical fixtures below five feet. These deficient practices affected five of sixteen floors at the Parnassus Campus and could result in an medical compressed gas tank initiated emergency.

NFPA 99 4-3.1.1.2 Storage Requirements
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electric Code, for Ordinary Locations. Electric wall fixtures, switches and receptacles shall be installed in fixed locations not less than 5 ft above the floor as a precaution against their physical damage.
8. When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.
4-3.5.2.2(b)2 If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
8-3.1.11.2(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.

Findings:

During a tour of the facility with staff members, the following observations were made:
1. On 10/12/10, at 2:15 p.m., on the 12th floor of the Long Building in room L1209, one of five E oxygen cylinders was left free standing without being secured.
2. On 10/13/10, at 3:33 p.m., on the 9th floor of the Moffit Building in the ICU East Wing, one of ten E oxygen cylinders was left free standing and unsecured.



27893

During a facility tour with staff, the facility's medical gas storage locations were observed.

Moffitt Building:

1. On 10/12/10 at 4:11 p.m., one of nine oxygen E cylinders in the compressed gas storage room M816A was free standing and unsecured.

Long Building:

1. On 10/13/10 at 3:48 p.m., the medical gas bulk storage room L99ML was observed. The room contained both H and E sized medical gas tanks/oxygen cylinders. The light switch and an electrical wall receptacle in the room measured to be approximately four feet high from the floor. The light switch must be above 60 inches off the ground.

2. On 10/14/10 at 11:59 a.m., there were eight nitrogen H tanks in the medical gas storage room L403 that were free standing and unsecured. The wall mounted security chains were not being utilized.

Based on document review and staff interview, the facility failed to maintain the relative humidity readings in the OR room equal to or greater than 35% as evidenced by no records for the operating rooms humidity at the Parnassus Campus. This condition affects all patients with the potential spread of smoke and fire in the event of a fire.

Findings:

During document review on 10/14/10, the records provided for the operating room humidity were for a monthly basis instead of a daily basis. Staff stated that the humidity of 28 operating rooms at the Parnassus Campus is being recorded once per month.

Based on observation and staff interview, the facility failed to comply with regulations regarding electrical wiring and utilities as evidenced by the use of surge protectors for motorized items, for medical equipment, and by the use of unapproved extension cords. This condition affected 9 of 15 floors at the Parnassus Campus, 2 of 7 floor at the Mount Zion Campus, and 1 of 1 floor at the Out Patient Ambulatory Center. These deficient practices could result in the potential to ignite an electrical fire.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a tour of the facility with a staff, the following observations were made:
Parnassus Campus
1. On 10/12/10, at 11:04 a.m., on the 15 th floor, in the West Wing, in the doctor's sleeping room, a refrigerator was plugged into a power strip instead of directly into the wall outlet.
2. On 10/12/10, at 11:59 a.m., on the 14th floor of Moffit, in room M1415B, two medical machines were plugged into a power strip instead of directly into the wall outlet.
3. On 10/12/10, at 1:57 p.m., on the 12th floor, in room 1230 a power strip was attached to an IV pole. Three pumps were plugged into the power strip instead of directly into the wall outlet.
4. On 10/12/10, at 2:20 p.m., blood pressure machines were plugged into power strips in the following rooms instead of directly to the wall outlet: L1201, L1207, L1231, and L1229.
5. On 10/12/10, at 2:49 p.m., on the 10th floor of Moffit, in the North ICU and in the East ICU there were a total of 8 medical machines plugged into power strips instead of directly into wall outlets.
Mt. Zion Campus
1. On 10/13/10, at 9:36 a.m., on the 5th floor of Building A, in room A509, three power strips were plugged into one power strip instead of directly into the wall outlet.
2. On 10/13/10, at 9:55 a.m., on the 4th floor of Building B, in the Nurse's Lounge, a microwave was plugged into an extension cord instead of directly into the wall outlet.
3. On 10/13/10, at 10:10 a.m., on the 4th floor of Building A, in room A407 the medication room, the Pyxis machines were plugged into a power strip instead of directly into the wall outlet.
Ambulatory Surgery Center
1. On 10/13/10, at 2:30 p.m., in operating rooms 58, 59 and 60, infusion pumps were plugged into power strip instead of directly into the wall outlet.
Staff stated that power strips are also used for anaesthesia equipment.




27893

During a facility tour with staff, the facility's electrical equipment and wiring were observed.

Moffitt Building:

1. On 10/12/10 at 3:53 p.m., computer equipment in M830 was plugged into a surge protected multi-outlet extension cord that was plugged into a grey non-surge protected extension cord.

2. On 10/12/10 at 4:14 p.m., a microwave oven and a miniature refrigerator in the staff office M815 was plugged into a surge protected multi-outlet extension cord.

3. On 10/13/10 at 8:34 a.m., a portable air conditioning unit in M726B near Bed 4 was plugged into a yellow non-surge protected extension cord.

4. On 10/13/10 at 8:36 a.m., a miniature refrigerator in staff room M727 was plugged into a surge protected multi-outlet extension cord.

5. On 10/13/10 at 8:36 a.m., the electrical wall receptacle behind the couch in staff room M727 was missing a faceplate. Electrical wiring was exposed.

6. On 10/13/10 at 8:43 a.m., a portable space heater in the staff office M701E was plugged into a surge protected multi-outlet extension cord. The warning tag on the heater's electrical cord indicated to avoid the use of extension cords because it may cause a fire.

7. On 10/13/10 at 9:01 a.m., computer equipment in staff office M712 was plugged into a surge protected multi-outlet extension cord that was plugged into an orange non-surge protected extension cord.

8. On 10/13/10 at 10:52 a.m., computer equipment in the staff office M613 was plugged into a grey non-surge protected multi-outlet extension cord.

9. On 10/13/10 at 2:21 p.m., computer equipment in the conference room M311 was plugged into a surge protected multi-outlet extension cord that was plugged into a non-surge protected extension cord.

10. On 10/13/10 at 2:30 p.m., computer equipment in the staff office M316A was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

11. On 10/13/10 at 3:57 p.m., computer equipment in the central receiving room M41 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

12. On 10/14/10 at 10:13 a.m., computer equipment in the staff office M181A was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

13. On 10/14/10 at 10:14 a.m., a portable space heater in staff office M181 was plugged into a surge protected multi-outlet extension cord. The warning tag on the heater's electrical cord indicated to avoid the use of an extension cord.

14. On 10/14/10 at 10:16 a.m., a microwave oven in the operating room scheduler's office M175 was plugged into an orange non-surge protected extension cord that was plugged into a surge protected multi-outlet extension cord. A portable space heater at the same location was plugged into that same surge protected multi-outlet extension cord.

15. On 10/14/10 at 10:19 a.m., a miniature refrigerator in the staff office M175 was plugged into a grey non-surge protected multi-outlet extension cord.

16. On 10/14/10 at 10:33 a.m., computer equipment in the staff area M140 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord. A portable space heater at that same location was plugged into a surge protected multi-outlet extension cord.

Long Building:

1. On 10/13/10 at 9:38 a.m., computer equipment in the staff office L697 was plugged into a white non-surge protected multi-outlet extension cord.

2. On 10/13/10 at 11:38 a.m., three portable space heaters in the lab area L554 were plugged into three different surge protected multi-outlet extension cords below three desks near the east wall of the room.

3. On 10/13/10 at 3:34 p.m., a microwave oven in the Dosimetry room L44 was plugged into a non-surge protected extension cord.

4. On 10/13/10 at 3:38 p.m., computer equipment in the staff office L29 were plugged into two separate surge protected multi-outlet extension cords. Those two surge protected multi-outlet extension cords were then plugged to one surge protected multi-outlet extension cord.

5. On 10/14/10 at 11:03 a.m., a date/time stamp device by room L156 was plugged into an orange non-surge protected extension cord that was plugged into a surge protected multi-outlet extension cord.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of alcohol based hand rub dispensers over or adjacent to ignition sources. This affected ten of sixteen floors at the Parnassus Campus. This could result in a fire due to ignition of an alcohol based hand rub.

Findings:

During a facility tour with staff, the facility's alcohol based hand rub dispensers were observed.

Moffitt Building:

1. On 10/12/10 at 3:28 p.m., an alcohol based hand rub dispenser in the intensive care unit M1106H near Bed 15 was mounted approximately twenty inches above an electrical receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

2. On 10/12/10 at 3:40 p.m., an alcohol based hand rub dispenser in the corridor near the supply closet M801L was mounted approximately twenty inches above an electrical receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

3. On 10/12/10 at 4:15 p.m., an alcohol based hand rub dispenser in the assistant patient care manager's office M815 was mounted approximately three inches to the left of a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

4. On 10/13/10 at 8:38 a.m., an alcohol based hand rub dispenser in the corridor by room M728 was mounted approximately twenty-seven inches above an electrical receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

5. On 10/13/10 at 10:48 a.m., an alcohol based hand rub dispenser in M626 across from the pediatric swing bed 2 was mounted approximately five inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

Long Building:

1. On 10/12/10 at 4:27 p.m., an alcohol based hand rub dispenser in the soiled utility room L809 was mounted approximately thirty-two inches above an electrical receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

2. On 10/13/10 at 9:14 a.m., an alcohol based hand rub dispenser in the biohazard room L709 was mounted approximately twenty inches above an electrical receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

3. On 10/13/10 at 9:29 a.m., an alcohol based hand rub dispenser in the negative pressure isolation room L707 was mounted approximately four inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

4. On 10/13/10 at 9:44 a.m., an alcohol based hand rub dispenser in the patient room L604 was mounted approximately six inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

5. On 10/13/10 at 9:51 a.m., an alcohol based hand rub dispenser in the patient room L628 was mounted approximately six inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

6. On 10/13/10 at 9:56 a.m., an alcohol based hand rub dispenser in the conference room L636B was mounted approximately thirty inches above a computer central processing unit. The hand rub was sixty-two percent ethyl alcohol by volume.

7. On 10/13/10 at 10:03 a.m., an alcohol based hand rub dispenser in the treatment room L668 was mounted approximately five inches to the upper left of a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

8. On 10/13/10 at 11:59 a.m., an alcohol based hand rub dispenser in the Catheterization Lab 2 L508 was mounted approximately five inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

9. On 10/13/10 at 1:53 p.m., the neuro-angio room L370N1 was observed. There was one alcohol based hand rub dispenser inside the room mounted above an electrical receptacle and one alcohol based hand rub dispenser on the wall outside of the room mounted approximately three inches above a light dimmer switch. The hand rubs were sixty-two percent ethyl alcohol by volume.

10. On 10/14/10 at 10:30 a.m., an alcohol based hand rub dispenser in the prepare room L170 was mounted approximately twenty-four inches above an electrical receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

11. On 10/14/10 at 10:52 a.m., an alcohol based hand rub dispenser in the patient room L138 was mounted approximately two inches above a light dimmer switch. The hand rub was sixty-two percent ethyl alcohol by volume.

12. On 10/14/10 at 12:01 p.m., an alcohol based hand rub dispenser in the central storage room L440 was mounted approximately three inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in ceilings and . This deficient practice affected 5 of 15 floors at the Parnassus Campus, 1 of 7 floors at the Mt. Zion campus and 1 of 1 floor at the Ambulatory Surgery Center and could result in the spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire.

Findings:

During the tour of the facility with facility staff the following observations were made:

Parnassus Campus

1. On 10/12/10, at 1:58 p.m., on the 12th floor of the Long Building in room 1232A, the damper control cover was hanging off the ceiling surface and exposed a penetration in the ceiling.
2. On 10/12/10, at 2:01 p.m., on the 12th floor of the Moffit Building across from the Nursing station in the office supply closet, two flex pipe conduits each one inch in diameter were not sealed.
3. On 10/12/10, at 2:35 p.m., on the 10th floor of the Long Building in room L1015, one of two escutcheons was hanging off the ceiling surface and exposed a two inch penetration in the ceiling surface. The damper control cover adjacent to the sprinkler head was missing.

Mount Zion Campus

1. On 10/13/10, at 10:00 a.m., on the 4th floor of Building A in room A434D, the junction box cover was missing.

Ambulatory Surgery Center
1. On 10/13/10, at 2:00 p.m., in room A42, there were two 1" penetrations along the bottom left wall.


27893

During a facility tour with staff, the walls and ceilings were observed.

Moffitt Hospital:

1. On 10/12/10 at 11:17 a.m., there was an approximately three and one half inch diameter unsealed penetration in the wall of the penthouse mechanical room 1699ML. The penetration was located on the right hand side wall when entering the room from the stairwell.

2. On 10/14/10 at 10:20 a.m., there was an approximately four inch by two and one half inch unsealed penetration in the wall of room M172. The penetration was located below the sink in that room to the right of the sink pipe.

Long Hospital:

1. On 10/13/10 at 11:53 a.m., there was an approximately twelve inch by ten inch unsealed penetration in the wall of the electrical room L5M5. The penetration was located at the base of the wall below the light switch to that room.

Based on observation, the facility failed to maintain corridor doors as evidenced by doors along the corridor that were obstructed from closing or latching. This affected eight of sixteen floors at the Parnassus Campus. This could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff, the doors in the facility were observed.

Moffitt Building:

1. On 10/13/10 at 9:07 a.m., the corridor door to the family lounge M715 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a trash receptacle positioned directly in the swing path of the door. The trash receptacle was relocated and the door was allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.

2. On 10/13/10 at 10:32 a.m., the corridor door to the staff office M691 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a rubber door wedge placed underneath the door leaf. The room was unoccupied at the time.

3. On 10/13/10 at 11:16 a.m., the corridor door to the Neuropathology office M551 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to the latching barrel that was taped over in the depressed position.

4. On 10/13/10 at 11:23 a.m., the corridor door to the staff break room M578 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a chair positioned directly in the swing path of the door. The room was unoccupied at the time.

5. On 10/13/10 at 2:52 p.m., the corridor doors to the 2nd floor kitchen were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. The doors failed to latch. The doors were obstructed from latching by the door closing delay device affixed at the top center portion of the door frame.

Long Building:

1. On 10/12/10 at 2:32 p.m., the corridor door to the pharmacy office L1126 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

2. On 10/12/10 at 4:24 p.m., the corridor door to the pharmacy office L865 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

3. On 10/12/10 at 4:36 p.m., the corridor door to the electrical closet near the 8th floor service elevators was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

4. On 10/13/10 at 9:16 a.m., the corridor door to the pantry L710 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.


27254

During a tour of the facility with staff members on 10/12/10, at 3:18 p.m., on the 9th floor of the Long Building in room L931, the corridor to the room was held open by a wood door wedge.

Based on observation, the facility failed to maintain smoke barrier doors as evidenced by smoke barrier doors that were obstructed from latching when the doors were released from their hold-open devices and by a roll down door that was obstructed by items stored on the counter top. This affected one of sixteen floors in the Moffitt Hospital and two of sixteen floors in the Long Hospital. This could result in a failure contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff, the facility's smoke barrier doors were observed.

Moffitt Hospital:

1. 10/12/10 at 4:16 p.m., the smoke barrier doors by room M815 were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of the two door leafs of the smoke barrier doors failed to latch. The door was obstructed from latching by the door frame.

Long Hospital:

1. On 10/13/10 at 1:31 p.m., the smoke barrier doors by room L399MB were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of the two door leafs of the smoke barrier doors failed to latch. The door was obstructed from latching by the other door leaf.

2. On 10/14/10 at 11:08 a.m., the smoke barrier doors across from room L121 were equipped with automatic closing devices. The doors were allowed to close. One of the two door leafs of the smoke barrier doors failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.




27254

During a tour of the facility on 10/12/10, at 1:41 p.m., on the 13th floor of the Moffitt Building, the roll down fire door at the Nursing Station of the ICU, items were placed in the path of the drop down door. The items on the counter top would prevent the full closure of the fire door in the event of a fire.

Based on observation, the facility failed to maintain a clear width of not less than 32 inches for smoke barrier doors as evidenced by one smoke barrier door that had a passage width less than thirty-two inches. This affected one of sixteen floors at the Parnassus Campus and could result in a delayed evacuation in the event of an emergency.

Findings:

During a facility tour with staff, the clear width passage through the smoke barrier doors were observed.

Moffitt Building:

1. On 10/13/10 at 2:02 p.m., the smoke barrier doors near M301 were observed. A gurney was positioned in front of the smoke barrier doors along one side of the corridor. The clear width measured from the gurney to the opposite door leaf of the closed smoke barrier door was approximately 24 inches.

Based on observation, the facility failed to maintain their hazardous areas as evidenced by doors to hazardous areas that were obstructed from latching. This deficient practice affected two of sixteen floors at the Parnassus Campus and one of seven floors at the Mount Zion Campus. This could result in a delay to contain smoke or fire to a hazardous area.

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

19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5lbf (22N) is applied at the latch edge of the door.

Findings:

During a facility tour with staff, the facility's hazardous areas were observed.

Moffitt Building:
1. On 10/13/10 at 8:51 a.m., the corridor door to the soiled utility room M702L was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Long Building:
1. On 10/14/10 at 10:57 a.m., the corridor door to compressed gas storage room L140C was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to a malfunctioning latching barrel that would not retract.


27254

During a tour of the facility with staff members on 10/13/10, at 11:22 a.m., at the Mount Zion Campus Building R, the door to the Gift Shop did not fully close during fire alarm testing. The doors were held open by magnets and released upon activation of the fire alarm system. The doors became stuck on one another and did not fully close and latch. These doors must function and latch shut during activation of the fire alarm system as required.

Based on observation, the facility failed to maintain exit access so that exits are readily accessible at all times as evidenced by the corridor behind the Intensive Care Nursery that had medical equipment stored along the right hand wall and diminished the width of the exit corridor. This condition affected one of sixteen floors in the Moffit Building and could result in a delay of egress in the event of an emergency exit.

NFPA 101, 2000 Life Safety Code
7.1.3.2.3 - An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, an area of refuge.
7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a tour of the facility wih staff members, the following observations were made:

Parnassus Campus
1. On 10/12/10, at 11:14 a.m., the 15 West Back corridor of the Moffitt Building had medical equipment stored along the right hand wall of the emergency egress pathway. The emergency exit corridor wisth had been decreased.

Ambulatory Surgery Center
1. On 10/13/10, at 2:10 p.m., a linen cart was stored in the corridor near room A57. The clean linen cart did not fit into the alcove and fully stuck out into the corridor.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by three sprinklers that were missing escutcheons and two sprinklers that did not have eighteen inches of clearance around their deflector plates. This affected three of sixteen floors at the Parnassus Campus. This could result in the passage of smoke through openings in the ceiling around the sprinkler or a delay in extinguishing a fire due to obstructions of a sprinkler.

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

NFPA 25, 1998 edition
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Findings:

During a facility tour with staff, the sprinklers in the facility were observed.

Moffitt Building:

1. On 10/12/10 at 4:08 p.m., the sprinkler in the environmental services closet M818C was missing an escutcheon.

2. On 10/13/10 at 8:17 a.m., the sprinkler in the environmental services closet adjacent to M799TA was missing an escutcheon.

Long Building:

1. On 10/12/10 at 2:25 p.m., the sprinkler in the bathroom for patient room L1116 was missing an escutcheon.

2. On 10/12/10 at 2:57 p.m., the sprinkler in the light bulb storage closet L1178 did not have eighteen inches of clearance around its deflector plate. The sprinkler was obstructed by the storage of light bulbs approximately three inches directly below the sprinkler.

3. On 10/12/10 at 3:00 p.m., the sprinkler in the storage closet L1181 did not have eighteen inches of clearance around its deflector plate. The sprinkler was obstructed by the storage of a box of paper towels approximately two inches directly below the sprinkler.

Based on observation, the facility failed to maintain the storage of medical gas cylinders as evidenced by oxygen cylinders that were stored without being secured, by eight nitrogen H tanks that were stored unsecured and one medical gas bulk storage location that had electrical fixtures below five feet. These deficient practices affected five of sixteen floors at the Parnassus Campus and could result in an medical compressed gas tank initiated emergency.

NFPA 99 4-3.1.1.2 Storage Requirements
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electric Code, for Ordinary Locations. Electric wall fixtures, switches and receptacles shall be installed in fixed locations not less than 5 ft above the floor as a precaution against their physical damage.
8. When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.
4-3.5.2.2(b)2 If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
8-3.1.11.2(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.

Findings:

During a tour of the facility with staff members, the following observations were made:
1. On 10/12/10, at 2:15 p.m., on the 12th floor of the Long Building in room L1209, one of five E oxygen cylinders was left free standing without being secured.
2. On 10/13/10, at 3:33 p.m., on the 9th floor of the Moffit Building in the ICU East Wing, one of ten E oxygen cylinders was left free standing and unsecured.



27893

During a facility tour with staff, the facility's medical gas storage locations were observed.

Moffitt Building:

1. On 10/12/10 at 4:11 p.m., one of nine oxygen E cylinders in the compressed gas storage room M816A was free standing and unsecured.

Long Building:

1. On 10/13/10 at 3:48 p.m., the medical gas bulk storage room L99ML was observed. The room contained both H and E sized medical gas tanks/oxygen cylinders. The light switch and an electrical wall receptacle in the room measured to be approximately four feet high from the floor. The light switch must be above 60 inches off the ground.

2. On 10/14/10 at 11:59 a.m., there were eight nitrogen H tanks in the medical gas storage room L403 that were free standing and unsecured. The wall mounted security chains were not being utilized.

Based on document review and staff interview, the facility failed to maintain the relative humidity readings in the OR room equal to or greater than 35% as evidenced by no records for the operating rooms humidity at the Parnassus Campus. This condition affects all patients with the potential spread of smoke and fire in the event of a fire.

Findings:

During document review on 10/14/10, the records provided for the operating room humidity were for a monthly basis instead of a daily basis. Staff stated that the humidity of 28 operating rooms at the Parnassus Campus is being recorded once per month.

Based on observation and staff interview, the facility failed to comply with regulations regarding electrical wiring and utilities as evidenced by the use of surge protectors for motorized items, for medical equipment, and by the use of unapproved extension cords. This condition affected 9 of 15 floors at the Parnassus Campus, 2 of 7 floor at the Mount Zion Campus, and 1 of 1 floor at the Out Patient Ambulatory Center. These deficient practices could result in the potential to ignite an electrical fire.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a tour of the facility with a staff, the following observations were made:
Parnassus Campus
1. On 10/12/10, at 11:04 a.m., on the 15 th floor, in the West Wing, in the doctor's sleeping room, a refrigerator was plugged into a power strip instead of directly into the wall outlet.
2. On 10/12/10, at 11:59 a.m., on the 14th floor of Moffit, in room M1415B, two medical machines were plugged into a power strip instead of directly into the wall outlet.
3. On 10/12/10, at 1:57 p.m., on the 12th floor, in room 1230 a power strip was attached to an IV pole. Three pumps were plugged into the power strip instead of directly into the wall outlet.
4. On 10/12/10, at 2:20 p.m., blood pressure machines were plugged into power strips in the following rooms instead of directly to the wall outlet: L1201, L1207, L1231, and L1229.
5. On 10/12/10, at 2:49 p.m., on the 10th floor of Moffit, in the North ICU and in the East ICU there were a total of 8 medical machines plugged into power strips instead of directly into wall outlets.
Mt. Zion Campus
1. On 10/13/10, at 9:36 a.m., on the 5th floor of Building A, in room A509, three power strips were plugged into one power strip instead of directly into the wall outlet.
2. On 10/13/10, at 9:55 a.m., on the 4th floor of Building B, in the Nurse's Lounge, a microwave was plugged into an extension cord instead of directly into the wall outlet.
3. On 10/13/10, at 10:10 a.m., on the 4th floor of Building A, in room A407 the medication room, the Pyxis machines were plugged into a power strip instead of directly into the wall outlet.
Ambulatory Surgery Center
1. On 10/13/10, at 2:30 p.m., in operating rooms 58, 59 and 60, infusion pumps were plugged into power strip instead of directly into the wall outlet.
Staff stated that power strips are also used for anaesthesia equipment.




27893

During a facility tour with staff, the facility's electrical equipment and wiring were observed.

Moffitt Building:

1. On 10/12/10 at 3:53 p.m., computer equipment in M830 was plugged into a surge protected multi-outlet extension cord that was plugged into a grey non-surge protected extension cord.

2. On 10/12/10 at 4:14 p.m., a microwave oven and a miniature refrigerator in the staff office M815 was plugged into a surge protected multi-outlet extension cord.

3. On 10/13/10 at 8:34 a.m., a portable air conditioning unit in M726B near Bed 4 was plugged into a yellow non-surge protected extension cord.

4. On 10/13/10 at 8:36 a.m., a miniature refrigerator in staff room M727 was plugged into a surge protected multi-outlet extension cord.

5. On 10/13/10 at 8:36 a.m., the electrical wall receptacle behind the couch in staff room M727 was missing a faceplate. Electrical wiring was exposed.

6. On 10/13/10 at 8:43 a.m., a portable space heater in the staff office M701E was plugged into a surge protected multi-outlet extension cord. The warning tag on the heater's electrical cord indicated to avoid the use of extension cords because it may cause a fire.

7. On 10/13/10 at 9:01 a.m., computer equipment in staff office M712 was plugged into a surge protected multi-outlet extension cord that was plugged into an orange non-surge protected extension cord.

8. On 10/13/10 at 10:52 a.m., computer equipment in the staff office M613 was plugged into a grey non-surge protected multi-outlet extension cord.

9. On 10/13/10 at 2:21 p.m., computer equipment in the conference room M311 was plugged into a surge protected multi-outlet extension cord that was plugged into a non-surge protected extension cord.

10. On 10/13/10 at 2:30 p.m., computer equipment in the staff office M316A was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

11. On 10/13/10 at 3:57 p.m., computer equipment in the central receiving room M41 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

12. On 10/14/10 at 10:13 a.m., computer equipment in the staff office M181A was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

13. On 10/14/10 at 10:14 a.m., a portable space heater in staff office M181 was plugged into a surge protected multi-outlet extension cord. The warning tag on the heater's electrical cord indicated to avoid the use of an extension cord.

14. On 10/14/10 at 10:16 a.m., a microwave oven in the operating room scheduler's office M175 was plugged into an orange non-surge protected extension cord that was plugged into a surge protected multi-outlet extension cord. A portable space heater at the same location was plugged into that same surge protected multi-outlet extension cord.

15. On 10/14/10 at 10:19 a.m., a miniature refrigerator in the staff office M175 was plugged into a grey non-surge protected multi-outlet extension cord.

16. On 10/14/10 at 10:33 a.m., computer equipment in the staff area M140 was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord. A portable space heater at that same location was plugged into a surge protected multi-outlet extension cord.

Long Building:

1. On 10/13/10 at 9:38 a.m., computer equipment in the staff office L697 was plugged into a white non-surge protected multi-outlet extension cord.

2. On 10/13/10 at 11:38 a.m., three portable space heaters in the lab area L554 were plugged into three different surge protected multi-outlet extension cords below three desks near the east wall of the room.

3. On 10/13/10 at 3:34 p.m., a microwave oven in the Dosimetry room L44 was plugged into a non-surge protected extension cord.

4. On 10/13/10 at 3:38 p.m., computer equipment in the staff office L29 were plugged into two separate surge protected multi-outlet extension cords. Those two surge protected multi-outlet extension cords were then plugged to one surge protected multi-outlet extension cord.

5. On 10/14/10 at 11:03 a.m., a date/time stamp device by room L156 was plugged into an orange non-surge protected extension cord that was plugged into a surge protected multi-outlet extension cord.