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Based on observation of the physical environment and interview with the facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not insuring that all interior finish components have the proper flame spread rating as required thereby creating a hazardous condition. Failure to insure proper flame spread ratings for interior surfaces in this area has the potential to cause harm to 10% of the staff and patients.

The findings include:

During the complaint survey at approximately 1125 hours on May 11, 2016 it was observed and confirmed through interview with the Senior Facilities Manager that in the Main Hospital 5th floor EEG (room 5W48) the walls of the room are covered with carpet type textile material. This is a non-sprinkler protected area used for patient care and administrative functions. The facility staff was not able to document the flame spread rating for this interior finish material.
(see also A10.3.1)

The failure to insure that materials used for interior finish have the required flame spread ratings can result in a fire occurring which has the potential to promote harm to occupants of the facility.

Based on review of facility documents and interviews with facility staff it was determined that the facility staff failed to follow the required Evacuation and Relocation Plan thereby creating an unsafe environment for the residents. The failure to follow the Evacuation and Relocation Plan as required has the potential to cause harm to 100% of the staff and patients.

The findings include:

During this complaint survey between April 28 and May 11, 2016 it was determined through review of the facility documents, review of the facility evacuation procedures, and interview with the Emergency Preparedness and Safety Officer and the Senior Facilities Manager that the Code requirement to have in effect an Evacuation and Relocation Plan for all supervisory personnel was not complied with. During the fire emergency which occurred on April 27, 2016 an evacuation of the hospital was ordered and communicated throughout the facility by the Operator(s) on duty, who were supervising the transmission and receipt of fire alarm signals and other information, at the direction of the fire alarm monitoring company contracted by the hospital resulting in a complete evacuation of the Main Hospital Building. The Hospital Fire Plan Policy (May 2015 revision) Section V. Evacuation Procedures, states "...If ever needed, the Baltimore City Fire Department, Hospital Command Center, will be responsible for initiating and directing the evacuation process." In addition, the "After Action Report" summarizing the April 27 Code Red fire event provided by the Hospital on May 3, 2016 on page 5 is a statement that "Per policy there are only 3 people who can initiate the full evacuation of the hospital, the VP of Operations, the ADN, and the President,..." There is no reference to this "policy" in the Hospital Fire Plan Policy submitted to this surveyor and this statement conflicts with the Fire Plan.

The failure to implement the facility evacuation plan as required has the potential to create a hazardous environment for residents as the staff may not be familiar with the procedures to follow in the event of a fire or other emergency.

Based on review of facility documents and interviews with facility staff it was determined that the facility staff failed to hold fire drills at random and unexpected times as required by this Code for all three shifts thereby creating an unsafe environment for the residents. The failure to hold fire drills as required has the potential to cause harm to 100% of the staff and residents.

The findings include:

During this complaint survey between April 28 and May 3, 2016 it was determined through review of the facility documents, review of the facility evacuation procedures, and interview with the Chief of Security that the Code requirement to hold fire drills at unexpected times is not in compliance. The facility 2015 and 2016 Fire Drill Schedules are duplicate forms (year to year) which have the fire drills planned in identical fashion for the same Occupancy, Date Scheduled, Drill Time, and Unit each year. The manner in which the facility holds and records fire drills does not confirm that each staff member has participated in a drill that insures they are familiar with procedures to be followed when a fire occurs in their work location.

For example, the Emergency Department is located in the O'Neill Building on the 1st floor and the Unit only had one fire drill per year, during the "Day" shift, in which ED staff responded to a scenario and performed emergency actions under varying conditions, as if a fire was located in the ED. No fire drills are documented as having been held during 2015 in which the "Evening" or "Night" shifts of the ED were made familiar with emergency actions and procedures to be followed in the event of a fire in the ED. The failure to have each staff member on all shifts of each Unit participate in a simulation of emergency fire conditions occurring within in their Unit is similarly illustrated throughout the facility.

The lack of holding and recording fire drills for staff in the required manner has the potential to create a hazardous environment for occupants of the facility as the staff may not be familiar with the procedures to follow in the event of a fire or other emergency.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not providing an approved automatic sprinkler system to all areas of the building as required. Failure to provide complete automatic sprinkler system coverage as required has the potential to cause harm to 10% of the staff and residents.

The findings include:

1) During the complaint survey on May 11, 2016 at approximately 1155 hours it was observed and confirmed through interview with the Senior Facilities Manager that within the Rehab Gym on the 2nd floor of the Main Hospital there are several sprinkler heads which were observed to not be located with the required spacing. There are sprinkler heads located in this area with varied spacing distances from 8' to 14' apart. A sprinkler survey should be conducted in this area to determine the proper spacing of the heads based on the effective range of the heads installed.

2) During the complaint survey on May 11, 2016 at approximately 1200 hours it was observed and confirmed through interview with the Senior Facilities Manager that within the fully automatic sprinkler system protected Rehab Gym on the 2nd floor of the Main Hospital there is a Ford pickup truck cab used for patient therapy purposes. This truck cab constitutes an enclosed space that is occupied during therapy sessions by Rehab patients which is not automatic sprinkler system protected.

3) During the complaint survey on May 11, 2016 at approximately 1300 hours it was observed and confirmed through interview with the Senior Facilities Manager that within the Kitchen dish washing area there are a mix of temperature ratings of the quick response automatic sprinkler heads within the same room. There are two ordinary temperature rated QR heads (red bulb) and the remainder are intermediate temperature rated QR heads (green bulb).

Automatic sprinkler systems installed in the health care facility are required to comply with NFPA 13. Failure to protect any area as required has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment, review of the facility's records, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining all water based suppression systems as required by NFPA 25. Failure to maintain these water based suppression systems as required has the potential to cause harm to 50% of the staff and residents.
The findings include:

During the complaint survey on May 1, 2016 between 1300 hours and 1430 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Senior Facilities Manager that the required inspection, testing and maintenance (ITM) of the building standpipe system was overdue. The Senior Facilities Manager was not able to produce any records related to the required annual ITM of the automatic sprinkler system for 2015 or 2016.

The failure to maintain the water based suppression systems as required could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not meeting all requirements of NFPA 101-9.2, by not properly maintaining ventilating equipment. Failure to maintain ventilating equipment as required has the potential to cause harm to 100% of the staff and patients.

The findings include:

During the complaint survey between April 28 and May 11, 2016 through observation of the physical environment and interview with the Senior Facilities Manager it was determined that the laundry dryer exhaust ventilating system was not maintained as required by NFPA 101-9.2 and NFPA 211, Standard for Chimneys, Fireplaces, Vents and Solid Fuel Burning Appliances, Chapter 13-Maintenance and 14-Inspections. Interview with the Senior Facilities Manager confirmed that there was no documentation that the facility has been performing the required annual inspections and cleaning of the laundry dryer exhaust ventilating system. The accidental ignition of accumulated lint and other materials within the dryer exhaust vent created the fire emergency which occurred on April 27, 2016.

Failure to provide required inspections and maintenance of ventilation equipment has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment, review of the facility's documents and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not meeting all requirements of NFPA 96 regarding fire protection for the cooking facilities. Failure to maintain cooking facilities as required has the potential to cause harm to 25% of the staff and patients.

The findings include:

1) During the complaint survey at approximately 1310 hours on May 11, 2016 through a review of the facility's documents, observation of the physical environment, and interview with the Senior Facilities Manager it was determined that the kitchen hood ventilating and extinguishing system was not maintained as required by NFPA 96, 1998 edition as 1 of 9 filter elements was missing.

2) During the complaint survey at approximately 1315 hours on May 11, 2016 through a review of the facility's documents, observation of the physical environment, and interview with the Senior Facilities Manager it was determined that the kitchen hood ventilating and extinguishing system was not maintained as required by NFPA 17A, 1998 edition. The facility has not been performing and documenting the required monthly inspections of the hood extinguishing and ventilating system.

Failure to provide or maintain the required fire protection and ventilation equipment has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide as safe an environment as possible by allowing non-compliant electric portable space heater use in the facility. Allowing non-compliant space heater use in this manner has the potential to cause harm to 10% of the staff and patients.

The findings include:

At approximately 1130 hours on May 11, 2016 during this complaint survey it was observed and confirmed through interview with the Senior Facilities Manager that there was a "glowing coil" type portable electric space heater plugged into a strip outlet with other appliances located in the 3rd floor ADN Office. The heater was removed immediately by facility staff at the direction of this surveyor.

The use of portable electric space heaters of this type and in this manner has the potential to promote harm to occupants of the facility.

K-130- Miscellaneous

NFPA 30, 2000 edition, Flammable and Combustible Liquids Code, 4.6.2 Safety and Security.
NFPA 704, 1996 edition, Standard for Identification of the Hazards of Materials for Emergency Responders

Based on observation of the physical environment and interview with facility staff it was determined that facility staff failed to provide a safe and hazard free environment by allowing flammable or combustible liquids to be stored without required identification or markings. Failure to properly maintain combustible liquid storage has the potential to cause harm to 50% of the staff and residents

The findings include:

During the complaint survey on May 11, 2016 at approximately 1330 hours it was observed and confirmed through interview with the Senior Facilities Manager that the 18000 gallon above ground storage tank for the emergency generator containing diesel fuel does not display the required NFPA 704 identification signs and the required "No Smoking" signs.

The failure to properly identify combustible liquids storage as required has the potential to promote harm to occupants of the building.

Based on review of facility documents, observation of the physical environment, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not fulfilling all emergency electrical systems inspection and testing requirements of NFPA 99 and 110. Failure to properly maintain the emergency generators has the potential to cause harm to 100% of the staff and residents.

The findings include:

During the complaint survey at approximately 1400 hours on May 3, 2016 it was determined through review of the facility's documents and confirmed through interview with the Senior Facilities Manager that the emergency electrical system for the building is not documented as having been inspected and tested as required by NFPA 99 and 110. The emergency electrical system test records do not indicate that the generators are inspected weekly as required.

Failure to properly inspect all components of the emergency electrical system as required has the potential to promote harm to occupants of the facility in the event of a fire or other emergency.

Based on observation of the physical environment and interview with facility staff it was determined that the facility failed to provide a safe and hazard free environment by having non-compliant electrical applications. Failure to maintain electrical wiring and equipment in accordance with this Code has the potential to cause harm to 100% of the staff and residents.

The findings include:

1) During the complaint survey at approximately 1125 hours on May 11, 2016 it was observed and confirmed through interview with the Senior Facilities Manager that in the Department of Nursing on the 3rd floor of the Main Hospital Building there was a toaster oven, a microwave oven, and a coffee maker all plugged into a 15 amp rated multi outlet extension cord that was plugged into a 120 VAC wall outlet.

2) During the complaint survey at approximately 1130 hours on May 11, 2016 it was observed and confirmed through interview with the Senior Facilities Manager that in the ADN Office on the 3rd floor of the Main Hospital Building there was a portable electric space heater plugged into a 15 amp rated multi outlet extension cord that was plugged into a 120 VAC wall outlet.

The use of these items in this manner will create hazards and can result in fire or electrical shock. NFPA 70, National Electrical Code states that extension cords shall not be used as a substitute for permanent wiring, or used to power appliances. NFPA 1, Uniform Fire Code states- 11.1.5; extension cords and flexible cords shall not be affixed to structures, extend through walls, ceilings or floors, or be subject to environmental or physical damage. 11.1.5.3.5. multi-plug adapters, such as multi-plug extension cords, cube adapters, strip plugs, and other devices, shall be listed and used in accordance with their listing.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not insuring that all interior finish components have the proper flame spread rating as required thereby creating a hazardous condition. Failure to insure proper flame spread ratings for interior surfaces in this area has the potential to cause harm to 10% of the staff and patients.

The findings include:

During the complaint survey at approximately 1125 hours on May 11, 2016 it was observed and confirmed through interview with the Senior Facilities Manager that in the Main Hospital 5th floor EEG (room 5W48) the walls of the room are covered with carpet type textile material. This is a non-sprinkler protected area used for patient care and administrative functions. The facility staff was not able to document the flame spread rating for this interior finish material.
(see also A10.3.1)

The failure to insure that materials used for interior finish have the required flame spread ratings can result in a fire occurring which has the potential to promote harm to occupants of the facility.

Based on review of facility documents and interviews with facility staff it was determined that the facility staff failed to follow the required Evacuation and Relocation Plan thereby creating an unsafe environment for the residents. The failure to follow the Evacuation and Relocation Plan as required has the potential to cause harm to 100% of the staff and patients.

The findings include:

During this complaint survey between April 28 and May 11, 2016 it was determined through review of the facility documents, review of the facility evacuation procedures, and interview with the Emergency Preparedness and Safety Officer and the Senior Facilities Manager that the Code requirement to have in effect an Evacuation and Relocation Plan for all supervisory personnel was not complied with. During the fire emergency which occurred on April 27, 2016 an evacuation of the hospital was ordered and communicated throughout the facility by the Operator(s) on duty, who were supervising the transmission and receipt of fire alarm signals and other information, at the direction of the fire alarm monitoring company contracted by the hospital resulting in a complete evacuation of the Main Hospital Building. The Hospital Fire Plan Policy (May 2015 revision) Section V. Evacuation Procedures, states "...If ever needed, the Baltimore City Fire Department, Hospital Command Center, will be responsible for initiating and directing the evacuation process." In addition, the "After Action Report" summarizing the April 27 Code Red fire event provided by the Hospital on May 3, 2016 on page 5 is a statement that "Per policy there are only 3 people who can initiate the full evacuation of the hospital, the VP of Operations, the ADN, and the President,..." There is no reference to this "policy" in the Hospital Fire Plan Policy submitted to this surveyor and this statement conflicts with the Fire Plan.

The failure to implement the facility evacuation plan as required has the potential to create a hazardous environment for residents as the staff may not be familiar with the procedures to follow in the event of a fire or other emergency.

Based on review of facility documents and interviews with facility staff it was determined that the facility staff failed to hold fire drills at random and unexpected times as required by this Code for all three shifts thereby creating an unsafe environment for the residents. The failure to hold fire drills as required has the potential to cause harm to 100% of the staff and residents.

The findings include:

During this complaint survey between April 28 and May 3, 2016 it was determined through review of the facility documents, review of the facility evacuation procedures, and interview with the Chief of Security that the Code requirement to hold fire drills at unexpected times is not in compliance. The facility 2015 and 2016 Fire Drill Schedules are duplicate forms (year to year) which have the fire drills planned in identical fashion for the same Occupancy, Date Scheduled, Drill Time, and Unit each year. The manner in which the facility holds and records fire drills does not confirm that each staff member has participated in a drill that insures they are familiar with procedures to be followed when a fire occurs in their work location.

For example, the Emergency Department is located in the O'Neill Building on the 1st floor and the Unit only had one fire drill per year, during the "Day" shift, in which ED staff responded to a scenario and performed emergency actions under varying conditions, as if a fire was located in the ED. No fire drills are documented as having been held during 2015 in which the "Evening" or "Night" shifts of the ED were made familiar with emergency actions and procedures to be followed in the event of a fire in the ED. The failure to have each staff member on all shifts of each Unit participate in a simulation of emergency fire conditions occurring within in their Unit is similarly illustrated throughout the facility.

The lack of holding and recording fire drills for staff in the required manner has the potential to create a hazardous environment for occupants of the facility as the staff may not be familiar with the procedures to follow in the event of a fire or other emergency.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not providing an approved automatic sprinkler system to all areas of the building as required. Failure to provide complete automatic sprinkler system coverage as required has the potential to cause harm to 10% of the staff and residents.

The findings include:

1) During the complaint survey on May 11, 2016 at approximately 1155 hours it was observed and confirmed through interview with the Senior Facilities Manager that within the Rehab Gym on the 2nd floor of the Main Hospital there are several sprinkler heads which were observed to not be located with the required spacing. There are sprinkler heads located in this area with varied spacing distances from 8' to 14' apart. A sprinkler survey should be conducted in this area to determine the proper spacing of the heads based on the effective range of the heads installed.

2) During the complaint survey on May 11, 2016 at approximately 1200 hours it was observed and confirmed through interview with the Senior Facilities Manager that within the fully automatic sprinkler system protected Rehab Gym on the 2nd floor of the Main Hospital there is a Ford pickup truck cab used for patient therapy purposes. This truck cab constitutes an enclosed space that is occupied during therapy sessions by Rehab patients which is not automatic sprinkler system protected.

3) During the complaint survey on May 11, 2016 at approximately 1300 hours it was observed and confirmed through interview with the Senior Facilities Manager that within the Kitchen dish washing area there are a mix of temperature ratings of the quick response automatic sprinkler heads within the same room. There are two ordinary temperature rated QR heads (red bulb) and the remainder are intermediate temperature rated QR heads (green bulb).

Automatic sprinkler systems installed in the health care facility are required to comply with NFPA 13. Failure to protect any area as required has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment, review of the facility's records, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining all water based suppression systems as required by NFPA 25. Failure to maintain these water based suppression systems as required has the potential to cause harm to 50% of the staff and residents.
The findings include:

During the complaint survey on May 1, 2016 between 1300 hours and 1430 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Senior Facilities Manager that the required inspection, testing and maintenance (ITM) of the building standpipe system was overdue. The Senior Facilities Manager was not able to produce any records related to the required annual ITM of the automatic sprinkler system for 2015 or 2016.

The failure to maintain the water based suppression systems as required could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not meeting all requirements of NFPA 101-9.2, by not properly maintaining ventilating equipment. Failure to maintain ventilating equipment as required has the potential to cause harm to 100% of the staff and patients.

The findings include:

During the complaint survey between April 28 and May 11, 2016 through observation of the physical environment and interview with the Senior Facilities Manager it was determined that the laundry dryer exhaust ventilating system was not maintained as required by NFPA 101-9.2 and NFPA 211, Standard for Chimneys, Fireplaces, Vents and Solid Fuel Burning Appliances, Chapter 13-Maintenance and 14-Inspections. Interview with the Senior Facilities Manager confirmed that there was no documentation that the facility has been performing the required annual inspections and cleaning of the laundry dryer exhaust ventilating system. The accidental ignition of accumulated lint and other materials within the dryer exhaust vent created the fire emergency which occurred on April 27, 2016.

Failure to provide required inspections and maintenance of ventilation equipment has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment, review of the facility's documents and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not meeting all requirements of NFPA 96 regarding fire protection for the cooking facilities. Failure to maintain cooking facilities as required has the potential to cause harm to 25% of the staff and patients.

The findings include:

1) During the complaint survey at approximately 1310 hours on May 11, 2016 through a review of the facility's documents, observation of the physical environment, and interview with the Senior Facilities Manager it was determined that the kitchen hood ventilating and extinguishing system was not maintained as required by NFPA 96, 1998 edition as 1 of 9 filter elements was missing.

2) During the complaint survey at approximately 1315 hours on May 11, 2016 through a review of the facility's documents, observation of the physical environment, and interview with the Senior Facilities Manager it was determined that the kitchen hood ventilating and extinguishing system was not maintained as required by NFPA 17A, 1998 edition. The facility has not been performing and documenting the required monthly inspections of the hood extinguishing and ventilating system.

Failure to provide or maintain the required fire protection and ventilation equipment has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide as safe an environment as possible by allowing non-compliant electric portable space heater use in the facility. Allowing non-compliant space heater use in this manner has the potential to cause harm to 10% of the staff and patients.

The findings include:

At approximately 1130 hours on May 11, 2016 during this complaint survey it was observed and confirmed through interview with the Senior Facilities Manager that there was a "glowing coil" type portable electric space heater plugged into a strip outlet with other appliances located in the 3rd floor ADN Office. The heater was removed immediately by facility staff at the direction of this surveyor.

The use of portable electric space heaters of this type and in this manner has the potential to promote harm to occupants of the facility.

K-130- Miscellaneous

NFPA 30, 2000 edition, Flammable and Combustible Liquids Code, 4.6.2 Safety and Security.
NFPA 704, 1996 edition, Standard for Identification of the Hazards of Materials for Emergency Responders

Based on observation of the physical environment and interview with facility staff it was determined that facility staff failed to provide a safe and hazard free environment by allowing flammable or combustible liquids to be stored without required identification or markings. Failure to properly maintain combustible liquid storage has the potential to cause harm to 50% of the staff and residents

The findings include:

During the complaint survey on May 11, 2016 at approximately 1330 hours it was observed and confirmed through interview with the Senior Facilities Manager that the 18000 gallon above ground storage tank for the emergency generator containing diesel fuel does not display the required NFPA 704 identification signs and the required "No Smoking" signs.

The failure to properly identify combustible liquids storage as required has the potential to promote harm to occupants of the building.

Based on review of facility documents, observation of the physical environment, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not fulfilling all emergency electrical systems inspection and testing requirements of NFPA 99 and 110. Failure to properly maintain the emergency generators has the potential to cause harm to 100% of the staff and residents.

The findings include:

During the complaint survey at approximately 1400 hours on May 3, 2016 it was determined through review of the facility's documents and confirmed through interview with the Senior Facilities Manager that the emergency electrical system for the building is not documented as having been inspected and tested as required by NFPA 99 and 110. The emergency electrical system test records do not indicate that the generators are inspected weekly as required.

Failure to properly inspect all components of the emergency electrical system as required has the potential to promote harm to occupants of the facility in the event of a fire or other emergency.

Based on observation of the physical environment and interview with facility staff it was determined that the facility failed to provide a safe and hazard free environment by having non-compliant electrical applications. Failure to maintain electrical wiring and equipment in accordance with this Code has the potential to cause harm to 100% of the staff and residents.

The findings include:

1) During the complaint survey at approximately 1125 hours on May 11, 2016 it was observed and confirmed through interview with the Senior Facilities Manager that in the Department of Nursing on the 3rd floor of the Main Hospital Building there was a toaster oven, a microwave oven, and a coffee maker all plugged into a 15 amp rated multi outlet extension cord that was plugged into a 120 VAC wall outlet.

2) During the complaint survey at approximately 1130 hours on May 11, 2016 it was observed and confirmed through interview with the Senior Facilities Manager that in the ADN Office on the 3rd floor of the Main Hospital Building there was a portable electric space heater plugged into a 15 amp rated multi outlet extension cord that was plugged into a 120 VAC wall outlet.

The use of these items in this manner will create hazards and can result in fire or electrical shock. NFPA 70, National Electrical Code states that extension cords shall not be used as a substitute for permanent wiring, or used to power appliances. NFPA 1, Uniform Fire Code states- 11.1.5; extension cords and flexible cords shall not be affixed to structures, extend through walls, ceilings or floors, or be subject to environmental or physical damage. 11.1.5.3.5. multi-plug adapters, such as multi-plug extension cords, cube adapters, strip plugs, and other devices, shall be listed and used in accordance with their listing.