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The facility failed to provide a building construction type per code. Findings include:

During the survey, the following is an example of what was observed:
Per observation and interview with the staff, the 1981 single story courtyard enclosure was found to be a Type II (000) structure. A two hour fire wall was not provided separating the different construction between the Type II (000) structure and the five story building. During the review of documentation provided by the facility staff other areas of this facility have been identified not meeting the building construction type for a five story building.

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or



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More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
2000 NFPA 101, 8.2.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following: (1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings. (2) The least fire-resistive type of construction of the connected portions, if no such separation is provided
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include:

During the survey, the following are examples of what was observed:

1. Linen Room door failed to positive latch Labor/Delivery corridor.


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2. Fourth Floor EVS corridor door had penetrating holes at the top of the door.

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2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

During the survey, the following are examples of what was observed.

1. Unsealed penetrations in the smoke barrier, around a water line, and a group of wiring location FDLD One.




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2. The following smoke barriers had unsealed rock wool at the roof deck:
Fifth Floor
a. At the Nurses' Station
Fourth Floor
b. In the Employees Breakroom
c. At the Nurses' Station
First Floor
3. The smoke barrier at the Electrical Room behind Mamo. had two copper pipes that were not sealed at the ends.
5. The smoke barrier at the smoke doors by Cardiopulmonary was observed with the following:
a. One unsealed penetration of a white wire
b. One unsealed penetration of a flex conduit
6. The smoke barrier in the Telephone Room was observed with the following:
a. Two unsealed conduit ends
b. Five unsealed holes in the concrete blocks


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2000 NFPA 101, 8.3.6.1 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.
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The facility failed to maintain smoke doors per code. Findings include:

During the survey, the following is an example of what was observed:
Fifth Floor
The left leaf of the smoke doors at PICU was not self-closing. The self-closing device had pulled out from the smoke door.



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2000 NFPA 101, 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. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following is an example of what was observed:
Fifth Floor
Patient Room 534 was being used for the storage of janitor carts and did not have a self-closing device on the door.

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.


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The facility failed to maintain stairways with at least 2 hour fire resistance rating.

During the survey, the following are examples of what was observed:

Unsealed penetrations around a sprinkler line, in the wall of North Stairwell First Floor.

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LSC 2000, 8.2.5.2, and 7.1.3.2.1 Where this code requires an exit to be separated from other parts of the building the separating construction shall meet the requirments these sections

The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories.




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The facility failed to provide continuous lighting for means of egress. Findings include:

During the survey, the following is an example of what was observed:


The light fixture was inoperable at the exit discharge for the exit from OR. This surveyor observed lights not to be illuminated, at approximatley 5:40pm was dark at this time.

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NFPA 101, 19.2.8 and 7.8.1.2. Illumination of means of egress shall be continuous.



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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following is an example of what was observed:
Documentation of the all facility personnel (nurses, interns, maintenance engineers, and administrative staff) participating in the fire drills was not provided at the time of the survey. Sign in sheets for staff were not complete.

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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.


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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include:

During the survey, the following are examples of what was observed:




1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame.

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission).

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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

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Sprinkler coverage was observed during the survey not adequately provided for the cover all construction type for the facility. Findings include:

During the survey, the following are examples of what was observed:

1. A sprinkler was obstructed by a water line in the boiler room.

2. Bend deflector on a sprinkler in cooler # 2.

3. Escutcheon plate missing on a sprinkler in Nurse manager Labor/Delivery.

4. Sprinkler coverage not provided in the bathroom, Resident Sleep Room, first room on the left.

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1999 NFPA 13, 5-5.5.2.1 and 5-6.5.2.1,

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.


2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

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First Floor
The following locations did not have automatic sprinkler coverage:
5. In the OR Suite - the closet in the Sterilization Room
6. The Breakroom/closet in the Mamo Tech Area
7. The Administrative Closet by the Board Room

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Type Stories
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:

During the survey, the following are examples of what was observed:

1. The fire department connection failed to rotate smoothly.

2. Documentation was not provided for five year replacement of riser gauges.

3. Documentation was not provided for the fifth year internal inspection.

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NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:


(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good conition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

NFPA 101, 9.7.5, and 1999 NFPA 25, 2-2 and Table 2-1.

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The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following are examples of what was observed:

The facility provides two designated smoking areas for the employees, neither were provided with metal self-closing containers for disposing of cigarette butts, or noncombustible ashtrays.

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NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.



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The facility failed to provide proper cooking appliances. Findings include:

During the survey, the following are examples of what was observed:


1. The deep fryer was flush against the stove, thus providing no separation.

2. The card provided for the monthly inspection of the dietary hood extinguishing system was blank.

3. Placard not provided for the K- Extinguisher.

4. Dietary hood in Pelican Grill had loose caulk.

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NFPA 96, 9-1.2.3 A space of 16" shall be provided between the deep fryer and surface flames from adjacent cooking equipment, or have an installed steel or tempered glass baffle plate at a minimum of 8" high.

NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) The system shows no physical damage or condition that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blow-off caps, where provided, are intact and undamaged. (h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

NFPA 96, 2-1.2 Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.



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The facility failed to prohibit portable space heating devices. Findings include:

During the survey, the following are examples of what was observed:
The following areas were observed with portable space heating devices:
Fifth Floor
1. The Unit Supervisor's Office
Second Floor
2. The Nursery
3. The Assistant Nurse Manager's Office (NICU)

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).
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The facility failed to provide documentation of flame resistance on curtains/draperies per code. Findings include:

During the survey, the following are examples of what was observed:
The facility failed to provide documentation of flame resistance on curtains/draperies in the following locations:
1. Administrator's Office
2. Assistant to the Administrator's Office
3. Conference Room
4. C.N.O's Office
5. P.R.'s Office
6. Special Projects Coordinator's Office
7. C.I.S.'s Office

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2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

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During the survey, battery-powered lighting was not observed in OR #1, and OR # 2, for Labor/Delivery.
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1999, NFPA 99, 3-3.2.1.2 (e) Battery-powered emergency lighting units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12 (e).




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The facility failed to provide receptacles for appliances. Findings include:

During the survey, the following are examples of what was observed:


1. A refrigerator, and mircowave were plugged into a surg protector in the Supervisor's office First Floor.
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Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.


2. An extension cord was in use in Anesthesia Attending Call Room First Floor.


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Fifth Floor
3. An extension cord was in use for a Christmas Tree at the fish tank
First Floor
4. An extension cord was in use for a Christmas Tree in the Lobby
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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.


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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following are examples of what was observed:
1. There was no designated times for doing the rounds (every 15 to 30 minutes)
2. Did not include notifying the state authority

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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.


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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following are examples of what was observed:
1. There was no designated times for doing the rounds (every 15 to 30 minutes)
2. Did not include notifying the state authority

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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.