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Based on record review and interview, the facility failed to inspect the emergency generator circuit breaker(s) annually, and exercise the circuit breakers periodically. This deficient practice increased the potential that emergency power would not be supplied to the facility during an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

This deficiency applies to the following buildings: 8 (Clarkson Doctors North/South), 9 (Durham Outpatient), 10 (Lied Transplant Center), 11 (Munroe Meyer Institute), 14 (Specialty Services Pavilion), 15 (Hixson Lied Center), 16 (Clarkson Tower), 17 (University Tower), 18 (Buffet Cancer Center), 19 (Lauritzen Outpatient).

Findings are:
Record review on 9-18-19, at 11:14 am revealed, a preventative maintenance plan was not adopted to inspect annually, and exercise periodically the emergency generator circuit breaker(s).

During an interview on 9-18-19, at 11:14 am, Facility Staff X confirmed the inspection and testing was not implemented.

NFPA Standard:
2012, NFPA 99 , 6.6.4.1.2
Circuitry shall be maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2.1*
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.


27394





27395




41670

K100 A
Based on observation and staff interview, the facility failed to separate hazardous areas with smoke resistive doors. This condition would allow smoke to migrate into the exit corridors. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, from 9:31 am to 12:36 pm revealed:
4th Floor:
1. The open end of a conduit was not sealed in the Elevator Equipment Room 4.14.006.
2. The Elevator Equipment Room Door 4.14.011 was located in a 2-hour fire barrier, according to the facility floor plan. The door did not possess a fire resistance tag to verify the rating of the door.
3. The Mechanical Room Door 4.14.122 was located in a 1-hour fire barrier, according to the facility floor plan. The door did not possess a fire resistance tag to verify the rating of the door.
3rd Floor:
4. The Communication Door 3.14.106 Door did not close/positively latched when self-closed.
5. A 4 inch by 4 inch hole around a conduit in the back wall of the Electrical Room 3.14.107 was not sealed.
2nd Floor:
6. The 3.14.109 Door was located in a 1-hour fire wall, according to the facility floor plan. The door did not possess a fire resistance tag to verify the rating of the door.
1st Floor:
7. The Coffee Area Storage Room Door 1.14.07B was propped open to prevent the door from self-closing at the time of observation. The door did not positively latch when self-closed.

In an interview on 9/11/19, from 9:31 am to 12:36 pm, Facility Staff E acknowledged the findings.

K100 B
Based on observation and staff interview, the facility allowed a non-fire sprinkler related item to be attached to sprinkler piping. This condition had the potential to damage sprinkler components. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 11:59 am revealed a data cable was wrapped around a fire sprinkler pipe in the 2nd Floor Medical Gas 2.14.078 Room.

In an interview on 9/11/19, at 11:59 am, Facility Staff E acknowledged the findings.

NFPA 13, 2010, 9.1.1.7* Support of Non-System Components. Sprinkler piping
or hangers shall not be used to support non-system components.

K100 C
Based on observation and staff interview, the facility failed to use electrical wiring and equipment in a way that would not create a fire. This condition had the potential to cause a fire, or prevent response to a fire. The facility census was 728 with a capacity of 488.
Findings are:

Observation on 9/11/19, from 9:46 am to 12:45 pm revealed:
4th Floor:
1. A microwave was plugged into a power strip, and not directly into a hardwired outlet at the desks in the Ortho Lab.
2. A cart obstructed access to electrical panels in Mechanical Room 4.14.122.
3rd Floor:
3. A coffee maker was plugged into a power strip, and not directly into a hardwired outlet, which was daisy chained into a UPS by Exam Room 18, Door 3.14.068.
1st Floor:
4. The electrical disconnects were obstructed by storage in the MRI Equipment Room 1.14.104.

In an interview on 9/11/19, from 9:46 am to 12:45 pm, Facility Staff E acknowledged the findings.

NFPA 70, 2011, 110.26 Spaces About Electrical Equipment. Access and
working space shall be provided and maintained about all
electrical equipment to permit ready and safe operation and
maintenance of such equipment.
(A) Working Space. Working space for equipment operating
at 600 volts, nominal, or less to ground and likely to
require examination, adjustment, servicing, or maintenance
while energized shall comply with the dimensions of
110.26(A)(1), (A)(2), and (A)(3) or as required or permitted
elsewhere in this Code.

NFPA 70, 2011, 210.23 Permissible Loads. In no case shall the load exceed
the branch-circuit ampere rating. An individual branch
circuit shall be permitted to supply any load for which it is
rated. A branch circuit supplying two or more outlets or
receptacles shall supply only the loads specified according
to its size specified in 210.23(A) through (D) and as summarized
in 210.24 and table 210.24.

K100 D
Based on observation and staff interview, the facility failed to provide fire sprinkler coverage to all areas of a room. This condition would prevent the suppression of a fire. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 12:40 pm revealed a wall partition was added in the southeast corner of Room 1.14.105 on the 1st Floor. A fire sprinkler was not installed inside this area, and a fire sprinkler was not within range to cover the area.

In an interview on 9/11/19, at 12:40 pm, Facility Staff E confirmed the findings.

NFPA 13, 2010, 4.1 Level of Protection. A building, where protected by an
automatic sprinkler system installation, shall be provided with
sprinklers in all areas except where specific sections of this
standard permit the omission of sprinklers.
8.5.5 Obstructions to Sprinkler Discharge.
8.5.5.1* Performance Objective. Sprinklers shall be located so
as to minimize obstructions to discharge as defined in 8.5.5.2
and 8.5.5.3, or additional sprinklers shall be provided to ensure
adequate coverage of the hazard. (See Figure A.8.5.5.1.)

K100 E
Based on observation, record review and staff interview, the facility failed to ensure a facility hot-work permit policy was in place for welding operations in a Business Occupancy. This condition increased the potential for the spread of a fire. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 9:50 am revealed a welder, with cylinders, was set up in the Ortho Lab on the 4th Floor.

Record review on 9/11/19, at 9:50 am revealed the facility did not have a hot-work permit policy in place for welding in the Ortho Lab.

In an interview on 9/11/19, at 9:50 am, Facility Staff E confirmed the findings.

NFPA 101, 2012, 4.6.1.2 Any requirements that are essential for the safety of
building occupants and that are not specifically provided for
by this Code shall be determined by the authority having jurisdiction.
Chapter 41 Welding, Cutting, and Other Hot WorkNFPA 1, 2012, 41.2.1* Management. Management or a designated agent shall be responsible for the safe operations of hot work activity.
[51B:4.1]
41.2.2 Permit Authorizing Individual (PAI). In conjunction
with management, the PAI shall be responsible for the safe
operation of hot work activities. [51B:4.2]
41.2.3 Hot Work Operator. The hot work operator shall
handle equipment safely and use it as follows so as not to endanger
lives and property:
(1) The operator shall have the PAI's approval before starting
hot work operations.
(2) All equipment shall be examined to ensure it is in a safe
operating condition, and, if found to be incapable of reliable
safe operation, the equipment shall be repaired by
qualified personnel prior to its next use or be withdrawn
from service.
(3) The operator shall cease hot work operations if unsafe conditions
develop and shall notify management, the area supervisor,
or the PAI for reassessment of the situation.
[51B:4.3]
41.3.2 Permissible Areas.
41.3.2.1 General. Hot work shall be permitted only in areas
that are or have been made fire safe. [51B:5.2.1]
41.3.2.2 Designated or Permit-Required Areas. Hot work shall
be performed in either designated areas or permit-required
areas. [51B:5.2.2]

K100 F
Based on observation and staff interview, the facility failed to ensure a stair door would remain shut in conditions. This condition would allow smoke or fire to enter the stair tower. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 12:17 pm revealed the 1st Floor Stair Door 1.14.98A did not positively latch when self-closed.

In an interview on 9/11/19, at 12:17 pm, Facility Staff E confirmed the findings.

NFPA 101, 2012, 8.3.3.1 Openings required to have a fire protection rating by
Table 8.3.4.2 shall be protected by approved, listed, labeled
fire door assemblies and fire window assemblies and their accompanying
hardware, including all frames, closing devices,
anchorage, and sills in accordance with the requirements of
NFPA 80, Standard for Fire Doors and Other Opening Protectives,
except as otherwise specified in this Code.

K100 G
Based on observation and staff interview, the facility failed to limit the quantity of propane cylinders indoors. This condition created the potential for a propane flash fire. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/12/19, at 9:09 am in the 1st Floor Receiving revealed two propane cylinders were labeled what appeared to be 30 pounds each, and were separated by 4 inches from each other. The propane cylinders were part of a supply system for Bunsen Burners on the 3rd Floor dental exam rooms and a work room.

In an interview, 9/12/19, at 9:09 am Facility Staff E confirmed the cylinders exceeded 20 pounds each, and were not separated by at least 20 feet.

NFPA 58, 2011, 6.19.7.2 Where cylinders are used in buildings housing educational
and institutional laboratory occupancies for research
and experimental purposes, the following shall apply:
(1) The maximum water capacity of individual cylinders used
shall be 50 lb (23 kg) [nominal 20 lb (9.1 kg) propane
capacity] if used in educational occupancies and 12 lb
(5.4 kg) [nominal 5 lb (2 kg) propane capacity] if used in
institutional occupancies.
(2) If more than one such cylinder is located in the same room,
the cylinders shall be separated by at least 20 ft (6.1 m).
(3) Cylinders not connected for use shall be stored in accordance
with Chapter 8.
(4) Cylinders shall not be stored in a laboratory room.

Based on observation and interview, the facility failed to maintain the two-hour fire barrier separation between buildings. This deficient practice would allow fire and smoke to migrate throughout the facility. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:

1. Observation on 9-12-19 at 10:05 am revealed the 90 minute door in the 2 hour firewall separation from corridor 5699S to corridor 5699E failed to close and latch.
2. Observation on 9-13-19 at 10:08 am revealed the 90 minute doors in the 2 hour firewall separation on 2nd floor between Durham Outpatient Center and the Buffet Cancer Center failed to close and latch.
3. Observation on 9-16-19 at 3:30 pm am revealed the 90 minute doors in the 2 hour firewall separation on 1st floor between Durham Outpatient Center and the Buffet Cancer Center failed to close and latch.
4. Observation on 9-17-19 at 2:01 pm revealed an unsealed 1-inch penetration above the door in the 2 hour separation from corridor 4699R to 4599E.


During interviews on 9-12-19 at 10:05 am, on 9-13-19 at 10:08 am, on 9-16-19 at 3:30 pm, and on 9-17-19 at 2:01 pm, Facility Staff F confirmed the findings.

Based on observation and interview, the facility failed to maintain a 2-hour fire rated separation doors. This deficient practice would allow smoke and fire to migrate between the occupancies. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-10-19 at 4:00 pm revealed:
4th Floor
1. The south 2-hour fire door 4.12.99F/C failed to latch within the doorframe.

During an interview on 9-10-19 at 4:00 pm, Facility Staff A confirmed the findings.

Ground Floor
Observations on 9-11-19 between 10:30 am and 12:16 pm revealed:
2. The undercut to the 2-hour fire rated door 0.12.99E was greater than ¾ inch.
1st Floor
3. The 2-hour fire rated door 1.12.05/99D had an excessive gap between the doors.
6th Floor
4. The 2-hour fire rated door between BCC and DOC failed to latch within the doorframe, the north door drug on the floor

During an interview on 9-11-19 between 10:30 am and 12:16 pm, Facility Staff A confirmed the findings.

Observations on 9-12-19 at 11:05 am:
4th Floor
5. The 2-hour fire rated wall in corridor 4.12.99B above the ceiling at fire door 4.12.99C/B, appeared to have an approximate 2-inch unsealed penetration around the top and sides.

During an interview on 9-12-19 at 11:05 am, Facility Staff A confirmed the findings.

Based on observation and interview, the facility failed to maintain a 2-hour fire separation doors. This deficient practice would allow smoke and fire to migrate between the occupancies. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-16-19 at 1:54 pm and 2:13 pm revealed:
4th Floor
1. The 2-hour fire door 4899R between Hixson Lied and Clarkson Tower had an excessive gap between the doors.
2. The 2-hour fire door 4899J between Hixson Lied and University Tower had an excessive gap between the doors.

During an interview on 9-16-19 at 1:54 pm and 2:13 pm, Facility Staff A confirmed the findings.

Based on observations and interview, the facility failed to assure doors in the means of egress were not capable of locking. This deficient practice would delay egress and cause confusion and panic in the event of an emergency, facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-11-19 at 11:18 am revealed:
Ground Floor
1. 4 of 4 Main Entrance doors were equipped with keyed thumb locks.

During an interview on 9-11-19 at 11:18 am, Facility Staff A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain an exit door so excessive force was not required to unlatch the door, and set the door in motion. This condition had the potential to prevent the evacuation of occupants during an emergency. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/16/19, at 2:10 pm revealed the panic hardware stuck when pressure was applied to the 1st Floor Exit Door by 18216, which required excessive force to unlatch the door and set it into motion.

In an interview on 9/16/19, at 2:10 pm, Facilities Staff E acknowledged the latch stuck, and the door was difficult to open.

NFPA 101, 2012, 7.2.1.4.5 Door Leaf Operating Forces.
7.2.1.4.5.1 The forces required to fully open any door leaf
manually in a means of egress shall not exceed 15 lbf (67 N) to
release the latch, 30 lbf (133 N) to set the leaf in motion, and
15 lbf (67 N) to open the leaf to the minimum required width,
unless otherwise specified as follows:
(1) The opening forces for interior side-hinged or pivoted swinging
door leaves without closers shall not exceed 5 lbf
(22 N).
(2) The opening forces for existing door leaves in existing
buildings shall not exceed 50 lbf (222 N) applied to the
latch stile.
(3) The opening forces for horizontal-sliding door leaves in
detention and correctional occupancies shall be as provided
in Chapters 22 and 23.
(4) The opening forces for power-operated door leaves shall
be as provided in 7.2.1.9.

Based on observation and interview, the facility failed to maintain means of egress free of obstructions for instant use in an emergency. This deficient practice could delay exiting or block the path of egress from the facility. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) Observations on 09/11/19 at 12:46 P.M. revealed the exit door at the bottom of west exit stairs in Clarkson Doctors North building had collection carts for combustibles obstructing the egress path to the exit door.

2) During an interview on 09/11/19 at approximately 12:46 P.M., Team # 4 Facility Staff A confirmed all the findings.

Based on observation and interview, the facility failed to maintain clear and unobstructed exits. This deficient practice would impede the full use of the exit corridor and delay exiting during an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-10-19 at 1:39 pm and 3:22 pm revealed:
7th Floor
1. A Cardinal Health Cart stored in the elevator lobby 7.12.99B/C.
Ground Floor
2. The chairs next to the fireplace area encroached the egress path and were not affixed.

During an interview on 9-10-19 at 1:39 pm and 3:22 pm, Facility Staff A confirmed the findings

NFPA Standard:
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. 2012 NFPA 101, 7.1.10.1

NFPA Standard:
2012 NFPA 101, 19.2.3.4*
Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2)*Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in.(1525 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c)*The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
(5)*Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f)*The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or
the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8.

Based on observation and interview, the facility failed to maintain clear and unobstructed exits. This deficient practice would impede the full use of the exit corridor and delay exiting during an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-16-19 at 1:39 pm and 2:22 pm revealed:
4th Floor
1. Six rolling dust carts, EVS cart, two desks, four large rolling carts, trash cans, ladder, numerous cardboard boxes stored in corridor 48208, outside elevator lobby.
2. Three cribs and two incubators stored in corridor 4899Q.

During an interview on 9-16-19 at 1:39 pm and 2:22 pm, Facility Staff A confirmed the findings

NFPA Standard:
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. 2012 NFPA 101, 7.1.10.1

Based on observation and interview, the facility failed to have exits and means of egress free of obstruction and readily identifiable as exits. This deficient practice allows for the means of egress and the exit itself to be misidentified or unusable by patients and staff in the event of a fire or other emergency.

Findings are:
1. Observation on 9/12/19 at 1:46 p.m. revealed the glass exit doors on the East wall of the Workout Area #1006B were painted to blend into the walls and curtains around the exit doors.
2. Observation on 9/12/19 at 1:57 p.m. revealed an electric bike being stored and charged in the Northeast exit stairwell.

During an interview at the time of the findings, all three members from Team G confirmed the findings.

Based on observation and interview, the facility failed to provide means of egress that were clear and free of obstruction. This deficient practice has the potential to block the egress path for patients and staff from the Optical Store.

Findings are:
1. Observation on 9/13/19 at 10:05 a.m. revealed the exit corridor #1002E from the Optical Store being used as a storage corridor.

During an interview at the time of the finding, all three members from Team G confirmed the finding.

Based on observation and interview, the facility failed to maintain clear and unobstructed exits and proper signage of Exits. This deficient practice would impede the full use of the exit corridor and delay exiting during an emergency. The facility had a capacity of 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-11-19 at 4:58 pm revealed:
5th floor
1. University Tower, Unit 2, Room 5299F items were being stored in the room leading to the exit stair tower.

During an interview on 9-11-19 at 4:58 pm, Facility Staff C confirmed the exiting obstructions.

Observation on 9-16-19 at 1:47 pm revealed:
2nd Floor
2. University Tower, Unit 4, Room 2485 (Pharmacy), the second exit corridor was obstructed by carts protruding into the required 44 inch egress width.

During an interview on 9-16-19 at 1:47 pm, Facility Staff C confirmed the exiting obstruction.


NFPA Standard:
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. 2012 NFPA 101, 7.1.10.1
No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2012 NFPA 101, 7.1.10.2.1

Based on observation and staff interview, the facility failed to maintain exit corridors free and clear of obstructions by not ensuring all marked exit doors swing in the direction of egress. This deficient practice would delay egress. This would affect all occupants in 1 of 2 smoke compartments (Lied Transplant Center 2nd floor east). The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-11-2019 at 10:34 AM revealed the following:

Lied Transplant Center 2nd floor Comparative Medicine secondary exit access had two marked exit doors (#2799M) that swing in the opposite direction of egress travel.

During an interview on 9-11-2019 at 10:34 AM, Facility Staff B confirmed the finding.

Based on observation and interview, the facility failed to post signage to operate delayed egress locks on a magnetically locked exit doors. This deficient practice would delay egress during an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-16-19 at 2:11 pm revealed:
4th Floor
1. The magnetically locked exit door 4899R/38203 did not have delayed egress operating instructions signage installed on the door.

During an interview on 9-16-19 at 2:11 pm, Facility Staff A confirmed the lack of delayed egress signage.

NFPA Standard:
2012 NFPA 101, 7.2.1.6.1.1
(4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1?8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:
PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS



27395

Based on observation and staff interview, the facility failed to post instructions to operate a delayed egress lock, and to remove components of an access control lock that were no longer in use. This condition would affect the evacuation of occupants during an emergency. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/16/19, from 3:48 pm to 3:58 pm revealed:
1. The magnetically locked 1st Floor 1899V Exit Doors did not have delayed egress operating instructions signage installed on the door.
2. The magnetically locked 1st Floor exit doors by Trauma in corridor 1839U/18291 had a motion sensor, and a push to exit button installed that were no longer in use.

In an interview on 9/16/19, at 3:48 pm, Facilities Staff E acknowledged the findings.

NFPA 101, 2012, 7.2.1.6.1 Delayed-Egress Locking Systems.
7.2.1.6.1.1 Approved, listed, delayed-egress locking systems
shall be permitted to be installed on door assemblies serving
low and ordinary hazard contents in buildings protected
throughout by an approved, supervised automatic fire detection
system in accordance with Section 9.6 or an approved,
supervised automatic sprinkler system in accordance with Section
9.7, and where permitted in Chapters 11 through 43, provided
that all of the following criteria are met:
(4)*A readily visible, durable sign in letters not less than 1 in.
(25 mm) high and not less than 1?8 in. (3.2 mm) in stroke
width on a contrasting background that reads as follows
shall be located on the door leaf adjacent to the release
device in the direction of egress:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on observation and interview, the facility failed to post signage to operate delayed egress on a magnetically locked exit doors. This deficient practice would delay egress during an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-11-19 between 10:17 am and 3:58 pm revealed:
Ground Floor
1. The magnetically locked exit door 0.12.99J did not have delayed egress operating instructions signage installed on the door.
1st Floor
2. The magnetically locked exit door 1.12.14 did not have delayed egress operating instructions signage installed on the door.
3. The magnetically locked exit door 1.12.99/220A did not have delayed egress operating instructions signage installed on the door.
2nd Floor
4. The magnetically locked exit door 2.12.99H/F did not have delayed egress operating instructions signage installed on the door.
6th Floor
5. The magnetically locked exit door 6.12.99B did not have delayed egress operating instructions signage installed on the door.

During an interview on 9-11-19, between 10:17 am and 3:58 pm, Facility Staff A confirmed the lack of delayed egress signage.

NFPA Standard:
2012 NFPA 101, 7.2.1.6.1.1
(4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1?8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:
PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS

Based on observation and interview, the facility failed to provide exit stairwells that were separated from the remainder of the building by self closing and latching doors. This deficient practice has the potential to allow smoke and heat spread to multiple floors of the building blocking off egress paths.

Findings are:
1. Observation on 9/13/19 at 9:25 a.m. revealed the 3rd Floor Stairwell door #3098A did not self close and latch.
2. Observation on 9/13/19 at 9:52 a.m. revealed the 2nd Floor Stairwell door #2098A did not self close and latch.

During an interview at the time of the findings, all three members from Team G confirmed the findings

Based on observation and interview, the facility failed to maintain an obstacle-free path of egress by allowing furniture to be stored in an exit stairwell. This deficient practice would delay the egress of occupants trying to use the stairwell in an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:

Observation of 9-17-19 at 9:58 am revealed 2 office chairs and an office table stored in stairwell number 0699C.

During an interview on 9-17-19 at 9:58 am, Facility Staff F confirmed the findings.

Based on observation, record review, and staff interview, the facility used the Emergency Department (ED) as a suite, but failed to designate/design the area as one. This condition would affect exiting and patient safety. The facility census was 728 with a capacity of 488.
Findings are:

Record review of facility floor plans on 9/16/19, at 3:30 pm revealed the ED was not designated/designed as a suite.
Observation on 9/16/19, at 3:30 pm of the ED revealed:
1. The sliding doors to Trauma 18256 did not have positive latching hardware installed in the corridor doors.
2. EMS 18223 was open to the exit corridor, and did not have smoke detection installed in the space.
3. Patients were stationed on wheeled beds throughout the exit corridors in the ED, due to lack of patient rooms, which obstructed the exit corridors.

In an interview on 9/16/19, at 3:30 pm, Facilities Staff E acknowledged the findings.

Based on observation and staff interview, the facility failed to provide emergency lighting of at least 1½-hour duration. This deficient practice would slow or prevent evacuation of occupants during an emergency under loss of normal power. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) The emergency lighting unit in the Clarkson Doctors North, third floor Surgery Room 31128 unit did not work when tested.

2) The emergency lighting unit in the Clarkson Doctors South, sixth floor room 61080 unit did not work when tested.

3) During an interview on 9-11-19 between 9:00 A.M. and 5:45 P.M., Team # 4 Facility Staff A confirmed all the findings.

Based on observation and interview, the facility failed to provide emergency lighting in the Large Auditorium. This deficient practice would cause confusion and delay egress during an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-11-10, at 10:28 am revealed, that when lights were turned to the off position in the ground floor Auditorium, no lights remained on and no emergency lighting was provided. A sign provided in the room listed the occupant load at 140.

During an interview on 9-11-19, at 10:28 am, Facility Staff A confirmed the lack of emergency lighting.

Based on observation and staff interview, the facility failed to maintain a battery powered emergency light. This condition allowed for the failure of emergency/task lighting. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/16/19, at 2:32 pm revealed a light in the battery backup light ballast was burnt out in OR 2, 28246.

In an interview on 9/16/19, at 2:32 pm, Facilities Staff E confirmed the light was burnt out.

Based on observations and staff interview, the facility failed to ensure interior emergency lighting fixtures were maintained and in working condition. This deficient practice would slow or prevent evacuation in the event of a loss of power, which would affect patients on 1 of 14 floors. Facility census was 488 and licensed for 728 at the time of the survey.

Findings are:
Observations on 9-16-2019 at 2:25 PM revealed the following:

1st Floor
Emergency lighting failed to activate in North Data Center IT room 18101 when the test button was pressed.

During an interview on 9-16-2019 at 2:25 PM Facility Staff I confirmed the emergency light failed.

Based on observation and interview, the facility failed to provide visible exit signs. This deficient practice had the potential for delay or to cause confusion during an emergency as occupants would be unable to locate exits. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-10-19 between 1:10 pm and 2:34 pm revealed:
8th Floor
1. While standing in south side corridor looking west, no exit sign was visible to direct occupants to the exit.
6th Floor
2. While standing in south side corridor looking west not exit sign was visible to direct occupants to the exit.

During an interview on 9-10-19 between 1:10 pm and 2:34 pm, Facility Staff A confirmed the lack of exit signage.

Observations on 9-11-19 at 12:03 pm and 1:33 pm revealed:
2nd Floor
3. While standing in corridor 2.12.99A looking south, no exit sign was visible to direct occupants to the exit.
1st Floor
4. While standing in corridor outside room 1.12.246 looking west the facility failed to provide an exit sign with a chevron to indicate direction of egress.

During an interview on 9-11-19 between 12:03 pm and 1:33 pm, Facility Staff A confirmed the lack of exit signage.

Based on observation and interview, the facility failed to have all means of egress readily marked by approved exit signage. This deficient practice allows the path the egress, in an emergency, to become confusing to patients and staff of the clinic.

Findings are:
Observation on 9/12/19 at 1:10 p.m. revealed that an exit sign was needed in the corridor by room #1012, leading people to the North exit corridor.

During an interview at the time of the finding, all three members from Team G confirmed the finding.

Based on observation and staff interview, the facility failed to ensure exit signage was visible in two separate directions in a corridor in the Emergency Department. This condition would prevent occupants from identifying a set of doors within a required means of egress as an exit. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/16/19, at 3:58 pm revealed an exit sign was not visible when looking towards the double doors by Trauma in Corridor 18399u/18291. A dead end of 38 feet was measured from centerline of the nearest corridor to the doors, which confirmed the doors were within the required means of egress.

In an interview on 9/16/19, at 3:58 pm, Facilities Staff E confirmed exit signage was not installed above the doors.

Based on observation and interview, the facility failed to provide visible exit signs. This deficient practice had the potential for delay or to cause confusion during an emergency as occupants would be unable to locate exits. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-17-18 between 1:00 pm and 3:10 pm revealed the following:

2nd Floor
1. University Tower, Unit 4, stair tower failed to have an exit sign in the tower at the 2nd floor exit to ground level.

3rd Floor
2. University Tower, Unit 4, at the south end of 3499G hallway failed to have an exit sign indicating a second egress from the hallway.

During an interview on 9-17-18 between 1:00 pm and 3:10 pm, Facility Staff C confirmed the findings.

Based on observation and interview, the facility failed to maintain the proper use of EXIT signage by having locks installed on doors that the EXIT signs directed occupants to use. This deficient practice would cause confusion and panic in the event of an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-17-19 between 9:12 am and 9:25 am revealed:
1. An exit sign in corridor 5699O directed occupants to a locked door in the middle of the corridor.
2. An exit sign in corridor 4699F directed occupants to a locked door in the middle of the corridor.
3. An exit sign in corridor 1699T directed occupants to a locked door in the middle of the corridor.

During interviews on 9-17-19 between 9:12 am and 9:25 am. Facility Staff F confirmed the findings.

Based on observation and staff interview, the facility failed to ensure a door to a stair would positively latch. This condition would allow smoke or fire to enter the stair tower. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/16/19, at 3:10 pm revealed the 2898J Stair Door did not positively latch when self-closed.

In an interview on 9/16/19, at 3:10 pm, Facility Staff E confirmed the findings.

NFPA 101, 2012, 8.3.3.1 Openings required to have a fire protection rating by
Table 8.3.4.2 shall be protected by approved, listed, labeled
fire door assemblies and fire window assemblies and their accompanying
hardware, including all frames, closing devices,
anchorage, and sills in accordance with the requirements of
NFPA 80, Standard for Fire Doors and Other Opening Protectives,
except as otherwise specified in this Code.

Based on observation and interview, the facility failed to assure that fire separation doors latched within the door frame. This deficient practice would allow fire, smoke, and gases to migrate into the exit corridor and into an atrium.

Finding are:

Observations on 9-18-19 at 11:35 am revealed the right leaf (when standing in corridor) of the double fire doors on the first floor to the Pain Clinic from the atrium failed to latch.

During an interview on 9-18-19 at 11:35 am, Facility Staff H confirmed the finding.

Based on observation and interview, the facility failed to maintain the fire separation between multiple floors. This deficient practice would allow smoke, gases and fire to travel between floors. The facility has the capacity for 728 beds, with a census of 488 on the day of survey.

Findings are:

Observations on 9-12-19 between 2:41 pm and 4:20 pm revealed:
1. A 9 inch hole had been broken through the 2 hour shaft wall in room 46111 southwest corner.
2. The automatic closer on the door to room 3645A (front desk) had been disconnected.
3. The double doors separating corridor 3699T and corridor 3699A failed to close and latch because of the coordinator.

During interviews on 9-12-19 between 2:41 pm and 4:20 pm, Facility Staff F confirmed the findings.

Based on observations and staff interview, the facility failed to maintain the required fire rated construction enclosing vertical openings between floors. This deficient practice would cause fire, smoke and gases to move vertically from floor to floor, which would affect patients on all 14 floors. Facility census was 488 and licensed for 728 at the time of the survey.

Observation and staff interview on 9-12-2019 at 3:05 PM revealed the following:

2nd Floor
1. An approximate 4" unsealed conduit penetration into a 2 hour fire rated vertical shaft was located above ceiling on 2nd floor at door 2899H east side.

During an interview on 9-12-2019 at 3:05 PM Facility Staff I confirmed the shaft penetration.

Observation and staff interview on 9-16-2019 between 3:12 PM and 3:45 PM revealed the following:

1st Floor
2. 90 minute fire rated stair door 1898A failed to latch.

During an interview on 9-16-2019 between 3:12 PM and 3:45 PM Facility Staff I confirmed the shaft conditions.

Based on observation and interview, the facility failed to assure the doors to hazardous areas would close and latch within the doorframe, failed to assure doors were not held open and that hazard rooms were smoke tight. These deficient practices would allow fire, smoke and gases to migrate into the exit corridor. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-16-19 between 2:16 pm and 2:56 pm revealed:
4th Floor
1. 1-hour fire rated doors 48212 had an excessive gap between the doors.
2. 1-hour fire rated doors 4899P/4899N failed to provide latching devices.
3. 1-hour fire rated doors 4899AA/4899EE failed to provide latching devices.
4. 1-hour fire rated door 48275 equipped with self-closing device failed to close and latch within the doorframe.
5. 1-hour fire rated door 48272 equipped with self-closing device failed to close and latch within the doorframe.

During an interview on 9-16-19 between 2:16 pm and 2:56 pm, Facility Staff A confirmed findings.


27395

Based on observation and staff interview, the facility failed to separate hazardous areas with smoke resistive doors. This condition would allow smoke to migrate into the exit corridors. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/16/19, from 1:50 pm to 2:37 pm revealed:
1. The 1st Floor Soiled Utility Door 18309 did not positively latch when self-closed.
2. The 1st Floor OR 17/Clean Core door did not positively latch when self-closed.
3. The 2nd Floor Soiled Utility Door 28275 did not positively latch when self-closed.

In an interview on 9/16/19, from 1:50 pm to 2:37 pm, Facility Staff E acknowledged the findings.

Based on observation and interview, the facility failed to assure the doors to hazardous areas would close and latch within the doorframe, failed to assure doors were not held open, and that hazard rooms were smoke tight. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridor. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-10-19 between 2:00 pm and 4:48 pm revealed:
7th Floor
1. Trash can holding door 7.12.26 open.
5th Floor
2. Electrical room 5.12.22A door equipped with a self-closing device failed to latch.
3. Family Laundry/Shower 5.12.99B door equipped with a self-closing device failed to latch.
4th Floor
4. The Storage room 4.12.38A door equipped with a self-closing device failed to latch.
1st Floor
5. MRI 1 Mechanical room 1.12.20 door failed to latch within the doorframe.
6. MRI 2 Mechanical room 1.12.24 room failed to be smoke tight, the west wall failed to go to deck.
7. The Communication room 1.12.120 door equipped with a self-closing device failed to latch.

During an interview on 9-10-19 between 2:00 pm and 4:48 pm, Facility Staff A confirmed findings.

Observation on 9-11-19 between 10:13 am and 4:25 pm revealed:
1st Floor
8. Room 1.12.246 door equipped with a self-closing device failed to latch.
9. Room 1.12.245 was used for soiled linen storage, the door was not smoke tight and failed to provide latching device.
Ground Floor
10. The Communication room 0.12.24 door equipped with a self-closing device failed to latch.
11. Unsealed penetration at cable tray in room 0.12.24.
12. Pantry door 0.12.121 equipped with a self-closing device was held open with a metal wedge.
13. Serving area in the Buffet Dining room door .12.131A equipped with a self-closing device was held open with a metal wedge.
14. Serving area in the Buffet Dining room door .12.131A equipped with a self-closing device failed to latch within the doorframe.
2nd Floor
15. The Storage room door 2.12.289 equipped with a self-closing device, failed to latch within the doorframe.
16. The EVS door 2.12.280 equipped with a self-closing device, failed to latch within the doorframe.
17. Room 2.12.73 1 hour fire rated double doors equipped with self-closing device failed to latch within the doorframe.
18. The 1-hour fire rated doors 2.12.266 had an excessive gap between the doors.
19. The door 2.12.271B into OR storage from OR 23, equipped with self-closing device failed to latch within the doorframe.
20. The door 2.12.266 into OR storage from OR 25, equipped with self-closing device failed to latch within the doorframe.
21. Penetration in the wall above the door in room 2.12.291.
22. The Soiled linen door 2.12.251 equipped with self-closing device failed to latch within the doorframe.
23. Room 2.12.157 fire rated door equipped with a self-closing device failed to latch within the doorframe.

During an interview on 9-11-19 between 10:13 am and 4:25 pm, Facility Staff A confirmed findings.

Based on observation and interview, the facility failed to provide smoke separation from hazardous rooms and the remainder of the building. These deficient practices have the potential to allow smoke to travel from the hazardous room into the exit corridors of the clinic affecting all patients and staff in the clinic.

Findings are:
1. Observation on 9/12/19 at 9:16 a.m. revealed an unsealed gap around the sprinkler piping, above the door, in the main electrical room.
2. Observation on 9/12/19 at 9:20 a.m. revealed an unsealed gap around electrical conduit, above the door to room #1.0.62

During an interview at the time of the findings, all three members from Team G confirmed the findings.

Based on observation and interview, the facility failed to have hazardous areas separated from the remainder of the building by smoke partitions. This deficient practice has the potential to allow smoke to spread from the hazardous room to the exit corridor blocking egress for patients and staff.

Findings are:
1. Observation on 9/13/19 at 9:54 a.m. revealed penetrations in the walls of the Communication Room #2021.

During an interview at the time of the finding, all three members from Team G confirmed the finding.

Based on observation and interview, the facility failed to provide smoke separation from hazardous rooms and the remainder of the building. This deficient practice has the potential to allow smoke to spread out of these hazardous rooms and into the exit corridor blocking egress for patients and staff.

Finding are:
1. Observations on 9/12/19 at 1:41 p.m. revealed penetrations throughout the Mechanical Room #1014.
2. Observations on 9/12/19 at 2:03 p.m. revealed office #3016 being used as a storage room with large amounts of combustible paper with no self closing device on the door.

During an interview at the time of the findings, all three members from Team G confirmed the findings.

Based on observation and staff interview, the facility failed to separate a hazardous area with a smoke resistive door. This condition would allow smoke to migrate into the exit corridors. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 11:33 am revealed the 2nd Floor Instrument/Supply Room Door 2.14.084.A was not equipped with a self-closure.

In an interview on 9/11/19, at 11:33 am, Facility Staff E acknowledged the findings.

Based on observation and interview, the facility failed to provide self-closing doors to hazardous areas. This deficient practice would allow fire, smoke, and gases to migrate into the exit corridor.

Findings are:

Observations on 9-18-19 at 1:19 pm revealed that storage room 2057D door failed to be self-closing

During an interview on 9-18-19 at 1:19 pm, Facility Staff H confirmed the findings

Based on observation and interview, the facility failed to provide self-closing doors to hazardous areas. This deficient practice would allow fire, smoke, and gases to migrate into the exit corridor.

Findings are:
Observations on 9-11-19 between 10:05 am and 10:15 am revealed:
1. Storage room 1012 door failed to be self-closing
2. Storage room 1028 door failed to be self-closing
3. Storage room 1039 door failed to be self-closing

During an interview on 9-11-19 between 10:05 am and 10:15 am, Facility Staff H confirmed the findings

Based on observation and interview, the facility failed to provide self-closing doors to hazardous areas. This deficient practice would allow fire, smoke, and gases to migrate into the exit corridor.

Findings are:
Observations on 9-11-19 between 1:24 pm and 1:25 pm revealed:
1. Storage room 1039 door failed to be self-closing
2. Storage room 1038 door failed to be self-closing

During an interview on 9-11-19 between 1:24 pm and 1:25 pm, Facility Staff H confirmed the findings

Based on observation and interview, the facility failed to provide self-closing doors to hazardous areas. This deficient practice would allow fire, smoke, and gases to migrate into the exit corridor.
Findings are:
Observations on 9-18-19 between 10:24 am and 10:31 am revealed:
1. Storage room 1028 door failed to be self-closing
2. Storage room 1046 door failed to be self-closing
3. Storage room 1045 door failed to be self-closing
During an interview on 9-18-19 between 10:24 am and 10:31 pm, Facility Staff H confirmed the findings.

Based on observation and staff interview, the facility failed to separate a hazardous area. This condition would allow fire and smoke to migrate into the adjacent surgery recovery area.


Findings are:


Observation on 9-11-19, at 2:06 pm revealed the "Bay 5" in the PACU area was used for storage of combustible materials with only a privacy curtain separating the space.


In an interview on 9-11-19, at 2:06 pm, Facility Staff H acknowledged the findings.

Based on observation and interview, the facility failed to assure the door to a hazardous area would close and latch within the doorframe, and failed to separate hazardous areas by smoke resistive partitions. These deficient practices would allow fire, smoke and gases to migrate into the exit corridor. . The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:

Observation on 9-11-19 between 11:19 am and 4:03 pm revealed:

7th Floor
1. University Tower, Unit 2, Rm 7204 being used for storage failed to be provided with a self-closing device.

5th Floor
2. University Tower, Unit 4, Rm 5477 being used for storage failed to be provided with a self-closing device.

During an interview on 9-11-19 between 11:19 am and 4:03 pm, Facility Staff C confirmed the doors did not have self-closing devices installed.

Based on observation and staff interview, the facility failed to separate hazardous areas from the remainder of the building by allowing unsealed penetrations in walls. This deficient practice would allow smoke and gases to migrate into the exit corridor. This would affect all building staff on the basement level of Clarkson Tower. The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-16-2019 between 2:03 PM and 2:21 PM revealed the following:

1) Clarkson Tower Basement gas room #B899H had an unsealed 1-inch conduit penetration in the wall.
2) Clarkson Tower Basement locker hallway by doors #B899C had an unsealed 1-inch conduit penetration in the wall above locker #49.
3) Clarkson Tower Basement storage room #B823 had an unsealed pipe penetration greater than 1-inch in the wall.

During interviews on 9-16-2019 between 2:03 PM and 2:21 PM, Facility Staff B confirmed the findings.


41670

Based on observation and staff interview, the facility failed to ensure all hazardous areas were separated by smoke resistant partitions. This deficient practice could cause smoke and gases to migrate into the corridor, which would affect patients on 2 of 14 floors. Facility census was 488 and licensed for 728 at the time of the survey.

Finding are:
Observations on 9-12-2019 at 10:50 AM revealed the following:

4th Floor
1. Door to Cath Lab storage room 4841 failed to close and securely latch into the frame under its own power.

During an interview on 9-12-2019 at 10:50 AM Facility Staff I confirmed that the door failed to close.

Observations on 9-16-2019 at 3:45 PM revealed the following:

Ground Floor
2. Laundry chute discharge room 8116 the 90 minute fire door from discharge room to corridor failed to latch.

During an interview on 9-16-2019 at 3:45 PM Facility Staff I confirmed that the door failed to latch.

Based on observation and staff interview, the facility filed to separate hazardous areas from the remainder of the building by allowing doors to not seal, damage holes in walls, and unprotected penetrations. This deficient practice would allow smoke and hot gases to migrate into the exit corridor. This would affect building occupants on 4 of 15 floors (2nd floor, 3rd floor, 6th floor, and 7th floor) of Lied Transplant Center. The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-11-2019 between 11:19 AM and 12:26 PM revealed the following:

1) Lied Transplant Center 2nd floor electrical room #2753 had a 1-inch conduit above the room door that was not sealed.
2) Lied Transplant Center 3rd floor room #3731 had an unsealed conduit penetration above the room door.

During interviews on 9-11-2019 between 11:19 AM and 12:26 PM, Facility Staff B confirmed the findings.

Observations on 9-12-2019 between 9:35 AM and 9:52 AM revealed the following:

1) Lied Transplant Center 6th floor oxygen storage room #6733 corridor door did not seal within the door frame.
2) Lied Transplant Center 7th floor EVS room #7705 had a 3-inch by 36-inch hole in the wall due to damage from the cleaning cart.

During interviews on 9-12-2019 between 9:35 AM and 9:52 AM, Facility Staff B confirmed the findings.

Based on observation and interview, the facility failed to maintain the 1-hour separation, and to assure the door to a hazardous area would close and latch within the doorframe. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridors. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-12-19 between 10:21 am and 2:30 pm revealed:
1. The door to storage room number 5693 failed to self-close and latch.
2. An unsealed half-inch gap around the one-inch yellow conduit on the north wall of electrical room number 46109.

Observations on 9-13-19 between 8:55 am and 10:58 am revealed:
1. An unsealed 1-inch hole in the north wall above the door of room number 36110.
2. An unsealed penetration in the south wall of electrical room number 26102.
3. Unsealed penetrations around the potable water pipe and around the condensate pipe in the southwest wall of mechanical room number 26107.

Observation on 9-16-19 at 3:53 pm revealed the door to room 1699AA failed to self-close and latch.

During interviews on 9-12-19 between 10:21 am and 2:30 pm, on 9-13-19 between 8:55 am and 10:58 am, and on 9-16-19 at 3:53 pm, Facility Staff F confirmed the findings.

Based on observation and staff interview, the facility failed to provide smoke resistant enclosures for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke and gases to migrate into the exit corridors, affecting approximately 30 occupants on 1 of 5 floors. (4th floor)

Finding are:
Observation and staff interview on 9-11-2019 at 9:55, 10:05 and 10:10 AM revealed the following:

1. Data room 4036 had five ¾" and one 2" open penetrations in the smoke separation walls.
2. Janitorial room 4013 had three 2" open penetrations in the smoke separation wall.
3. IT room 4014 had a 3"x 3" open penetration above the door in the smoke separation wall.

During interview on 9-11-2019 at 10:10 AM Facility Staff I confirmed the open penetrations.

Based on observation and interview, the facility failed to provide fire-extinguishing protection over a hamburger fryer. This deficient practice would allow a fire to spread and become uncontrollable. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) Observations on 09/11/19 at approximately 11:30 A.M. in the Clarkson Doctors North revealed the facility was using a Wolf Gang Puck fryer appliance in breakroom 11135 without the protection of a hood exhaust system and required fire-extinguishing system.

2) During an interview on 09/11/19 at approximately 11:30 A.M., Team # 4 Facility Staff A confirmed all the findings.

Based on observation and interview the facility failed to maintain the wheeled appliances under the kitchen exhaust hood to be in the same location after cleaning and failed to provide a shield for the deep fat fryer from the adjacent flame appliance. This deficient practice would alter the protection coverage of the fire suppression system and could potentially delay extinguishment of a fire under the kitchen exhaust hood. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-11-19 at 11:14 am revealed:
1. The wheeled appliances under the kitchen hood failed to provide a method to ensure that they would be placed in the approved location after cleaning in room 0.12.131.
2. The deep fat fryer failed to provide a shield from the adjacent flame appliance.
3. Hood appeared to be covered with an accumulation of grease.

During an interview on 9-11-19, at 11:14 am, Facility Staff A confirmed the findings.

NFPA Standard:
An approved method shall be provided that will ensure that the appliance is returned to an approved design location. 2001 NFPA 96, 12.1.2.3.1

12.1.2.4 All deep fat fryers shall be installed with at least a 406-mm (16-in.) space between the fryer and surface flames from adjacent cooking equipment.
12.1.2.5 Where a steel or tempered glass baffle plate is installed at a minimum 203 mm (8 in.) in height between the fryer and surface flames of the adjacent appliance the requirement for a 406 mm (16 in.) space shall not apply.
12.1.2.5.1 If the fryer and the surface flames are at different horizontal planes, the minimum height of 203 mm (8 in.) shall be measured from the higher of the two.

Based on observation and staff interview, the facility failed to maintain the kitchen exhaust hood free of excessive grease build-up. The deficient practice had the potential to allow extra fuel to be provided in the event of a fire under the hood and could overpower the fire-extinguishing system's ability to extinguish the fire. The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-13-19 at 10:30 am revealed:

3rd Floor
1. University Towers, Unit 4, 3415 (Mac & Cheese Bar) excessive grease build up inside the kitchen hood.

During an interview on 9-13-19 at 10:30 am, Facility Staff C confirmed the buildup of grease under the Kitchen hood.

11.6 Cleaning of Exhaust Systems.
11.6.1 Upon inspection, if the exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction.
11.6.2* Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to remove combustible contaminants prior to surfaces becoming heavily contaminated with grease or oily sludge.

Based on observation and interview, the facility failed to provide complete fire alarm notification throughout the facility. This deficient practice has the potential to affect all staff using the conference room in the clinic.

Findings are:
1. Observation on 9/12/19 at 9:17 a.m. revealed that no fire alarm notification device was provided in the large conference room #1.0.17

During an interview at the time of the finding, all three members from Team G confirmed the findings.

Based on observation and interview, the facility failed to maintain a fire alarm initiating device. This deficient practice would not alert occupants of smoke within the room and would allow smoke to enter the exit corridor. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
5th Floor
Observations on 9-16-19 at 1:50 pm revealed, the heat detector in elevator room 58200 was hanging by its wires in the northeast corner near elevator SE3.

During an interview on 9-16-19 at 1:50 pm, Facility Staff A confirmed the finding.


27395

Based on record review and staff interview, the facility failed to test all duct detectors annually. This condition increased the potential of the devices failing to initiate during a fire. The facility census was 728 with a capacity of 488.

Findings are:
Record review on 9/17/19, at 2:42 pm revealed 8 duct detectors on the 2/25/19 and the 3/1/18 fire alarm inspection report failed testing, due to the devices being unreachable.

In an interview on 9/17/19, at 2:42 pm Facilities Staff E confirmed the findings.

Based on observation and staff interview, the facility failed to provide fire sprinkler coverage to all areas of a room. This condition would prevent the suppression of a fire. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/16/19, from 1:48 pm to 2:25 pm revealed:
1. 1st Floor MRI 3 Equipment Room 18323 did not have sprinkler protection below an air duct that exceeded 4 feet in width, and no sprinkler coverage was installed below the obstructions to the upright fire sprinklers.
2. 2nd Floor IT Closet 28252 fire sprinkler was obstructed by a light fixture.

In an interview on 9/16/19, from 1:48 pm to 2:25 pm, Facility Staff E confirmed the findings.

NFPA 13, 2010, 4.1 Level of Protection. A building, where protected by an
automatic sprinkler system installation, shall be provided with
sprinklers in all areas except where specific sections of this
standard permit the omission of sprinklers.
8.5.5 Obstructions to Sprinkler Discharge.
8.5.5.1* Performance Objective. Sprinklers shall be located so
as to minimize obstructions to discharge as defined in 8.5.5.2
and 8.5.5.3, or additional sprinklers shall be provided to ensure
adequate coverage of the hazard. (See Figure A.8.5.5.1.)

Based on observation and staff interview, the facility failed to provide fire sprinkler coverage to all areas of a room. This condition would prevent the suppression of a fire. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 11:32 am revealed the back corner/alcove in the 2nd Floor Sterile Processing Room 2.14.083 was not provided a fire sprinkler. The alcove measured 8 feet deep, and the nearest fire sprinkler was out of range to cover the alcove.

In an interview on 9/11/19, at 11:32 am, Facility Staff E confirmed the findings.

NFPA 13, 2010, 4.1 Level of Protection. A building, where protected by an
automatic sprinkler system installation, shall be provided with
sprinklers in all areas except where specific sections of this
standard permit the omission of sprinklers.
8.5.5 Obstructions to Sprinkler Discharge.
8.5.5.1* Performance Objective. Sprinklers shall be located so
as to minimize obstructions to discharge as defined in 8.5.5.2
and 8.5.5.3, or additional sprinklers shall be provided to ensure
adequate coverage of the hazard. (See Figure A.8.5.5.1.)

Based on observation and interview, the facility failed to provide fire sprinkler protection in all areas of the building. This deficient practice would allow fire, smoke, and gases to grow without control.

Findings are:

Observations on 9-18-19 at 1:10 pm revealed that room 2040 did not have a fire sprinkler.

During an interview on 9-18-19 at 1:10 pm, Facility Staff H confirmed the findings

Based on observation and staff interview, the facility failed to provide complete sprinkler coverage. This deficient practice had the potential to allow a fire to potentially grow beyond the capabilities of the sprinkler system. The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:

Observation on 9-16-19 at 4:15 pm revealed:

Ground Level
1. University Tower, Unit 4, Room 0406, an office being used for storage, failed to have required fire sprinkler coverage.

During an interview on 9-25-18 at 2:15 pm, Facility Staff C confirmed the findings of no sprinkler protection in the room.

Based on observation and staff interview, the facility failed to install fire sprinklers to provide protection in all areas of the building. The unprotected areas would allow heat to bypass fire sprinklers and accumulate in a raised ceiling area therefore not allowing the fire sprinkler system to operate as designed. This would affect all building occupants on floors 1-13. The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-11-2019 between 9:44 AM and 12:26 PM revealed the following:

1) Lied Transplant Center 1st floor main entrance raised architectural ceiling by door #1799K did not have proper sprinkler protection coverage.
a. Raised ceiling measures approximately 12-foot diameter by 18-inches to 36-inches in height'

2) Lied Transplant Center south elevator glass lobby on floors 1-13 had a raised ceiling without proper fire sprinkler protection coverage.
a. Raised ceilings measured approximately 7-foot 6-inches wide, 5-foot 6-inched deep, and between 3-feet and 5-feet in height.

3) Lied Transplant Center 3rd floor main staircase skylight did not have proper fire sprinkler protection coverage.
a. Skylight measures approximately 36-feet long by 8-feet wide and 8-feet in height.

During interviews on 9-11-2019 between 9:44 AM and 12:26 PM with Facility Staff B confirmed the findings.

Based on observations and staff interview, the facility failed to ensure the facility was protected throughout by an approved automatic sprinkler system. This deficient condition would allow fire, smoke and gases to overpower the sprinkler system in adjoining spaces, which would affect patients on 1 of 14 floors. Facility census was 488 and licensed for 728 at the time of the survey.

Findings are:
Observations on 9-16-2019 at 2:30 PM revealed the following:

1st Floor
No fire sprinkler protection was provided in the North Data room Lobby 18100.

During an interview on 9-16-2019 at 2:30 PM Facility Staff I confirmed no sprinkler protection was provided.

Based on observation and interview, the facility failed to provide and maintain all required equipment and appurtenances for the fire sprinkler system. This deficient practice increased the potential that the fire sprinklers would not remain in the proper orientation upon activation of the sprinkler system and function as designed. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

Observations on 9/16/19 between the hours at 1:00 P.M. and 5:00 P.M., revealed the escutcheon rings on fire sprinklers for rooms 0626A, 0631, and 04073 were missing.

During an interview on 9/16/19 between the hours of 1:00 P.M. and 5:00 P.M. Team # 4 Facility Staff A confirmed the findings.


39858

Based on observation and interview, the facility failed to assure that fire sprinklers were not obstructed and allowed unsealed penetrations in the ceilings. This deficient practice would affect the operating temperature of the fire sprinklers and increased the potential that the sprinkler system would fail to activate as designed during a fire in the Durham Outpatient Center. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-12-19 between 9:27 am and 4:20 pm revealed:
1. A missing escutcheon for fire sprinklers in corridor by restroom 4626, and above the 4th floor window (second from north) on atrium 2697 side.
2. A majority of the sprinklers on floors 5 and 4 were covered with dust and lint.
3. Ceiling tile out of the grid in Room 4653.
4. Two holes in the ceiling tile of Room 4622.

Observations on 9-13-19 between 8:45 am and 11:30 am revealed:
1. A majority of the fire sprinklers on floors 3 and 2 were covered with dust and lint.

Observations on 9-16-19 between 1:35 pm and 3:55 pm revealed:
1. 2 missing escutcheons by the north wall in atrium 2697.
2. 2 missing escutcheons in the northeast corner of atrium 2697, by 3rd floor windows.
3. A majority of the sprinklers on floor 1 were covered with dust and lint.

During interviews on 9-12-19, 9-13-19, and 9-16-19 Facility Staff F confirmed the findings.

Based on observation and interview, the facility failed to maintain sprinkler components, allowed non-sprinkler components to be attached to on sprinkler piping and failed to assure ceiling tiles were in place to allow sprinkler operation. This deficient practice increased the potential for damage to the sprinkler piping and could delay the response of the fire sprinklers resulting in a larger fire that could spread outside of the room of origin. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-11-19 between 10:14 am and 10:59 am revealed:
Ground Floor
1. Ceiling tile out of grid in room 0.12.101B
2. Ceiling tile out of grid in the north vestibule.
3. Wire attached to sprinkler pipe in room 0.12.130
4. Missing sprinkler escutcheon in the Kitchen cooler in room 0.12.124.

During an interview on 9-11-19 between 10:14 am and 10:59 am, Facility Staff A confirmed the findings.

Observation on 9-12-19 at 9:26 am revealed:
8th Floor
5. Wire attached to the sprinkler pipe above the ceiling grid near smoke door 8.12.299C.

During an interview on 9-12-19 at 9:26 am, Facility Staff A confirmed the findings.

Based on observation and interview, the facility failed to maintain sprinkler components. This deficient practice increased the potential for damage to the sprinkler and could delay the response of the sprinkler heads resulting in a larger fire that could spread outside of the room of origin. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-16-19 at 2:18 pm revealed:
4th Floor
1. Missing sprinkler escutcheon in women's restroom 48217.

During an interview on 9-16-19 at 2:18 pm, Facility Staff A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain the required minimum clearance around a fire sprinkler deflector, maintain sprinkler deflectors free of dust accumulation, provide an escutcheon ring, and maintain ceiling tile. The deficient practice could prevent the fire sprinkler from activation in the case of fire and could obstruct the spray pattern of the sprinkler resulting in inefficient coverage and failure to extinguish a fire. The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-11-19 between 11:17 am and 4:16 pm revealed the following:

7th Floor
1. University Tower, Unit 2, Room 7204 had a shoe rack that encroached into the required minimum 18 inch clearance from obstructions to the sprinkler deflector.

5th Floor
2. University Tower, Unit 3, Room 5312 items stored on the top shelf measured 14" from the sprinkler defector encroached into the required minimum 18 clearance.

During interviews on 9-11-19 between 11:17 am and 4:16 pm, Facility Staff C confirmed the findings.

Observations on 9-13-19 between 9:32 am and 10:58 am revealed the following:

3rd Floor
3. University Tower, Unit 4, outside of Room 3480 a ceiling tile is broke missing a corner.
4. University Tower, Unit 3, Room 3303 had dust accumulated on sprinkler deflectors.
5. University Tower, Unit 4, Room 3430 (dishwasher room) had dust accumulated on sprinkler deflectors.
6. University Tower, Unit 3, Room 3417 is missing a ceiling tile in the kitchen by the pillar above the fire-extinguishing system tanks for the kitchen exhaust hood.
7. University Tower, Unit 4, Room 3416 (Bakery Room) had dust accumulated on sprinkler deflectors.
8. University Tower, Unit 4, Room 3415 (Mac & Cheese Bar) had dust accumulated on sprinkler deflectors.
9. University Tower, Unit 4, Room 3421(Kitchen Storage Room) Items stored on top shelves encroached into the required 18 clearance from obstructions and had dust accumulated on the sprinkler deflectors.
10. University Tower, Unit 4, Room 3442B was missing an escutcheon ring above the condiment counter.

During Interviews on 9-13-19 between 9:32 am and 10:59 am, Facility Staff C confirmed the findings.

Observations on 9-16-19 between 1:39 pm and 4:18 pm revealed the following:

2nd Floor
11. University Tower, Unit 4, Room 2472, above the central desk area in the pharmacy dust accumulation on four fire sprinklers.

Ground Floor
12. University Tower, Unit 4, Outside of Room 0401 and Rm 0407 multiple ceiling tile that are broke with missing corners.

During Interviews on 9-16-19 between 1:39 pm and 4:18 pm, Facility Staff C confirmed the findings.

Observations on 9-17-19 at 3:10 pm revealed:

3rd Floor
13. University Tower, Unit 4, Hallway 3499G seven fire sprinklers had dust accumulated on them.

During Interview on 9-17-19 at 3:10 pm, Facility Staff C confirmed the findings.

Based on observation and staff interview, facility failed to maintain the fire sprinkler system by allowing combustible materials to be stored with 18-inches of the fire sprinkler deflector, and by allowing missing ceiling tiles. These deficient practices would not ensure the fire sprinkler system would operate as designed due to obstructions to water spray patterns and by allowing heat to accumulate in the space above the ceilings above the fire sprinklers. This would affect all building occupants on 1st floor. The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-11-2019 between 9:52 AM and 10:41 AM revealed the following:

1) Lied Transplant Center storage room #1704 had item on shelves that were within 18-inches of a fire sprinkler head deflector.
2) Lied Transplant Center storage room #1718 had multiple missing ceiling tiles.

During interviews on 9-11-2019 between 9:52 AM and 10:41 AM, Facility Staff B confirmed the findings.

Based on observation and staff interview, the facility failed to ensure activation of the sprinkler system at the designated temperature rating and an unobstructed water spray pattern to the point of fire origin. These deficient practices would delay activation of the sprinkler system allowing fire, smoke and gases to spread, which would affect patients on 6 of 14 floors. Facility census was 488 and licensed for 728 at the time of the survey.

Finding are:
Observation on 9-11-2019 between 3:13 PM and 4:55 PM revealed the following:

9th Floor
1. Recessed fire sprinkler was missing an escutcheon plate in 9th Floor Conference room 9813.
7th Floor
2. A metal file cabinet was placed approximately 8" below a fire sprinkler on 7th floor in Storage room 7849.

During interview on 9-11-2019 at 3:13 PM and 4:55 PM Facility Staff I confirmed the fire sprinkler conditions.

Observation on 9-12-2019 at 1:45 PM revealed the following:

3rd Floor
3. An acoustical ceiling tile was missing on 3rd floor, above cooler #32 located beside room 3872

During interview on 9-12-2019 at 1:45 PM Facility Staff I confirmed the fire sprinkler conditions.

Observation on 9-13-2019 between 8:50 AM and 9:40 AM revealed the following:

2nd Floor
4. Excessive lint buildup on a fire sprinkler located in Pre-op bay 2843.
5. Excessive lint buildup on fire sprinkler located in Pre-op bay 28105.
6. Excessive lint buildup on fire sprinkler located in Hallway 28112 end of hall.
7. Excessive lint buildup on fire sprinkler located above electrical panel at 2824.
8. Excessive lint buildup on fire sprinkler located 2827 in front of Bay #18.
9. Storage placed on wire shelving was located approximately 10" below fire sprinklers in Storage room 28125.
10. Unsealed ceiling penetrations around feeder conduit above electrical panel in room 2813.

During interview on 9-13-2019 between 8:50 AM and 9:40 AM Facility Staff I confirmed the fire sprinkler conditions.

Observation on 9-16-2019 between 2:30 PM and 4:05 PM revealed the following:

1st Floor
11. Two ceiling tiles missing in SW corner of North Data IT room 18101.
Ground Floor
12. Laundry chute discharge room 8116 missing 7 ceiling tiles.
13. Excessive lint buildup on fire sprinkler located in corridor in front of room 08102.
14. Sprinkler missing escutcheon plate in decontamination room 0884.

During interview on 9-16-2019 between 2:30 PM and 4:05 PM Facility Staff I confirmed the fire sprinkler conditions.

Observation on 9-17-2019 between 9:00 AM and 9:25 AM revealed the following:

Ground Floor
15. 3"x 4" hole in ceiling tile in corridor 0899R next to exit sign.
16. Room 0835 missing 4 full ceiling tiles.
17. Corridor 0899M had 5, 4" holes in a series down the corridor ceiling.

During interview on 9-17-2019 between 9:00 AM and 9:25 AM Facility Staff I confirmed the fire sprinkler conditions.

Based on observation and staff interview, the facility failed to ensure that there were no obstructions to fire sprinkler discharge and failed to provide an intact ceiling to ensure activation of the sprinkler system. This deficient practice would obstruct the water spray pattern from the sprinkler system causing water to not reach the point of fire origin and delay activation of the sprinkler system allowing fire, smoke and gases to spread affecting approximately 60 occupants on 2 of 5 floors.

Finding are:
Observation and staff interview on 9-11-2019 at 10:00, 10:15 and 10:45 AM revealed the following:

1. 4th floor Storage room 4035B was missing a ceiling tile.
2. 3rd floor storage room 3028 had a box located approximately 2" below a fire sprinkler.
3. 3rd floor Day Room restroom 3032 had a ¾" hole in the ceiling around the fire sprinkler.
4. 2nd floor room 2007 fire sprinkler was misaligned and touching a ceiling tile.

During interview on 9-11-2019 at 10:45 Facility Staff I confirmed the fire sprinkler conditions.

Code standard: 2011 edition NFPA 25, 5.2.1

Based on record review and interview, the facility failed to assure that a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19 at 11:42 am, of the fire watch procedures revealed:
1. The fire watch policy failed to list insurance carrier, the alarm company, property owner or designated representative, supervisors and other authorities having jurisdiction (SFM, HHSS, OFD) have been notified.

During an interview on 9-18-19 at 11:42 am, Facility Staff A confirmed the lack of specific items were included in the fire watch policy.

NFPA Standard:
NFPA 25, 2011
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

Based on record review and interview, the facility failed to assure that a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19 at 11:42 am, of the fire watch procedures revealed:
1. The fire watch policy failed to list insurance carrier, the alarm company, property owner or designated representative, supervisors and other authorities having jurisdiction (SFM, HHSS, OFD) have been notified.

During an interview on 9-18-19, at 11:42 am, Facility Staff A confirmed the lack of specific items were included in the fire watch policy.

NFPA Standard:
NFPA 25, 2011
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

Based on observation and interview, the facility failed to provide accessible portable fire extinguishers. This deficient practice would not assure the extinguisher was available when needed. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-10-19 at 3:12 pm and 5:00 pm revealed:
4th Floor
1. Chair in the elevator lobby 4.12.99A blocking the fire extinguisher cabinet.
1st Floor
2. A fire extinguisher on the floor in room 1.12.121.

During an interview on 9-10-19 at 3:12 pm and 5:00 pm, Facility Staff A confirmed the blocked and unsecured fire extinguisher.

Observations on 9-11-19 at 11:12 am revealed:
Ground Floor
3. The Class K fire extinguisher in 0.12.131 Kitchen was obstructed with trash cans, floor sweeper.

During an interview on 9-11-19, at 11:12 am, Facility Staff A confirmed the blocked fire extinguisher.

NFPA Standard:
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location. 1998 NFPA 10, 1-6.7

Based on observation and staff interview, the facility failed to install portable fire extinguishers so the top of the extinguisher was no more than five feet above the finished floor. This condition could prevent staff from accessing a fire extinguisher during a fire, which would allow a fire to increase in size. The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:

Observation on 9-11-19 at 11:54 am revealed:

8th Floor
1. University Tower, Unit 2, Room 8200 the fire extinguisher installed at the top of the stairs measured 64 inches to the top of the handle from the floor.

During an interview on 9-11-19 at 11:54 am, Facility Staff C confirmed the measurement.

Observation on 9-16-19 at 2:04 pm revealed:

2nd Floor
2. University Tower, Unit 4, Room 2499F the fire extinguisher installed in a cabinet measured 62 inches to the top of the handle from the floor.

During an interview on 9-16-19 at 2:04 pm, Facility Staff C confirmed the measurement.

Based on observation and staff interview, the facility failed to install portable fire extinguishers so the top of the extinguisher was no more than five feet above the finished floor. This condition could prevent staff from accessing a fire extinguisher during a fire, which would allow a fire to increase in size affecting the safety and evacuation of all residents. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-12-19 between 9:27 am and 4:20 pm, on 9-13-19 between 8:45 am and 11:30 am, and on 9-16-19 between 1:35 pm and 3:55 pm revealed a majority of the portable fire extinguishers were placed in old fire hose cabinets and therefore exceeded the maximum height of 5 feet to the top of the handle.

During interviews on 9-12-19, 9-13-19, and 9-16-19, Facility Staff F confirmed the findings.

Based on observation and staff interview, the facility failed to provide a separation between use areas and corridors by construction that would resist the passage of smoke. This practice would allow smoke to enter into the corridor during a fire emergency affecting all patients, staff, and visitors that use the facility. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) Observations on 09/11/19 at approximately 12:30 P.M. hours in the Clarkson Doctors North revealed a large hole unsealed in the corridor wall above the ceiling just above door 01108, which serves the basement corridor.

2) During an interview on 9/11/19 at approximately 12:30 P.M. Team # 4 Facility Staff A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain corridor separation walls by allowing unsealed pipe, wire, and conduit penetrations to be left exposed above the ceiling. This deficient practice would allow smoke and hot gases to migrate into the exit corridors affecting all building occupants of Durham Outpatient Center. The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-17-2019 between 1:51 PM and 2:18 PM revealed the following:

1. Above ceiling by door #2640 there was an unsealed fire alarm conduit penetration through the wall greater than 1-inch.
2. Above ceiling by door #1699E there was an unsealed pipe penetration through the wall greater than 1-inch.

During interviews on 9-17-2019 between 1:51 AM and 2:18 PM, Facility Staff B confirmed the findings.

Based on observation and staff interview, the facility failed to maintain corridor separation walls by allowing unsealed pipe, wire, and conduit penetrations to be left exposed above the ceiling. This deficient practice would allow smoke and hot gases to migrate into the exit corridors affecting all building occupants of Hixon-Lied Center. The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-17-2019 between 9:52 AM and 10:34 AM revealed the following:

1) Above ceiling by storage room #18292 in corridor #18399U, there were unsealed wire penetrations greater than 1-inch through the wall.
2) Above ceiling by door #18399U there were unsealed copper pipe penetrations greater than 1-inch.
3) Above ceiling by door #18399S there was unsealed data cable penetrations of greater than 1-inch.
4) Above ceiling by door #28299H there were three 4-inch holes in the wall.

During interviews on 9-17-2019 between 9:52 AM and 10:34 AM, Facility Staff B confirmed the findings.

Based on observation and interview the facility failed to maintain corridor doors to resist the passage of smoke. This deficient practice would allow smoke and fire gases to migrate throughout the smoke compartment. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

Observations on 9/16/19 at 2:00 P.M. revealed the doors to Supply Management failed to latch and one door had a 1 ½ inch in diameter hole through the door.

During an interview on 9/16/19 at 2:00 P.M. Team # 4 Facility Staff A confirmed the findings.

Based on observation and interview, the facility failed to ensure that the corridor room doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire and smoke within the exit corridors. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-10-19 between 2:08 pm and 3:08 pm revealed:
4th Floor
1. Suite doors 4899EE/N were equipped with a self-closing devices and no latching device.
2. Suite doors 48248/4899P were equipped with a self-closing devices and no latching device.

During an interview on 9-16-19 between 2:08 pm and 3:08 pm Facility Staff A confirmed the findings.

Based on observation and interview, the facility failed to ensure that the corridor room doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire and smoke within the exit corridors. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-10-19 between 2:08 pm and 4:08 pm revealed:
7th Floor
1. Patient door 7.12.26 was equipped with a self-closing device and failed to latch within the doorframe.
6th Floor
2. Patient door 6.12.30 equipped with a small leaf failed to latch within the doorframe, appeared coordinator failed to operate.
3. 12 of 12 ICU patient doors failed to be equipped with auto latching devices, when doors were closed small leaf failed to engage the doorframe, manual locks were provided an not engaged doors were not smoke tight.
4th Floor
4. Procedure room door 4.12.36 equipped with a self-closing device was obstructed by a trash can.
5. Double doors 4.12.300 to the Chihuly Room failed to latch.

During an interview on 9-10-19 between 2:08 pm and 4:08 pm Facility Staff A confirmed the findings.

Observation on 9-11-19 at 10:12 am and 3:54 pm revealed:
Ground Floor
6. Door 0.12.23 was equipped with a self-closing device, failed to latch within the doorframe.
2nd Floor
7. Door 2.12.99H/236 to the corridor failed to close and latch within the doorframe.
8. OR suite door in south corridor 2.12.236 doors equipped with self-closing device, failed to latch within the door frame.
9. Fire rated doors 2.12.99H/F suite doors had an excessive gap between the doors.

During an interview on 9-11-19, at 10:12 am and 3:54 pm, Facility Staff A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain corridor doors to resist the passage of smoke and gases. This deficient practice would allow smoke and fire gases to migrate throughout the smoke compartment. The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-11-19 between 9:56 am and 3:48 pm revealed the following:

7th Floor
1. University Tower, Unit 4, Room 7434 door failed to latch and seal within the door frame. Latch was repaired during survey.

5th Floor
2. University Tower, Unit 4, Room 5472 door failed to latch and seal within the door frame.

During interviews on 9-11-19 between 9:56 am and 3:48 pm, Facility Staff C confirmed the findings.

Based on observation and staff interview, the facility failed to ensure no items would obstruct the fire rated shutter in the lab for a corridor pass-through opening. This condition would allow smoke and fire to spread into the exit corridor. The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:

Observation on 9-13-19 at 9:41 am revealed:

3rd Floor
1. University Tower, Unit 3, Room 3312 items being stored on the counter under the 1 hour rated fire shutter would obstruct the shutter from closing.

In an interview on 9-13-19 at 9:41 am, Facility Staff C confirmed the items on the counter would obstruct the shutter from closing.

Based on observation and staff interview, the facility failed to maintain a smoke barrier that would resist the passage of smoke. This deficient practice would allow smoke to migrate between smoke compartments, which would allow smoke to spread. The facility has a capacity of 728 and a census of 488 residents at the time of the survey.

Findings are:
2nd Floor
Observation on 9-12-19, at 3:25 pm revealed, unsealed penetration in two cable trays in the smoke barrier wall above ceiling tiles at doors 2.12.99/F

In an interview on 9-12-19, at 3:25 pm, Facility Staff A confirmed the unsealed penetration.

Based on observation and staff interview, the facility failed to maintain a smoke barrier that would resist the passage of smoke. This deficient practice would allow smoke to migrate between smoke compartments, which would allow smoke to spread. The facility has a capacity of 728 and a census of 488 residents at the time of the survey.

Findings are:
Observation on 9-17-19 between 9:21 am and 10:46 am revealed:
4th Floor
1. Unsealed penetration above cable trays in the smoke barrier wall above ceiling tiles at doors 4899J.
2. Unsealed penetration above cable trays in the smoke barrier wall above ceiling tiles at doors 4899N.
3. Unsealed penetration above cable trays in the smoke barrier wall above ceiling tiles at doors 4899EE.
4. Unsealed penetration above cable trays in the smoke barrier wall above ceiling tiles at doors 4899AA/Z.
5. Unsealed penetration above cable trays in the smoke barrier wall above ceiling tiles at doors 4899R/Q.

During an interview on 9-17-19 between 9:21 am and 10:46 Facility Staff A confirmed the unsealed penetration.

Based on observation and staff interview, the facility failed to provide a smoke barrier that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 3:13 pm revealed on the 2nd Floor above Doors 2.14
99.A, a hole in the wall, and holes around insulated pipes were not sealed.

In an interview on 9/11/19, at 3:13 pm, Facility Staff E acknowledged the findings.

Based on observation and staff interview, the facility failed to provide a complete smoke barrier that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments.


Findings are:


Observation on 9-11-19, at 2:34 pm revealed a square opening approximately 3 inches by 3 inches in the smoke barrier wall, above the ceiling in room 1056 on west wall, north of the door.


In an interview on 9-11-19, at 2:34 pm, Facility Staff H acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain smoke barrier walls by allowing unprotected penetrations through the walls. This deficient practice did not ensure smoke barrier walls would resist the passage of smoke by allowing smoke and gases to migrate into exit corridor. This would affect all occupants in 1 of 2 smoke compartments on 7th floor of Lied Transplant Center. The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-12-2019 at 10:11 AM revealed the following:

1) Lied Transplant Center 7th floor above door #7799A/B had a 1-inch hole around a wire penetration.

During an interview on 9-12-2019 at 10:11 AM, Facility Staff B confirmed the finding.

Based on observation and interview, the facility did not ensure that fire rated doors in a smoke barrier would resist the passage of smoke from one compartment to another. This deficient practice would not prevent the spread of fire and smoke on the ground floor in the Durham Outpatient Center and the Buffet Cancer Center. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

Observation on 9/16/19 at 1:30 P.M., revealed the fire separation doors between the Durham Outpatient Center and the Buffet Cancer Center equipped with a latching device failed to latch properly.

During an interview on 9/16/19 at 1:30 P.M., Team # 4 Facility Staff A confirmed the findings.

Based on observation and interview, the facility did not ensure that fire rated corridor separation doors would resist the passage of smoke from one compartment to another. This deficient practice would not prevent the spread of fire and smoke. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-10-19 between 1:16 pm and 4:44 pm revealed:
8th Floor
1. The north smoke door 8.12.99F/E equipped with latching hardware failed to latch within the doorframe.
2. The north smoke door 8.12.99B/C equipped with latching hardware failed to latch within the doorframe.
7th Floor
3. Fire rated smoke doors 7.12.99B/C had an excessive gap between the doors.
6th Floor
4. Fire rated smoke doors 6.12.99E/F had an excessive gap between the doors.
5. Fire rated smoke doors 6.12.99E/P had an excessive gap between the doors.
6. The north smoke door 6.12.99B/C equipped with latching hardware failed to latch within the doorframe.
4th Floor
7. The east fire rated smoke door 4.12.99A/B equipped with latching hardware failed to latch within the doorframe.
8. Fire rated smoke doors 4.12.99A/B had an excessive gap between the doors.
9. The smoke door 4.12.160/170 equipped with latching hardware failed to latch within the doorframe.
10. The south smoke door 4.12.99F/C equipped with latching hardware failed to latch within the doorframe.
2nd Floor
11. Fire rated smoke doors 2.12.64/236 failed to provide latching devices on the doorframe.
12. Fire rated smoke doors 2.12.264/250 had an excessive gap between the doors.
13. The south smoke door 2.12.223/240 equipped with latching hardware failed to latch within the doorframe.
14. Fire rated smoke doors 2.12.213/210 had an excessive gap between the doors.
15. Fire rated smoke doors 2.12.299D/C had an excessive gap between the doors.

During an interview on 9-10-19 between 1:16 pm and 4:44 pm, Facility Staff A confirmed the findings.

Observation on 9-11-19 between 8:42 am and 3:24 pm revealed:
1st Floor
16. Fire rated smoke doors 1.12.15/14 had an excessive gap between the doors.
17. Fire rated smoke doors 1.12.99J had an excessive gap between the doors.
18. The fire rated smoke doors 1.12.240/217 equipped with latching hardware failed to latch within the doorframe.
19. The fire rated smoke doors 1.12.240/259 equipped with latching hardware failed to latch within the doorframe.
20. The east fire rated smoke door 1.12.2013/240 equipped with latching hardware failed to latch within the doorframe.
21. Fire rated smoke doors 1.12.250 failed to close in order and no coordinator was provide so the doors were not smoke tight.
Ground Floor
22. Smoke doors 0.12.101 had an excessive gap between the doors.
23. Smoke doors 0.12.127 failed to close in order and no coordinator was provide so the doors were not smoke tight.
24. Two of two sets of fire rated smoke doors into room 0.12.100A, had an excessive gap between the doors.

During an interview on 9-11-19 between 8:42 am and 3:24 pm , Facility Staff A confirmed the findings.

Based on observation and interview, the facility failed to ensure smoke separation doors were capable of resisting the passage of smoke. The deficient practice would allow smoke and gases to spread between smoke compartments. The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-11-19 between 12:08 pm and 12:23 pm revealed the following:

6th Floor
1. University Tower, Unit 2, 6299 C/D Double 90 min rated fire doors failed to close and latch within the door frame.
2. University Tower, Unit 2, 6299 E/B Double 45 min rated fire doors failed to close and latch within the door frame.

During an interview on 9-11-19 between 12:08 pm and 12:23 pm Facility Staff C confirmed the findings.

Based on observation and staff interviews, the facility failed to maintain smoke barrier doors by not ensuring smoke door closing coordinators were functioning as designed. This deficient practice would allow smoke and gases to migrate into the exit access corridor. This would affect all building occupants on 1st floor. The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-11-2019 at 10:14 AM revealed the following:

1) Lied Transplant Center 1st floor south elevator lobby smoke doors #1799B door coordinator failed to properly function by not allowing both doors to fully close.

During an interview on 9-11-2019 at 10:14 AM with Facility Staff B confirmed the finding.

Based on observation and interview, the facility allowed storage to obstruct access to electrical panel boxes. This deficient practice could cause a delay and injury when turning off the power during an electrical issue emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-10-19, at 2:08 pm revealed:
6th Floor
1. A ladder obstructed the electrical panel box in 6.12.79 Electrical Room.

During an interview on 9-10-19, at 2:08 pm, Facility Staff A confirmed the items stored in front of panel boxes.

NFPA Standard:
2011 NFPA 70, 110.26
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

Based on observation and staff interview, the facility failed to ensure a clear working space was provided in front of electrical panels. This deficient practice would cause delayed access to the electrical panels during an emergency event, which would affect patients on 1 of 14 floors. Facility census was 488 and licensed for 728 at the time of the survey.

Finding are:
Observation and staff interview on 9-12-2019 at 10:40 AM revealed the following:

4th Floor
3 Bio-hazard plastic totes were obstructing access to the electrical panels in Bio-hazard storage room 4834.

During interview on 9-12-2019 at 10:40 AM Facility Staff I confirmed the obstructed panels.

Based on observation and interview the facility failed to assure that the rated soiled linen chute door was not obstructed. This deficient practice had the potential to spread smoke, gasses and fire into the chute to the floors above. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-10-19 at 4:50 pm revealed:
1st Floor
1. Numerous bags of soiled linen obstructed the rated chute door from closing in the discharge room 1.12.103.
2. The fire rated door to the soiled linen discharge room failed to close and latch 1.12.103.

During an interview on 9-10-19 at 4:50 pm, Facility Staff A confirmed the rated chute door was obstructed by soiled linen bags and that the door failed to latch.

Observations on 9-11-19 at 2:30 pm revealed:
2nd Floor
3. The fire rated door to the trash and soiled linen chute room 2.12.142 failed to close and latch within the doorframe.

During an interview on 9-11-19, at 2:30 pm, Facility Staff A confirmed the door to the chute room failed to latch.

Based on observations and staff interview, the facility failed to maintain the required fire rated construction enclosing vertical openings between floors. This deficient practice would cause fire, smoke and gases to move vertically from floor to floor, which would affect patients on all 14 floors. Facility census was 488 and licensed for 728 at the time of the survey.

Findings are:
Observation and staff interview on 9-16-2019 between 3:12 PM and 3:45 PM revealed the following:
Ground Floor

1. A fire rated self-closing door was not provided on trash chute inside of trash discharge room 0897.

Code reference: 2009 edition NFPA 82-5.2.3.2.2
The bottom of a linen chute shall be protected by a listed automatic closing or self-closing door in accordance with 5.2.3.

2. Laundry chute discharge room 8116 Chute door was obstructed by 4 dirty laundry bags.

During an interview on 9-16-2019 between 3:12 PM and 3:45 PM Facility Staff I confirmed the shaft conditions.

Based on interview and record review, the facility failed to provide a complete fire plan. This deficient practice would delay evacuation and affected all smoke compartments and all occupants. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19, at 12:36 pm revealed, the fire evacuation plan failed to include the evacuation of the smoke compartments, failed to assure that staff do not cross the room where the fire originates and did not include the evacuation of the patient triangle and failed to assure the evacuation of the floors above and below the location of the fire.

During an interview on 9-18-19 at 12:26 pm, Facility Staff X confirmed the lack of specific evacuation.

Based on interview and record review, the facility failed to provide a complete fire plan. This deficient practice would delay evacuation and affected all smoke compartments and all occupants. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19, at 12:36 pm revealed, the fire evacuation plan failed to include the evacuation of the smoke compartments, failed to assure that staff do not cross the room where the fire originates and did not include the evacuation of the patient triangle and failed to assure the evacuation of the floors above and below the location of the fire.

During an interview on 9-18-19 at 12:36 pm, Facility Staff X confirmed the lack of specific evacuation.

Based on interview and record review, the facility failed to provide a complete fire plan. This deficient practice would delay evacuation and affected all smoke compartments and all occupants. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19, at 12:36 pm revealed, the fire evacuation plan failed to include the evacuation of the smoke compartments, failed to assure that staff do not cross the room where the fire originates and did not include the evacuation of the fire triangle and failed to assure the evacuation of the floors above and below the location of the fire.

During an interview on 9-18-19 at 12:26 pm, Facility Staff X confirmed the lack of specific evacuation.

Based on interview and record review, the facility failed to provide a complete fire plan. This deficient practice would delay evacuation and affected all smoke compartments and all occupants. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19, at 12:36 pm revealed, the fire evacuation plan failed to include the evacuation of the smoke compartments, failed to assure that staff do not cross the room where the fire originates and did not include the evacuation of the patient triangle and failed to assure the evacuation of the floors above and below the location of the fire.

During an interview on 9-18-19 at 12:26 pm, Facility Staff X confirmed the lack of specific evacuation

Based on record review and staff interview, the facility failed to conduct fire drills quarterly under varying conditions. This practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels. The facility census was 728 with a capacity of 488.

Findings are:

Record review on 9/17/19 at 1:56 pm of fire drills revealed fire drills were conducted less than one hour apart between each quarter 3/23/18 at 2:00 pm and 11/19/18 at 1:49 pm.

In an interview on 9/17/19 at 1:56 pm, Facilities Staff E confirmed the fire drill times were not varied.

Based on record review and staff interview, the facility failed to conduct fire drills quarterly under varying conditions. This practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels. The facility census was 728 with a capacity of 488.

Findings are:

Record review on 9/17/19 at 3:09 pm of fire drills revealed fire drills were conducted less than one hour apart between each quarter for the 2nd Shift: 6/26/18 at 5:44 pm and 12/28/18 at 5:43 pm, 2/6/19 at 7:00 pm, 8/5/19 at 7:48 pm, 3/13/19 at 5:21 pm and 6/13/19 at 5:09 pm.

In an interview on 9/17/19 at 3:09 pm, Facilities Staff E confirmed the fire drill times were not varied.

Based on observation and staff interview, the facility failed to label oxygen cylinders as empty or full. This deficient practice would create the possibility of an empty cylinder being exchanged when a full one was needed. This would affect all residents in Clarkson Tower. The facility had a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-16-2019 at 2:03 PM revealed the following:

1) Clarkson Tower Basement oxygen room #B899H had multiple oxygen cylinders that were not labeled and had no identification stating if they were full, in-use, or empty.

During an interview on 9-16-2019 at 2:03 PM, Facility Staff B confirmed the finding.

Based on observation and staff interview, the facility failed to maintain the building electrical system by allowing electrical junction boxes to remain open and energized electrical wires to be left exposed. This deficient practice increased the potential for an electrical fire or injury, affecting all occupants of Durham Outpatient Center. The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-17-2019 between 1:34 PM and 2:26 PM revealed the following:

1) There was an open electrical junction box above the ceiling by door #24114.
2) There were two open electrical junction boxes above the ceiling by door #1685.

During interviews on 9-17-2019 between 1:34 PM and 2:26 PM, Facility Staff B confirmed the findings.

Based on observation and interview, the facility failed to assure that electrical receptacles in areas were children were present were tamper proof. This deficient practice would have the potential for electrical shock. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-11-19, at 4:36 pm revealed, the electrical outlets in the Children's Playroom 2.12.106 failed to be tamper resistant.

During an interview on 9-11-19, at 4:36 pm, Facility Staff A confirmed the outlets in the playroom were not tamper proof.

Based on record review and interview, the facility failed to conduct an individualized assessment for non-hospital grade receptacles at patient bed locations, including the continuity of the grounding circuit, polarity and retention force. This deficient practice increased the risk of fire from an outlet. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19, at 11:01 am revealed, documentation of annual patient bed location receptacle testing was not provided for review.

During an interview on 9-18-19, at 11:01 am, Facility Staff X confirmed the testing documentation was not provided and testing was not implemented.

NFPA Standard:
NFPA 99, 2012, 6.3.4.1.1
Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on record review and staff interview, the facility failed to test all patient bed receptacles annually throughout the facility. This practice increased the risk of fire from a failed outlet. The facility census was 728 with a capacity of 488.

Findings are:
Record review on 9/12/19, at 8:59 am revealed documentation of annual patient bed location receptacle testing on the 2nd Floor was not provided for review.

In an interview on 9/12/19, at 8:59 am, Maintenance A confirmed the testing documentation was not provided.

NFPA 99, 2012, 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be
confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each
electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections
in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each
electrical receptacle (except locking-type receptacles) shall be
not less than 115 g (4 oz).

Based on record review and interview, the facility failed to inspect the emergency generator circuit breaker(s) annually, and exercise the circuit breakers periodically. This deficient practice increased the potential that emergency power would not be supplied to the facility during an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19, at 11:14 am revealed, a preventative maintenance plan was not adopted to inspect annually, and exercise periodically the emergency generator circuit breaker(s).

During an interview on 9-18-19, at 11:14 am, Facility Staff X confirmed the inspection and testing was not implemented.

NFPA Standard:
2012, NFPA 99 , 6.6.4.1.2
Circuitry shall be maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2.1*
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

K918
Based on record review and interview, the facility failed to inspect the emergency generator circuit breaker(s) annually, and exercise the circuit breakers periodically. This deficient practice increased the potential that emergency power would not be supplied to the facility during an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19, at 11:14 am revealed, a preventative maintenance plan was not adopted to inspect annually, and exercise periodically the emergency generator circuit breaker(s).

During an interview on 9-18-19, at 11:14 am, Facility Staff X confirmed the inspection and testing was not implemented.

NFPA Standard:
2012, NFPA 99 , 6.6.4.1.2
Circuitry shall be maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2.1*
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

Based on observation and interview, the facility failed to assure that electrical junction boxes were covered. This deficient practice increased the potential for electrical fire on fourth floor. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) Observations on 9/17/19 at 2:30 P.M. revealed an open electrical junction box above the ceiling near 4498A on the fourth floor.

2) During an interview on 9/17/19 at 2:30 P.M., Team # 4 Facility Staff A confirmed the open junction box.


38543

Based on observation and staff interview the facility failed to provide approved cover plates for an electrical junction box. This deficient practice increased the potential of an electrocution injury or fire from unintended contact with live electrical equipment. The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-11-19 at 9:34 am revealed:

8th Floor
1. University Tower, Unit 4 Room 8400 an electrical junction box was missing a cover plate above Electrical Panel UT48Q1H4.

During an interview on 9-11-19 at 9:34 am, Facility Staff C confirmed the finding.

Based on observation and staff interview the facility failed to maintain clearance and a clear working space around electrical service panels. This condition would not allow access to the electrical panel during an emergency. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) Observations on 09/11/11 at approximately 10:00 A.M. revealed in the Clarkson Doctors North Laboratory 31131 there was a large machine in front of the electrical panel not allowing for required the 36-inch clearance at the panel.

2) During an interview on 09/11/19 at approximately 10:00 A.M., Team # 4 Facility Staff A confirmed all the findings.

Based on observation and interview, the facility failed to assure that electrical components did not create a fire hazard. This deficient practice increased the potential for electrical fire. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
4th Floor
Observations on 9-16-19 at 2:02 pm revealed, an open electrical junction box in the ceiling in electrical room 48206.

During an interview on 9-16-19 at 2:02 pm, Facility Staff A confirmed the open junction box.


27395

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in a way that would not create a fire. This condition had the potential to cause a fire, or prevent response to a fire. The facility census was 728 with a capacity of 488.

Findings are:

Observation on 9/16/19, from 1:57 pm to 3:00 pm revealed:
1. 1st Floor Radiology Control Room 18295 and 18299 electrical disconnects were blocked by desks, a refrigerator, and other storage.
2. 2nd Floor IT Closet 28318, an electrical junction box was missing a cover.
3. 2nd Floor IT Closet 28318 power strips were daisy-chained.
4. 2nd Floor Electrical Room 28313, an electrical junction box by the door was missing a cover.
5. 2nd Floor Electrical Room 28313, ladders were blocking electrical disconnects.

In an interview on 9/16/19, from 1:57 pm to 3:00 pm, Facility Staff E acknowledged the findings.

NFPA 70, 2011, 110.26 Spaces About Electrical Equipment. Access and
working space shall be provided and maintained about all
electrical equipment to permit ready and safe operation and
maintenance of such equipment.
(A) Working Space. Working space for equipment operating
at 600 volts, nominal, or less to ground and likely to
require examination, adjustment, servicing, or maintenance
while energized shall comply with the dimensions of
110.26(A)(1), (A)(2), and (A)(3) or as required or permitted
elsewhere in this Code.

Based on observation and interview, the facility failed to assure that electrical junction boxes were covered. This deficient practice increased the potential for electrical fire. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-12-19, at 10:55 am revealed, an open electrical junction box above the ceiling tile in corridor 4.12.99F on the east side of the smoke door near the women's restroom 4.12.04.

During an interview on 9-12-19, at 10:55 am, Facility Staff A confirmed the open junction box.

Based on observation and interview, the facility failed to assure that electrical junction boxes were covered. This deficient practice increased the potential for an electrical fire. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:

Observation on 9-12-19 at 9:41 am revealed, an open electrical junction and switch box for the northeast heater in Mechanical Room W5651.

During an interview on 9-12-19 at 9:41 am, Facility Staff F confirmed the open junction box.

Based on observation and staff interview, the facility allowed the use of a 3-way electrical splitter as a substitute for adequate wiring. This deficient practice could cause electrical injury or fire which would affect approximately 30 occupants on 1 of 5 floors (3rd floor)

Finding are:
Observation on 9-11-2019 at 10:20 AM revealed the following:

A 3-way electrical splitter was being used to power a coffee pot and refrigerator in office 3029.

During interview on 9-11-2019 at 10:20 AM, Facility Staff I confirmed the electrical splitter.

Code standard: 2011 edition NFPA 70.

Based on observations and staff interview, the facility failed to ensure electrical junction boxes were equipped with cover plates to protect persons from accidental contact. This deficient practice could cause injury or fire, which would affect patients on 1 of 14 floors. Facility census was 488 and licensed for 728 at the time of the survey.

Finding are:
Observation and staff interview on 9-12-2019 at 3:20 PM revealed the following:

2nd Floor
An open low voltage electrical junction box labeled "Door Hold" was located above ceiling at door 2899E/F.

During an interview on 9-12-2019 at 3:20 PM Facility Staff I confirmed the open junction box.

Based on observation and staff interview, the facility failed to maintain the electrical system of the facility in accordance with NFPA 70, 2011 ed. by having flexible cords installed as a substitute for permanent wiring. This practice has the potential of the wiring shorting out and causing a fire. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) Observation on 09/11/19 at 09:23 A.M. revealed that in the Clarkson Doctors North pulmonary clinic patient corridor near 41154 had an extension cord plugged into a duplex receptacle behind the file cabinets along the north wall. The cord had a power strip plugged into another power strip which a copy machine had plugged into it. There was another cord plugged into the power strip going up above the drop ceiling.

2) During an Interview on 09/11/19 at 09:23 A.M. Team # 4 Facility Staff A confirmed the use of the extension cord and power strips to power the appliances.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 2011 NFPA 70, article 400-8

Based on observation and interview, the facility failed to have all electrical power taps in compliance with the National Electrical Code. This deficient practice has the potential to allow smoke to spread from the work room area into the exit corridor affecting patients and staff of the clinic.

Findings are:
1. Observation on 9/12/19 at 10:57 a.m. revealed power taps that were being "daisy chained" in the work room #2004

During an interview at the time of the finding, all three members from Team G confirmed the finding.

Based on observation and staff interview, the facility allowed the use of an extension cord in lieu of permanent wiring. This condition had the potential to cause a fire. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 11:59 am revealed the 2nd Floor OR 2 microscope was plugged into a wall outlet with an extension cord. Further observation revealed all microscopes used the same extension cord throughout the OR's.

In an interview on 9/11/19, at 11:59 am, Facility Staff E acknowledged the findings.

Based on observation and interview, the facility failed to prohibit the use of extension cords and power strips as a substitute for adequate wiring. This deficient practice would create electrical injury and increase the probability of a fire. The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-11-19 at 10:10 am revealed:

7th Floor
1. University Tower, Unit 4, Room 7478 had two extension cord reels that were mounted to the ceiling and plugged into an outlets in the ceiling.

During an interviews on 9-11-19 at 10:10 am, Facility Staff C confirmed the two cord reels mounted to the ceiling.

Observations on 9-16-19 between 2:11 pm and 2:41 pm revealed the following:

2nd Floor
2. University Tower, Unit 4, Room 2441, had a Non-hospital grade power strip lying on the floor plugged into the wall receptacle. Maintenance Staff removed the power strip at the time of observation.
3. University Tower, Unit 3, Room 2301 (Security Dispatch Center), had a power strip hanging by the cord, with an extension cord plugged into it used to plug in a cell phone charger cord.
4. University Tower, Unit 3 Room 2301 (Security Dispatch Center) had a power strip plugged into a power strip with multiple pieces of equipment plugged into it.

During an interviews on 9-16-19 between 2:11 pm and 2:41 pm, Facility Staff C confirmed the use of power strips.

Observations on 9-17-19 at 1:06 pm revealed:

Ground Level
5. University Tower, Unit 4, Room 0407 an ice maker was plugged into a 50' extension cord. Facility Staff removed the extension cord at the time of observation.

During an interviews on 9-16-19 between 2:11 pm and 2:41 pm, Facility Staff C confirmed the use of the extension cord.

Based on observation and staff interview, the facility failed to prohibit the use of electric extension cords as a substitute for adequate wiring. This deficient practice increased the potential of injury or electrical fire. This affected all building occupants in 1 of 3 smoke compartments (Lied Transplant Center north corridor #1799B). The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-11-2019 at 10:54 AM revealed the following:

1) Lied Transplant Center mechanical room #1710/1799C had a condensation pump plugged into an electric extension cord that was plugged into an electric extension cord.

During an interview on 9-11-2019 at 10:54 AM, Facility Staff B confirmed the finding.

Based on observation and interview, the facility failed to prohibit the use of extension cords and power strips as a substitute for adequate wiring. This deficient practice would create electrical injury and increase the chances of a fire on 4th floor in the Durham Out-patient Center. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-12-19, between 11:12 am and 3:01 pm on the 4th floor revealed:
1. A refrigerator and microwave plugged into a power strip in Nurse's work room 4663.
2. A Keurig coffee maker and a microwave plugged into a power strip in room 4683.
3. The Stork's Nest cabinet in Lobby #4602 was plugged into an extension cord and the insulation on the cord was torn open and exposing the wires inside.
4. Three Power strips were hanging by their cords under the desks in room 4641.

During interviews on 9-12-19 between 11:12 am and 3:01 pm, Facility Staff F confirmed the findings.

Based on observation and interview, the facility failed to ensure gas equipment was secured when not in use. This deficient practice could cause the potential for rapid fire growth within the room in the event of cylinder falling over, which would affect patients on 1 of 14 floors. Facility census was 488 and licensed for 728 at the time of the survey.

Finding are:
Observations on 9-12-2019 at 9:45 AM revealed the following:

5th Floor
One oxygen cylinder was not restrained or in a hand cart on 5th floor, in patient room 5831.

During interview on 9-12-2019 at 9:45 AM Facility Staff I confirmed that the cylinder was not restrained.