HospitalInspections.org

Based on observations made during tours, it was determined that the facility failed to ensure that corridor walls were constructed and maintained to resist the passage of smoke.

Findings include:

1. During the tour of the facility from 06/16/10 to 06/18/10, it was noted that various areas of the corridor in the facility (that were not sprinklered) were not maintained with construction of as at least 1/2 hour fire resistive rating and had penetrations. Examples, including but not limited to, are:

a. On 06/16/09 at 2:45PM, an unsealed penetration about 2-3 inches made by a HVAC duct was observed above the dropped ceiling in the corridor wall of the communication closet (near ICU).

b. On 06/17/10 at 11:15PM, a hole was noted filled by joint compound (not rated material) by the double door of the smoke barrier of the Med/Surg unit on 2nd floor.

c. A penetration was noted made by conduit in the corridor wall of the Information Technology closet in the Med/Surg unit 2nd floor.

Findings were verified with Staff #21 at the time of observation.

Section A-19-2.1.1.1 of NFPA 99 1999 states that:
"Characteristics of building construction housing hyperbaric chambers and ancillary facilities are no less important to safety from fire hazards than are the characteristics of the hyperbaric chambers themselves. It is conceivable that a fire emergency occurring immediately outside a chamber, given sufficient fuel, could seriously endanger the life or lives of those inside the chamber."

Based on observation, the facility failed to ensure that the door to Hyperbaric unit (which is considered as a hazardous area), is held open with approved devices which are arranged to automatically close all such doors upon the activation of the fire alarm systems, as per NFPA 101 19.2.2.2.6.

Findings include:

1.a. During observation on 06/17/10 at 2:45PM, it was noted that the door to the Hyperbaric Unit on 5th floor was kept propped open by means of an elastic/hair band connected from the door handle to the wall. This arrangement of holding the door open is not approved and would prevent the automatic closure of the doors upon the activation of the facility's fire alarm systems.

1.b. Furthermore, during the survey it could not be verified if the door of the Hyperbaric unit, opening to the corridor and protecting the room, is rated or not. There was no label on the door.

Section 19-2.1.1.1* of NFPA 99 for Hyperbaric suite states that 'If there are connecting doors through such common walls of contiguity, they shall be at least B-label, 11/2-hour fire doors'.

Findings were verified with Staff #21 and Staff #23 at the time of observation.

Subsection 8.3.4.1 of NFPA 101 requires that: The doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Based on observations and testing, the facility failed to ensure that the smoke barrier doors dividing the facility into smoke/fire compartments are maintained to provide smoke/fire resistance.

Findings include:

During the tour on 06/16/10 at 10:50AM, it was noted that the smoke barrier door in the basement adjacent to the Physical and Occupational unit was the swing type and held open with electromagnetic holding devices. When manually released and attempt was made to close, the door did not close completely, resulting in a wide longitudinal gap along the entire door length. Therefore, this situation compromised the smoke resistant status of the door and, in case of fire/smoke, will not provide smoke-tight partition between the two smoke compartments as was intended by building construction/arrangement.

Finding was verified with Staff #21 and Staff #22 at the time of observation.

A. Based on observation and interview during a tour of the facility, it was determined that the hospital did not ensure that hazardous areas are protected from other areas by fire rated partitions or approved fire extinguishing system.

Findings include:

1. During the tour of the Physical/Occupational Therapy unit on 06/14/10 at 11:30AM, it was noted that the 'Hydrotherapy' room was converted, without approval, to a storage area. As per Staff #21, this room/area is approximately 500 sq ft. This area/room was stored with an abundant amount of items such as equipment, boxes, a gallon of pink paint, Christmas decorations, and other similar items.
Two hydrotherapy whirlpool tubs used for patient treatment (as per Staff #20) were noted present among these stored items in the room. All the stored items mentioned above, jeopardize patient safety by creating potential for fire hazard because:
a. This area was noted not separated or sprinklered.
b. At the time of survey the door of the 'Hydrotherapy room' was found wide open to the corridor.

Findings were verified with Staff #21 and Staff #22 at the time of observation.

B. Based on observation, the facility did not ensure that all hazardous areas are safeguarded from other spaces by doors which are self-closing or automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1.

Findings include:

1. During the tour of the facility from 06/14/10 to 06/18/10 between 10:45AM to 2:45PM, it was noted that multiple soiled utility rooms, clean utility/storage rooms and housekeeping closet did not have a self-closure installed at the door or did not latch positively. Examples, including but not limited to, are:

1.a. On 06/16/10, it was noted that housekeeping closet opening into the corridor of the OR suite, did not have a self-closure at the door.

1.b. On 06/16/10, it was noted that the soiled utility door in the Post Anesthesia Care Unit (PACU) did not latch positively since the latching plate was taped up to prevent positive latching.

1.c. On 06/16/10, it was noted that the Bio-hazard room door on the Ambulatory Surgery Unit did not latch positively.

1.d. On 06/17/10, it was noted that the clean utility door on the Med/Surg unit 2nd floor (this room was not labelled but identified by Staff #6 as clean utility room) did not latch positively.

1.e. On 06/18/10, it was noted that housekeeping closet opposite the EKG suite on 1st floor, did not have a self-closure at the door.

All the above findings were shared with and brought to the attention of escorts accompanying the surveyor at the time of survey, such as Staff #21 and Staff #22.

Based on document review and interview, the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1

Findings include:

1. On 06/18/10 at 11:45PM, during review of the vendor's sprinkler inspection report dated 01/20/10, it was noted that the internal inspections for obstructions were not conducted on the sprinkler piping, the alarm valves and associated trim, and check valves for the main campus.

Staff #23 stated that the vendor has been changed recently, and therefore it is a possibility that the 5 year test had already been done on the sprinkler system. Staff #23 tried to locate the information but failed to provide any document for this requirement.

2. It was brought to the surveyor's attention during record review that the only off-site extension clinic of the facility having a sprinkler system was the Methadone clinic. No information was provided for the regular testing and maintenance of the sprinkler system installed in that clinic and for the 5 year obstruction test. Staff #22 stated that the records were not located at the main campus.

Based on observation, it was determined that the facility failed to ensure that all portable fire extinguishers are installed conspicuously and that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10).

Findings include:

1. During observations of the pantry/nourishment room of the ICU Unit, on 06/16/10 at 12:00PM, it was noted that a portable fire extinguisher was installed on the wall with its topmost portion at more than 60 inches from the floor.

2. A similar finding was observed outside the cafeteria on 2nd floor where the fire extinguisher was also installed with its topmost portion between 64-67 inches above the floor.

Findings were shared with Staff #21 and Staff #22 at the time of observation.

Based on documentation review and staff interview, it was determined that the facility failed to ensure that all fire dampers installed at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair, and in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

On 06/18/10 at 11:50AM, during review of fire/smoke damper assessment report from 'TSB Associates' dated 05/19/09, it was noted that 45 dampers failed the test and 34 were not tested. No follow up report or work order was provided to verify that the defective fire damper were replaced/repaired. For the 34 dampers that were not tested, Staff #21 stated that sometimes due to patients occupying an area or other reasons the damper cannot be accessed and therefore is not tested. No documentation was provided regarding whether the facility intended to test those 34 dampers that could not be tested earlier.

Finding was verified with Staff #21 and Staff #23 at the time of observation.

Based on observations, the facility did not ensure that bulk oxygen storage tanks were stored in a safe manner protected from elements as per NFPA 2-2.12, and that the storage area was clear of debris as per NFPA 99 4-3.1.2.2

Findings include:

1. During survey of the oxygen bulk storage outside the building on 06/14/10 at 3:15PM, it was noted that a car parking space was designated right next to the metal fence surrounding the oxygen bulk storage. A reserve oxygen bulk tank was noted situated very near to this fence. At the time of survey, a car was not found parked in the designated space. However, no signage or barriers were around the fence cautioning people not to park there.

Note:
As per NFPA 99 Section 2-2.12, distance of the bulk storage from exposure should be '10 ft (3 m) from any public sidewalk or parked vehicles'. Also, Section 2-2.14 states that 'The distance in 2-2.12 shall not apply where protective structures having a minimum fire resistance of 2 hours interrupt the line-of-sight between uninsulated portions of the bulk oxygen storage installation and the exposure.

It is also noted that no ignition source should be near the oxygen storage area.

2. The oxygen bulk storage area was also dirty with accumulation of foliage and dry leaves inside the fence (around the bulk oxygen tank). These are combustible materials which create a fire hazard.

Findings were shared with Staff #21 and Staff #22 at the time of observation.

Based on observation and staff interview, it was determined that the facility did not maintain the piped in medical gas system as per NFPA 99.

Findings include:

During the tour of the facility from 06/16/10 to 06/17/10 between 10:30AM to 4:00PM, it was noted that the oxygen pressure in various oxygen gauges in the medical gas panels around the facility were reading between 56 PSI - 59 PSI. An example is that on 06/16/10 at 12:00PM during the PACU tour, the pressure reading on the oxygen gauge was 59 PSI and on 06/17/10 at 3:00PM, the pressure reading on the oxygen gauge outside the Hyperbaric unit was 58 PSI. As per NFPA 99, Table 4-3.1.2.4, the standard pressure to be maintained for oxygen delivery is 50 PSI (+5 and -0).

At the time of observation, findings were verified with Staff #21 who stated that he will have the pressure lowered to the required level.

Staff #21 stated that some gauges may be old and might not be giving an accurate reading despite the presence of correct pressure. Facility needs to ensure that if the pressure is as per code, that the gauges/equipment are maintained in good operating condition to ensure that pressure readings are true.

Based on observation and interview, it was determined that the hospital failed to maintain the humidity in anesthetizing locations in accordance with NFPA.

Findings include:

During observations of the ORs on 06/15/10 at 11:00AM, Staff #21 was interviewed regarding how the humidity is monitored for the ORs. Staff #21 stated that engineering does not have a mechanism to check or monitor the humidity. Staff #10 was asked how nursing staff ensure before surgery or during surgery, that the humidity is acceptable. Staff #10 did not know and stated that she needs to ask her other nursing staff. No answer was given nor were any monitoring logs provided.

Therefore, it could not be determined what humidity values were maintained in the ORs, and what the values were during surgery and if they were in compliance.

Staff #21 ordered humidity monitors for the ORs on 06/15/10. A policy and log was initiated, indicating that the facility will monitor the humidity 3 times daily and record/trend it. Also, if the ranges are not within limit, appropriate actions will be taken.

Section 3-4.1-1.15, NFPA 99, requires that a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12).

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.

(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(1) Low lubricating oil pressure
(2) Low water temperature (below those required in 3-4.1.1.9)
(3) Excessive water temperature
(4) Low fuel-when the main fuel storage tank contains less than a 3-hour operating supply.
(5) Overcrank (failed to start)
(6) Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. (110:3-5.5.2)

Based on observation and staff interview during the survey, the facility did not ensure that 2 generators at the campus are provided with a remote annunciator to operate outside of the generating room so as to indicate the alarm conditions stated under Section 3.4.1.1.15 of NFPA 99.

Findings include:

During tour of the facility between 06/14/10 to 06/18/10, it was noted that the facility maintains life support equipment to provide general anesthesia in the operating room and for ventilators in the ICU units.
The facility has installed 2 generators to provide emergency power to the facility, including life support equipment, in case the normal electrical power to the facility is lost. The operating rooms are supplied by both generators.

Remote annunciator panel/s outside of the generator room were not provided at a constantly attended location for the conditions under 3.4.1.1.15. Facility only has a derangement signal for remote annunciation installed in the 24/7 manned security room for both of its generators. Absence of a remote annunciator was verified with Staff #21 at the time of survey.

Based on observation and staff interview, it was determined that the facility did not ensure that the master alarm system, provided to monitor the operation and condition of the piped in oxygen supply system, consists of two or more alarm panels located in two separate locations, as per NFPA 99, health care facilities.

Findings include:

During the tour of the facility between 06/14/10 and 06/18/10, it was observed that the facility is equipped with the piped in oxygen supply and suction system throughout the building. On 06/17/10 at 12:15PM, Staff #21 was asked if master alarm panels for monitoring the oxygen supply, medical gas and suction systems have been provided in two separate locations, as per NFPA 99, health care facilities. Staff #21 could not verify the location of two master alarm panel in the facility. Staff #21 stated that only one signal panel of audible and visual alarm device has been provided in the 24/7 manned security office.

Based on observation, it was determined that the facility did not ensure that 'No smoking' signs were installed around the fence where bulk oxygen was stored.

Findings include:

During the tour of the facility grounds on 06/14/10 at 3:15PM, it was noted that the area where bulk storage was located did not have any "No smoking" sign installed around the fence.

Furthermore, a parking lot is nearby with no caution sign alerting to the presence of oxygen. Findings were verified with Staff #21 and Staff #22 at the time of observation.

Based on observations made during tours, it was determined that the facility failed to ensure that corridor walls were constructed and maintained to resist the passage of smoke.

Findings include:

1. During the tour of the facility from 06/16/10 to 06/18/10, it was noted that various areas of the corridor in the facility (that were not sprinklered) were not maintained with construction of as at least 1/2 hour fire resistive rating and had penetrations. Examples, including but not limited to, are:

a. On 06/16/09 at 2:45PM, an unsealed penetration about 2-3 inches made by a HVAC duct was observed above the dropped ceiling in the corridor wall of the communication closet (near ICU).

b. On 06/17/10 at 11:15PM, a hole was noted filled by joint compound (not rated material) by the double door of the smoke barrier of the Med/Surg unit on 2nd floor.

c. A penetration was noted made by conduit in the corridor wall of the Information Technology closet in the Med/Surg unit 2nd floor.

Findings were verified with Staff #21 at the time of observation.

Section A-19-2.1.1.1 of NFPA 99 1999 states that:
"Characteristics of building construction housing hyperbaric chambers and ancillary facilities are no less important to safety from fire hazards than are the characteristics of the hyperbaric chambers themselves. It is conceivable that a fire emergency occurring immediately outside a chamber, given sufficient fuel, could seriously endanger the life or lives of those inside the chamber."

Based on observation, the facility failed to ensure that the door to Hyperbaric unit (which is considered as a hazardous area), is held open with approved devices which are arranged to automatically close all such doors upon the activation of the fire alarm systems, as per NFPA 101 19.2.2.2.6.

Findings include:

1.a. During observation on 06/17/10 at 2:45PM, it was noted that the door to the Hyperbaric Unit on 5th floor was kept propped open by means of an elastic/hair band connected from the door handle to the wall. This arrangement of holding the door open is not approved and would prevent the automatic closure of the doors upon the activation of the facility's fire alarm systems.

1.b. Furthermore, during the survey it could not be verified if the door of the Hyperbaric unit, opening to the corridor and protecting the room, is rated or not. There was no label on the door.

Section 19-2.1.1.1* of NFPA 99 for Hyperbaric suite states that 'If there are connecting doors through such common walls of contiguity, they shall be at least B-label, 11/2-hour fire doors'.

Findings were verified with Staff #21 and Staff #23 at the time of observation.

Subsection 8.3.4.1 of NFPA 101 requires that: The doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Based on observations and testing, the facility failed to ensure that the smoke barrier doors dividing the facility into smoke/fire compartments are maintained to provide smoke/fire resistance.

Findings include:

During the tour on 06/16/10 at 10:50AM, it was noted that the smoke barrier door in the basement adjacent to the Physical and Occupational unit was the swing type and held open with electromagnetic holding devices. When manually released and attempt was made to close, the door did not close completely, resulting in a wide longitudinal gap along the entire door length. Therefore, this situation compromised the smoke resistant status of the door and, in case of fire/smoke, will not provide smoke-tight partition between the two smoke compartments as was intended by building construction/arrangement.

Finding was verified with Staff #21 and Staff #22 at the time of observation.

A. Based on observation and interview during a tour of the facility, it was determined that the hospital did not ensure that hazardous areas are protected from other areas by fire rated partitions or approved fire extinguishing system.

Findings include:

1. During the tour of the Physical/Occupational Therapy unit on 06/14/10 at 11:30AM, it was noted that the 'Hydrotherapy' room was converted, without approval, to a storage area. As per Staff #21, this room/area is approximately 500 sq ft. This area/room was stored with an abundant amount of items such as equipment, boxes, a gallon of pink paint, Christmas decorations, and other similar items.
Two hydrotherapy whirlpool tubs used for patient treatment (as per Staff #20) were noted present among these stored items in the room. All the stored items mentioned above, jeopardize patient safety by creating potential for fire hazard because:
a. This area was noted not separated or sprinklered.
b. At the time of survey the door of the 'Hydrotherapy room' was found wide open to the corridor.

Findings were verified with Staff #21 and Staff #22 at the time of observation.

B. Based on observation, the facility did not ensure that all hazardous areas are safeguarded from other spaces by doors which are self-closing or automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1.

Findings include:

1. During the tour of the facility from 06/14/10 to 06/18/10 between 10:45AM to 2:45PM, it was noted that multiple soiled utility rooms, clean utility/storage rooms and housekeeping closet did not have a self-closure installed at the door or did not latch positively. Examples, including but not limited to, are:

1.a. On 06/16/10, it was noted that housekeeping closet opening into the corridor of the OR suite, did not have a self-closure at the door.

1.b. On 06/16/10, it was noted that the soiled utility door in the Post Anesthesia Care Unit (PACU) did not latch positively since the latching plate was taped up to prevent positive latching.

1.c. On 06/16/10, it was noted that the Bio-hazard room door on the Ambulatory Surgery Unit did not latch positively.

1.d. On 06/17/10, it was noted that the clean utility door on the Med/Surg unit 2nd floor (this room was not labelled but identified by Staff #6 as clean utility room) did not latch positively.

1.e. On 06/18/10, it was noted that housekeeping closet opposite the EKG suite on 1st floor, did not have a self-closure at the door.

All the above findings were shared with and brought to the attention of escorts accompanying the surveyor at the time of survey, such as Staff #21 and Staff #22.

Based on document review and interview, the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25 1998 Table 2-1 and Table 9-1

Findings include:

1. On 06/18/10 at 11:45PM, during review of the vendor's sprinkler inspection report dated 01/20/10, it was noted that the internal inspections for obstructions were not conducted on the sprinkler piping, the alarm valves and associated trim, and check valves for the main campus.

Staff #23 stated that the vendor has been changed recently, and therefore it is a possibility that the 5 year test had already been done on the sprinkler system. Staff #23 tried to locate the information but failed to provide any document for this requirement.

2. It was brought to the surveyor's attention during record review that the only off-site extension clinic of the facility having a sprinkler system was the Methadone clinic. No information was provided for the regular testing and maintenance of the sprinkler system installed in that clinic and for the 5 year obstruction test. Staff #22 stated that the records were not located at the main campus.

Based on observation, it was determined that the facility failed to ensure that all portable fire extinguishers are installed conspicuously and that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10).

Findings include:

1. During observations of the pantry/nourishment room of the ICU Unit, on 06/16/10 at 12:00PM, it was noted that a portable fire extinguisher was installed on the wall with its topmost portion at more than 60 inches from the floor.

2. A similar finding was observed outside the cafeteria on 2nd floor where the fire extinguisher was also installed with its topmost portion between 64-67 inches above the floor.

Findings were shared with Staff #21 and Staff #22 at the time of observation.

Based on documentation review and staff interview, it was determined that the facility failed to ensure that all fire dampers installed at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair, and in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

On 06/18/10 at 11:50AM, during review of fire/smoke damper assessment report from 'TSB Associates' dated 05/19/09, it was noted that 45 dampers failed the test and 34 were not tested. No follow up report or work order was provided to verify that the defective fire damper were replaced/repaired. For the 34 dampers that were not tested, Staff #21 stated that sometimes due to patients occupying an area or other reasons the damper cannot be accessed and therefore is not tested. No documentation was provided regarding whether the facility intended to test those 34 dampers that could not be tested earlier.

Finding was verified with Staff #21 and Staff #23 at the time of observation.

Based on observations, the facility did not ensure that bulk oxygen storage tanks were stored in a safe manner protected from elements as per NFPA 2-2.12, and that the storage area was clear of debris as per NFPA 99 4-3.1.2.2

Findings include:

1. During survey of the oxygen bulk storage outside the building on 06/14/10 at 3:15PM, it was noted that a car parking space was designated right next to the metal fence surrounding the oxygen bulk storage. A reserve oxygen bulk tank was noted situated very near to this fence. At the time of survey, a car was not found parked in the designated space. However, no signage or barriers were around the fence cautioning people not to park there.

Note:
As per NFPA 99 Section 2-2.12, distance of the bulk storage from exposure should be '10 ft (3 m) from any public sidewalk or parked vehicles'. Also, Section 2-2.14 states that 'The distance in 2-2.12 shall not apply where protective structures having a minimum fire resistance of 2 hours interrupt the line-of-sight between uninsulated portions of the bulk oxygen storage installation and the exposure.

It is also noted that no ignition source should be near the oxygen storage area.

2. The oxygen bulk storage area was also dirty with accumulation of foliage and dry leaves inside the fence (around the bulk oxygen tank). These are combustible materials which create a fire hazard.

Findings were shared with Staff #21 and Staff #22 at the time of observation.

Based on observation and staff interview, it was determined that the facility did not maintain the piped in medical gas system as per NFPA 99.

Findings include:

During the tour of the facility from 06/16/10 to 06/17/10 between 10:30AM to 4:00PM, it was noted that the oxygen pressure in various oxygen gauges in the medical gas panels around the facility were reading between 56 PSI - 59 PSI. An example is that on 06/16/10 at 12:00PM during the PACU tour, the pressure reading on the oxygen gauge was 59 PSI and on 06/17/10 at 3:00PM, the pressure reading on the oxygen gauge outside the Hyperbaric unit was 58 PSI. As per NFPA 99, Table 4-3.1.2.4, the standard pressure to be maintained for oxygen delivery is 50 PSI (+5 and -0).

At the time of observation, findings were verified with Staff #21 who stated that he will have the pressure lowered to the required level.

Staff #21 stated that some gauges may be old and might not be giving an accurate reading despite the presence of correct pressure. Facility needs to ensure that if the pressure is as per code, that the gauges/equipment are maintained in good operating condition to ensure that pressure readings are true.

Based on observation and interview, it was determined that the hospital failed to maintain the humidity in anesthetizing locations in accordance with NFPA.

Findings include:

During observations of the ORs on 06/15/10 at 11:00AM, Staff #21 was interviewed regarding how the humidity is monitored for the ORs. Staff #21 stated that engineering does not have a mechanism to check or monitor the humidity. Staff #10 was asked how nursing staff ensure before surgery or during surgery, that the humidity is acceptable. Staff #10 did not know and stated that she needs to ask her other nursing staff. No answer was given nor were any monitoring logs provided.

Therefore, it could not be determined what humidity values were maintained in the ORs, and what the values were during surgery and if they were in compliance.

Staff #21 ordered humidity monitors for the ORs on 06/15/10. A policy and log was initiated, indicating that the facility will monitor the humidity 3 times daily and record/trend it. Also, if the ranges are not within limit, appropriate actions will be taken.

Section 3-4.1-1.15, NFPA 99, requires that a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12).

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.

(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(1) Low lubricating oil pressure
(2) Low water temperature (below those required in 3-4.1.1.9)
(3) Excessive water temperature
(4) Low fuel-when the main fuel storage tank contains less than a 3-hour operating supply.
(5) Overcrank (failed to start)
(6) Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. (110:3-5.5.2)

Based on observation and staff interview during the survey, the facility did not ensure that 2 generators at the campus are provided with a remote annunciator to operate outside of the generating room so as to indicate the alarm conditions stated under Section 3.4.1.1.15 of NFPA 99.

Findings include:

During tour of the facility between 06/14/10 to 06/18/10, it was noted that the facility maintains life support equipment to provide general anesthesia in the operating room and for ventilators in the ICU units.
The facility has installed 2 generators to provide emergency power to the facility, including life support equipment, in case the normal electrical power to the facility is lost. The operating rooms are supplied by both generators.

Remote annunciator panel/s outside of the generator room were not provided at a constantly attended location for the conditions under 3.4.1.1.15. Facility only has a derangement signal for remote annunciation installed in the 24/7 manned security room for both of its generators. Absence of a remote annunciator was verified with Staff #21 at the time of survey.

Based on observation and staff interview, it was determined that the facility did not ensure that the master alarm system, provided to monitor the operation and condition of the piped in oxygen supply system, consists of two or more alarm panels located in two separate locations, as per NFPA 99, health care facilities.

Findings include:

During the tour of the facility between 06/14/10 and 06/18/10, it was observed that the facility is equipped with the piped in oxygen supply and suction system throughout the building. On 06/17/10 at 12:15PM, Staff #21 was asked if master alarm panels for monitoring the oxygen supply, medical gas and suction systems have been provided in two separate locations, as per NFPA 99, health care facilities. Staff #21 could not verify the location of two master alarm panel in the facility. Staff #21 stated that only one signal panel of audible and visual alarm device has been provided in the 24/7 manned security office.

Based on observation, it was determined that the facility did not ensure that 'No smoking' signs were installed around the fence where bulk oxygen was stored.

Findings include:

During the tour of the facility grounds on 06/14/10 at 3:15PM, it was noted that the area where bulk storage was located did not have any "No smoking" sign installed around the fence.

Furthermore, a parking lot is nearby with no caution sign alerting to the presence of oxygen. Findings were verified with Staff #21 and Staff #22 at the time of observation.