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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations in the facility to prevent the spread of fire and smoke. This failure affected 1 of 5 floors in the Patient Tower and 3 of 5 floors in the Main Building. This could result in potential harm to patients, staff and visitors in the event of a fire.

Findings:

During the facility tour with the Director of Facilities and the Director of Security on March 14, 2011 through March 18, 2011, the facility walls and ceilings were observed.

Patient Tower - Fifth Floor on 3/15/11:
At 11:18 a.m., in the CDC Kitchen/Supply room there was a 1 inch penetration in the wall behind the door where the door closure hits the wall.

Main Building - Fifth Floor on 3/15/11:
At 11:48 a.m., the Storage room filled with boxes next to the stair well had a 1/ 2 inch penetration in the back wall.
Main Building - Fourth Floor on 3/15/11:
At 12:00 p.m., the Storage room filled with supply's next to the stair well had a 3/4 inch penetration in the back wall.

Main Building - First Floor on 3/16/11:
At 10:25 a.m., next to the desk in Respiratory there was a discontinue phone jack that was removed and revealed a 2 inch by 4 inch penetration in the wall.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected two of two floors in the Southwest Hospital, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with the Supervisor of Plant Operations on March 15, 2011 and March 16, 2011, the walls and ceilings in the Southwest hospital were observed.

Southwest Hospital - Second Floor on 3/15/11:
At 9:51 a.m., there was an approximately 1/4 inch by 5 inch penetration in the ceiling, adjacent to the shower light fixture, in the bathroom of Room 2158.

At 9:54 a.m., there was an approximately 1/2 inch by 3 inch penetration in the ceiling, adjacent to the shower light fixture, in the bathroom of Room 2156.

At 10:24 a.m., there were two approximately 1/4 inch penetrations in the back wall of the staff lounge, of the Med Surge nurses ' station, near the refrigerator.

At 10:35 a.m., there was an approximately 2 inch by 4 inch penetration in the back wall of the I.S. Room, on the right-hand side, around an electrical conduit.

At 11:04 a.m., there were four approximately 1/4 inch penetrations in the left wall of the Women ' s Care Center janitor ' s closet, near the mop sink. There was an approximately 1 1/2 inch penetration in the right wall, near the door.

First Floor:

At 2:51 p.m., there was an approximately 1/2 inch penetration in the left wall, near the front corner, of the biomedical engineering office.

At 3:45 p.m., there were two approximately 1 inch penetrations in the front wall of Room 1139, behind the x-ray viewing machine.

Based on observation, the facility failed to maintain its doors to close and resist the passage of smoke and the integrity of the doors to provide an effective smoke barrier in the event of a fire. This failure affected 1 of 5 floors in the Main Building and 2 of 5 floors in the Patient Tower. This could result in the potential harm to patients, staff and visitors.
Findings:

During the facility tour with the Director of Facilities and the Director of Security on March 14, 2011 through March 18, 2011, the corridor doors were observed.

Main Building - Fourth Floor on 3/15/11:
At 11:53 a.m., the door to Patient room 424 failed to latch when closed.
At 12:07 p.m., the door to Patient room 425 was equipped with a self closure device that was disassembled.

Patient Tower - Fourth Floor on 3/15/11:
At 12:15 p.m., the door to patient room 405 failed to latch when closed.
Patient Tower - Third Floor on 3/15/11:
At 3:11 p.m., the door to Patient room 306 failed to latch when closed.
At 3:29 p.m., the door to Patient room 317 failed to latch when closed.
At 3:32 p.m., the door to Patient room 309 failed to latch when closed.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by penetrations in doors, and doors that failed to latch. This affected two of two floors in the Southwest hospital, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with the Supervisor of Plant Operations on March 15, 2011 and March 16, 2011 , the doors were observed.

Southwest Hospital - Second Floor on 3/15/11:
At 10:37 a.m., the door to the I.S. Room, equipped with a self-closing device, closed but failed to latch.

At 10:44 a.m., the door to the rehab services mailroom, equipped with a self-closing device, closed but failed to latch.

At 11:01 a.m., there was an approximately 1/2 inch penetration, in the upper right-hand corner of the quality nurse ' s office door, in the Women ' s Care Center.

At 11:35 a.m., there was an approximately 1/4 inch penetration, in the upper right-hand corner of the door to Room 2337.


First Floor:
At 2:16 p.m., the door to the Room 1367, equipped with a self-closing device, closed but failed to latch.

At 2:45 p.m., the door to the supply closet across from the administration office, equipped with a self-closing device, closed but failed to latch.

At 3:08 p.m., the door to the admitting supervisor ' s office, equipped with a self-closing device, closed but failed to latch.

At 3:51 p.m., the door to the Room 1160, equipped with a self-closing device, closed but failed to latch.

At 4:00 p.m., the door to the security office, equipped with a self-closing device, closed but failed to latch.


First Floor on 3/16/11:
At 10:45 a.m., the corridor double doors, outside the pharmacy, closed but failed to latch, upon release from a magnetic hold-open device, during fire alarm testing.

Based on observation, the facility failed to maintain door devices connected to the fire alarm system to release doors upon activation of fire alarms. This was evidenced by doors that failed to release from held open devices during the testing of the fire alarm system. This could result in the failure to contain smoke to a compartment and affected patients, staff and visitors in 5 of 5 floors in the Patient Tower.

Findings:

During the testing of the fire alarm system with the Director of Facilities, Director of Security, and Supervisor of Plant Operations on March 16, 2011 and March 17, 2011, doors held open by devices were observed.

Patient Tower - First Floor through Fifth Floor on 3/16/11:
At 3:10 p.m., the smoke barrier doors on the first floor entering the cafeteria and the smoke barrier doors in the corridors (two sets of doors) failed to release from the held open devices during the testing of the fire alarm system.
At 3:20 p.m., 3 of 3 smoke barrier doors on the second floor failed to release from the held open devices during the testing of the fire alarm system.
At 3:30 p.m., During interview, facility staff confirmed the smoke barrier doors on the first floor through the fifth floor in the Patient Tower (also known as the 81 Building) were not releasing upon activation of the fire alarm system. During interview with the Director of Facilities and Director of Security both stated they were not aware of any problems with doors not closing.
At 4:00 p.m., the Director of Facilities stated a Fire Watch for the Patient Towers would be implemented and the fire alarm vendor would be contacted.
Total Census for Patient Tower: 60

Patient Tower - First Floor through Firth Floor on 3/17/11:
At 9:15 a.m., the fire alarm vendor stated they were in the process of repairing the problem with the door devices.
At 9:40 a.m., the fire alarm vendor stated they had found wires that were not connected and stated that they did not know why or who may have disconnected the wires and stated this was the reason the doors were not releasing.
At 9:50 a.m., smoke barrier doors entering the first floor Cafeteria and the two sets of smoke barrier doors all release and latched during fire alarm testing.
At 9:55 a.m., 3 of 3 smoke barrier doors on the second floor Patient Tower released and latched.

At 10:15 a.m., Staff confirmed the smoke barrier doors in the Patient Tower floors 1 through 5 were releasing from their devices during fire alarm testing.

At 12:00 p.m., on 3/17/11, after the completion of the fire alarm testing on floors 1 through 5 in the Patient Tower and the doors were observed to be releasing from their devices the Patient Tower Fire Watch was abated.

Based on observation, the facility failed to maintain doors held open by approved hold-open devices. This was evidenced by one door, in an elevator enclosure, that failed to release from a hold-open device, during fire alarm testing. This affected one of two floors in the Southwest hospital, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with the Supervisor of Plant Operations on March 16, 2011, in the Southwest hospital, doors held open with magnetic devices were observed.

Southwest Hospital - First Floor on 3/16/11:
At 10:45 a.m., the left leaf of the double doors, enclosing the elevators across from the pharmacy, did not release from the magnetic hold-open device, during fire alarm testing. The right leaf released and closed.

Based on observation, the facility failed to maintain the integrity of its fire rated smoke barrier construction as evidenced by unsealed penetrations in the smoke barrier walls. This affected 2 of 5 floors on the Patient Tower and 1 of 4 Floors in the Treatment and Diagnostic Building. The failure to maintain the integrity of the walls would allow the spread of fire and smoke from one compartment to another resulting in potential harm to patients, staff and visitors.

Findings:

During the facility tour with the Director of Facilities and Director of Security on March 14, 2011 through March 18, 2011, the smoke barrier walls were observed.

Patient Tower - Fifth Floor on 3/15/11:
At 11:00 a.m., the East smoke barrier wall had a 3/4 inch penetration around grey wires in the center of the wall and two unsealed conduits on the left side of the wall.
At 11:05 a.m., the West smoke barrier wall had two unsealed flexible conduits with a 1/4 inch penetration around two flexible conduits in the center of the wall and an unsealed conduit with wires running through.

Patient Tower - Third Floor on 3/15/11:
At 3:04 p.m., the East smoke barrier wall had a 1/2 inch penetration around grey wires in the right side of the wall.

Treatment and Diagnostic - Second Floor on 3/15/11:
At 4:33 p.m., the smoke barrier wall entering the Emergency Department (ER) had a two inch unsealed conduit with grey wires running through and a 4 inch by 6 inch penetration in the left side of the wall.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls, as evidenced by penetrations in one smoke barrier wall. This affected one of two floors in the Southwest hospital, and could result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During the facility tour with staff, from 3/15/11 - 3/16/11, the smoke barrier walls in the Southwest hospital were observed.

Southwest Hospital - Second Floor on 3/15/11:
At 10:02 a.m., there was an approximately 5 inch by 5 inch penetration, in the center of the smoke barrier wall, by Room 2154, around an electrical conduit.

Based on observation, the facility failed to maintain its fire rated smoke barriers doors on hold open devices to latch and resist the passage of smoke upon activation of the fire alarm system as evidenced by smoke barrier doors that failed to latch on 2 of 5 Floors in the Main Building and 2 of 5 floors in the Patient Tower Building. The failure to maintain doors could result in the potential spread of smoke from one compartment to another in the event of a fire causing harm to patients, staff and visitors.

Findings:

During the testing of the fire alarm system with the Director of Facilities, Director of Security and Plant Operations Supervisor on March 16, 2011 and March 17, 2011, the smoke barrier doors were observed.

Main Building - Third Floor on 3/17/11:
At 10:13 a.m., the smoke barrier door entering the Main Building from the Treatment and Diagnostic Building failed to latch shut during the activation of the fire alarms.
Main Building - Fourth Floor on 3/17/11:
At 11:04 a.m., the smoke barrier door entering the Main Building from the Treatment and Diagnostic Building failed to latch shut during the activation of the fire alarms.

Patient Tower - Third Floor on 3/17/11:
At 10:26 a.m., the left leaf of the smoke barrier door next to the Charge Nurse office failed to latch upon activation of the fire alarms.
Patient Tower - Fifth Floor on 3/17/11:
At 11:30 a.m., the left leaf of the smoke barrier door next to the Charge Nurse office failed to latch upon activation of the fire alarms.

Based on observation, the facility failed to maintain their smoke barrier doors, as evidenced by one smoke barrier door that failed to latch. This affected one of two floors in the Southwest hospital, and could result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During fire alarm testing with the Supervisor of Plant Operations on March 16, 2011, the smoke barrier doors were observed.

Southwest Hospital - Second Floor on 3/16/11:
At 9:40 a.m., the right leaf of the smoke barrier double doors, outside Room 2108, closed but failed to latch, upon release from a magnetic hold-open device, during fire alarm testing.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by one door to a hazardous area that did not latch, and by one hazardous area that has penetrations in the walls, and is not protected by self-closing door. This affected two of two floors in the Southwest hospital, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with the Supervisor of Plant Operations on March 15, 2011 and March 16, 2011 , the hazardous areas were observed.

Southwest Hospita - Second Floor on 3/15/11:
At 10:23 a.m., the door to the biohazard waste room, near the Med Surge nurses ' station, equipped with a self-closing device, closed but failed to latch.

First Floor on 3/15/11:
At 2:02 p.m., the interior door of the gift shop storage room was observed. The room is greater than 50 square feet in size and contained shelves of cardboard boxes, decorations, stuffed animals, and other combustibles. The door was not equipped with a self-closing device.

At 2:08 p.m., there were three approximately 1/2 inch penetrations, and one approximately 1 inch penetration, in the back wall of the gift shop storage room, above the flower refrigerator.

Based on observation, document review, interview and fire alarm testing, the facility failed to maintain it's fire alarm system, in accordance with the NFPA 72, National Fire Alarm Code as evidenced by: 1) failing to provide documentation of repairing or replacing devices that failed during the past four quarterly testing; 2) failing to maintain and repair a fire alarm system "trouble" reported on the main fire alarm panel and sub-panels; 3) failing to provide documented evidence of acknowledging trouble alarms and investigating the problems for repairs; and 4) failure of audible devices. The failure to maintain the fire alarm system could result in the system not functioning as required in the event of a fire or other emergency. This affected the entire facility and could result in potential harm to patients, staff and visitors.

Findings:

During document review with the Director of Facilities on March 15, 2011, between 2:00 p.m., and 4:30 p.m., the past four quarterly test and inspection reports dated May 2010, August 2010, November 2010 and February 2011, from a licensed vendor were reviewed. The reports noted failures. During interview, the Director of Facilities was asked for the documentation for the repairs that were noted in the quarterly reports. The Director of Facilities stated he did not have any documentation and did not know if any repairs had been completed.

During the tour of the facility with the Director of Facilities and Director of Security on March 16, 2011, at 10:55 a.m., the fire alarm sub panel outside of CDC 5th floor Patient Tower noted trouble mode "Node 5" and at 11:20 the fire alarm panel located in CDC Kitchen noted the same trouble "Node 5". During interview, the Director of Facilities and the Director of Security both stated they were not aware that the fire alarm panel was in a trouble mode and did not have any documentation of acknowledging when the fire alarm panel is in trouble modes.

During observation of the main fire alarm panel with the Director of Facilities and the Director of Security, on March 16, 2011, the main fire alarm panel located on the first floor in PBX noted two troubles for "Node 4 and Node 5". During interview, staff in PBX stated they log all fire alarms including troubles on a note pad and also stated they would call engineering.

During interview with Director of Facilities and Director of Security on March 16, 2011, at 4:45 p.m., the facility failed to provide documentation of acknowledging and documentation of repairing fire alarm system issues. The Director of Facilities stated the fire alarm vendor was contacted and would be onsite tomorrow morning.

During the testing of the fire alarm system with the Director of Facilities, Director of Security, and Supervisor of Plant Operations on March 16, 2011 and March 17, 2011, the audible and visual devices were observed.

Main Building - First Floor on 3/16/11:
At 2:30 p.m., the chime next to the Nurse Station in the Endoscopy Department failed to activate an audible alarm during testing.
At 2:35 p.m., chime in the Respiratory Therapy corridor failed to activate an audible alarm during testing.

Treatment and Diagnostic - First Floor on 3/16/11:
At 2:40 p.m., the strobe across the Dietary Freezers failed to activate during alarm testing.

Patient Tower - Fourth Floor on 3/17/11:
At 10:37 a.m., the chime located next to the House Keeping closet failed to activate an audible alarm during testing.

Main Building - Fourth Floor on 3/17/11:
At 11:00 a.m., chime next to room 423 and room 433 failed to activate an audible alarm during testing.

During interview with the fire alarm vendor with the Director of Facilities on March 17, 2011, at 9:30 a.m., the vendor stated he found and corrected the problem for the doors not releasing and was trouble shooting the "Node 4 and 5" problem in the fire alarm panel. Fire alarm testing was continued due to the activation of alarms would override the Node problems according to the fire alarm vendor. This was confirmed by the activation of smoke detectors, manual pulls and water flow devices that reported to the main fire alarm panel and the fire alarm activity report that was provided by the outside monitoring company.

On March 18, 2011, at 8:10 a.m., the main fire alarm panel in PBX and the fire alarm panel in the control room were observed to be in trouble mode.

On March 18, 2011, at 8:55 a.m., the facility provided a copy of a memo from the fire alarm vendor dated March 18, 2011, stating they would be back on site to continue working on the fire alarm. The memo also stated "these troubles will not affect the way the Fire Alarm system reports".

Based on observation and interview, the facility failed to maintain their fire alarm system. This was evidenced by one area with no alarm annunciator. This affected one of two floors in the Southwest hospital, and could result in a delay of notification, in the event of a fire.

Findings:

During fire alarm testing with the Supervisor of Plant Operations on March 16, 2011, the fire alarm annunciators were observed.

Southwest Hospital - First Floor on 3/16/11:
At 10:50 a.m., there was no audible or visual fire alarm device in the pharmacy. Near the back of the pharmacy, no alarm can be seen or heard during fire alarm testing.
During an interview at 10:51 a.m., a pharmacy staff member, working in the back of the pharmacy, stated that he had not heard any alarms since he started his shift at 10:00 a.m. Fire alarm testing began at 9:05 a.m. that day, and five alarm devices were activated between 10:00 a.m. and 10:50 a.m. The device activated at 10:10 a.m. alarmed for more than seven minutes. The pharmacy staff member did not hear any of the alarms.

Based on observation and interview, the facility failed to maintain its fire alarm system as evidenced by a smoke detector that was disassembled and missing its base. This failure affected 1 of 5 floors in the Main Building and could result in failure to activate the fire alarm system and notify the facility of a fire in the facility. This had potential to cause harm to patients, staff and visitors.

Findings:

During the facility tour with the Director of Facilities and Director of Security on March 14, 2011 through March 18, 2011, the fire alarm devices were observed.

Main Building - Fourth Floor on 3/15/11:
At 12:04 p.m., the smoke detector located in the Nurse Station was missing. During interview nursing staff stated they did not know how long ago the smoke detector was removed.
At 12:05 p.m., During interview, the Director of Facilities stated the smoke detector was removed due to water damage, but did not know when. The Director of Facilities found a report from the fire alarm vender stating the smoke detector was removed on 3/11/11 and the Facility Director did not know why it had not been replaced.

Based on observation, the facility failed to ensure the automatic sprinkler system was maintained and inspected periodically as evidenced by sprinklers there were contaminated with paint, corroded, sprinkler escutcheon rings that were not flush with the ceiling had gaps or were missing. This failure could result in the sprinkler system not functioning as designed and affected 1 of 5 floor in the Patient Tower, 1 of 5 floors in the Main Building and 1 of 4 floors in Treatment and Diagnostic Building.

NFPA 25, 1998 Edition
2-2 Inspection. 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During the facility tour with the Director of Facilities and Director of Security on March 14, 2011 through March 18, 2011, the sprinkler system was observed.

Patient Tower - Fifth Floor on 3/15/11:
At 11:25 a.m., in the Staff locker room\Time clock room 3 of 3 sprinkler escutcheon ring had gaps and were not flush with the ceiling.

Treatment and Diagnostic - Second Floor on 3/15/11:
At 4:19 p.m., the sprinkler in Radiology room 6 had signs of corrosion.
At 4:36 p.m., the sprinkler in the Emergency Department corridor next to room 229 was contaminated with paint.

Main Building - First Floor on 3/16/11:
10:35 a.m., the sprinkler escutcheon ring was missing in the corridor entering the Respiratory break room.
10:44 a.m., the sprinkler escutcheon ring was missing in the Dialysis Storage room that is located next to Housekeeping break room.
11:30 a.m., the sprinkler escutcheon ring was missing in the Loading dock corridor.
At 11:44 a.m., 1 of 6 sprinkler escutcheon rings was missing in the Dietary break room.
At 11:46 a.m., the sprinkler escutcheon ring was missing in the Dietary office corridor.
At 12:01 p.m., 1 of 2 sprinkler escutcheon rings was missing in the Dietary Dry Storage room.

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Based on record review and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by three sprinkler tamper switches that failed inspections since November 2009, by one water flow detector that failed inspections since November 2010, and by no documents for quarterly testing of the sprinkler system for two of four quarters. This affected two of two floors in the Southwest hospital, and could result in a delay in extinguishing a fire, in the event of a fire.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition.

1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Findings:

During document review from March 14, 2011 through March 17, 2011, the sprinkler system maintenance documents for the Southwest hospital were requested.

Southwest Hospital on 3/14/11:
At 4:15 p.m., the sprinkler system testing documents were provided for November 2010 and February 2011. The sprinkler system testing was performed by a vendor, which tests the facilities fire alarm system quarterly. The documents indicated that one tamper switch in the North Pump Room, two tamper switches in the Core Hall 1404, and the main water flow detector, failed during inspections on November 2010 and February 2011.

Southwest Hospital on 3/15/11:
At 8:31 a.m., the records of the vendor ' s inspections of the fire alarm system on May 2010, and August 2010, were provided. The records indicated that the sprinkler system was not tested during these inspections.
During an interview at 8:32 a.m., the Supervisor of Plant Operations stated that the vendor does all the inspections.

Southwest Hospital on 3/17/11:
At 2:20 p.m., the records of the vendor ' s November 2009 inspection indicated that one tamper switch in the North Pump Room, and two tamper switches in Core Hall 1404, failed during the inspection.

There was no documentation provided, dated from November 2009 to March 14, 2011, indicating that the facility attempted to repair the tamper switches that failed. Documentation provided indicated that the tamper switches in Core Hall 1404, and the main water flow detector, were repaired on 3/16/11 by the vendor, and the tamper switch in the North Pump Room was repaired on 3/17/11.

Based on observation, and interview, the facility failed to maintain their portable fire extinguishers as evidenced by fire extinguishers that were obscured from view. This affected 1 of 5 floors in the Main Building and 1 of 5 floor in the Patient Tower. This had the potential for inaccessibility to the fire extinguisher in the event of a fire, which could result in potential harm to patients and staff.

NFPA 10, Standard for Portable Fire Extinguishers (1998 Edition)
1-6 General Requirements.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14kg) shall be installed so the the top of the fire extinguisher is not more than 5ft (1.53 m) above the floor.

Findings:

During the tour of the facility with the Director of Facilities and Director of Security on March 14, 2011 through March 18, 2011, the fire extinguishers were observed.

Main Building - First Floor on 3/16/11:
At 11:27 a.m., the fire extinguisher in Pharmacy next to the exit door was mounted less than 12 inches from the floor and was visually obstructed by the counter. There was no sign to indicate there was a fire extinguisher.

Patient Tower - Fourth Floor on 3/17/11:
At 10:54 a.m., the fire extinguisher in ICU 1 was mounted less that 10 inches from the floor and was not visible to staff. There was no sign to indicated there was a fire extinguisher. During an interview, the Registered Nurse stated she did not know there was a fire extinguisher across from the nurse station because its was mounted very low and was obscured by a collum.

Based on observation, the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This was evidenced by one fire extinguisher that was obstructed, and by one fire extinguisher that had not been serviced for more than one year. This affected one of two floors in the Southwest hospital, and could result in a delay in extinguishing a fire.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1.6.3 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.
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.

4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Findings:

During the facility tour with the Supervisor of Plant Operations on March 15, 2011 and March 16, 2011, the fire extinguishers in were observed.

Southwest Hospital - First Floor on 3/16/11:
At 9:54 a.m., the fire extinguisher, mounted on the front wall of O.R. 2, was obstructed by a biohazard bin.

At 10:01 a.m., the fire extinguisher in the sterile storage room was last serviced on 10/5/09. There were three monthly checks on the tag dated 11/10, 04/10, and 12/09.

Based on observation and interview, the facility failed to ensure the storage of medical gas is in accordance with NFPA 99, as evidenced by oxygen stored with combustible material such as plastic supplies, clean linen and wheel chairs in a non sprinklered room. This affected 1 of 5 floors in the Main Building and could result in potential harm to patients, staff and visitors in the event of a fire.

NFPA 99, 1999 (Edition)
8-3.1.11 Storage Requirements.
8-3.1.11.2 Storage for non Flammable gases less than 3000 ft (85 m 3)
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustible or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 12, standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of on-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Findings:

During the facility tour with the Director of Facilities and Director of Security on March 14, 2011 through March 18, 2011, oxygen storage in the facility was observed.

Main Building - Fourth Floor on 3/15/11:
At 12:02 p.m., 12 oxygen "E" tanks were observed to be stored in a shower room that was converted for storage. The storage room was not sprinklered and the door was prop open. During interview, the Registered Nurse stated that the room was used for storage including the storage of oxygen tanks.

Based on document review and interview the facility failed to maintain an emergency generator inspection and maintenance program documenting weekly visual inspection for 2 of 2 generators in accordance with NFPA 99 and NFPA 110. This failure affected the entire facility and could result in the emergency generator not functioning as required.

NFPA 110, 1999 Edition Standard for Emergency and Standby Power Systems
6-3.6 Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

6-4 Operational Inspection and Testing.
6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Findings:

During document review with the Director of Facilities and Plant Operations Supervisor on March 14, 2011, the emergency generator maintenance logs were requested.

At 4:00 p.m., the facility failed to provide written documentation of conducting weekly visual inspections for its two emergency generators. During interview the Plant Operations Supervisor stated only the monthly load test is documented. He was not aware of the required weekly inspections.

Based on record review and interview, the facility failed to maintain their generator, as evidenced by no documentation of weekly visual inspections. This affected two of two floors in the Southwest hospital, and could result in the potential failure of the generator during a power outage.

Findings:

During record review with the Director of Facilities on March 14, 2011, the maintenance records for the Southwest hospital generator were requested.

Southwest Hospital:
At 4:26 p.m., the generator maintenance records were provided. There was no documentation of weekly visual inspections.
During an interview on 3/15/11 at 8:40 a.m., the Supervisor of Plant Operations stated that staff does not document weekly visual inspections of the generator. They document generator inspections during monthly load tests.

Based on observation the facility failed to maintain the electrical equipment and wiring in accordance with NFPA 70, National Electrical Code, as evidenced by microwave ovens and/or refrigerators that were not plugged directly into a wall outlet and the unauthorized use of electrical equipment such as power strips plugged into power strips and the use of extension cords with no overcurrent protection. This failure affected 2 of 5 floors in the Main Building and 2 of 5 floors in the Patient Tower. This failure could increase the potential risk of an electrical fire causing harm to patients, staff and visitors.

NFPA 70 National Electrical Code (1999 Edition), Chapter 4 Article 400-Flexible Cords and Cables
Section 400-8.
Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cable shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceiling, dropped ceiling, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind buildings walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

NFPA 70, (1999 Edition) Article 240-4, and HFCA Transmittal Notice 22-99, prohibits the use of extension cords without overcurrent protection.
Section 240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

Findings:

During the facility tour with the Director of Facilities and Director of Security on March 14, 2011, through March 18, 2011, the electrical equipment and wiring was observed.

Patient Tower - Fifth Floor on 3/15/11:
At 11:14 a.m., a white extension cord in use with no overcurrent protection was plugged into a power strip in the Lieutenant Office.
At 11:23 a.m., a power strip was plugged into a power strip observed to be in use in the Charge Nurse office.
At 11:27 a.m., a white extension cord with no overcurrent protection observed in use at the Nurse Station.
At 11:28 a.m., a power strip was plugged into a power strip observed to be in use at the Tele monitor desk.
Main Building - Third Floor on 3/15/11:
At 2:30 p.m., a power strip was plugged into a three outlet adapter with no overcurrent protection and a refrigerator was plugged into the adapter in the Home Health Liaison office.
At 2:35 p.m., there were two white extension cords with no overcurrent protection in use behind the desk of the Case Management office.
At 2:40 p.m., in the Nurse Staffing office there was a green extension cord, a white extension cord and a three outlet adapter with no overcurrent protection in use. The Refrigerator and microwave was plugged into a power strip and not directly into the wall receptacle.
At 2:55 p.m., microwave and refrigerator plugged into a power strip and not directly into the wall receptacle in the Transfer Center office.
At 2:58 p.m., in the Case Manager office there was a three outlet adapter with no overcurrent protection in use behind the fish tank.
Patient Tower - Third Floor on 3/15/11:
At 3:06 p.m., three power strips were observed to be plugged into one power strip in the Charge Nurse office.
Main Building - First Floor on 3/16/11:
At 10:25 a.m., a three outlet wall adapter and extension cord with no overcurrent protection was in use in the Respiratory break room.
At 10:35 a.m., a microwave and refrigerator observed to be plugged into a power strip and not directly into the wall receptacle.
At 10:50 a.m., a microwave was observed to be plugged into a power strip and not directly into the wall receptacle in the Enterostomal Therapy office.
At 11:49 a.m., the refrigerator in the Dietary break room was plugged into a power strip and not directly into a wall receptacle.

Based on observation, the facility failed to maintain their electrical wiring, as evidenced by a refrigerator plugged into a six-plug surge protector. This affected one of two floors of the Southwest hospital, and could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During the facility tour with the Supervisor of Plant Operations on March 15, 2011 and March 16, 2011, the electrical wiring was observed.

Southwest Hospital - Second Floor on 3/15/11:
At 11:07 a.m., there was a refrigerator plugged into a six-plug surge protector in Room 2155.

ALCOHOL BASED HAND RUB DISPENSERS NOT IN CORRIDORS
NFPA 30 (1996 Edition) 4-8.5 Control of Ignition Sources. Precautions shall be taken to prevent the ignition of flammable vapors. Sources of ignition include, but are not limited to: open flames; lightning; smoking; cutting or welding; hot sources; frictional heat; static electricity; electrical or mechanical sparks; spontaneous heating, including heat-producing chemical reactions; and radiant heat.

Based on observation the facility failed to comply with the installation requirements for Alcohol Based Hand Rub (ABHR) dispenser as evidenced by dispensers installed above ignition sources such as electrical outlets or light switches and affected 3 of 5 floor in the Patient Tower and 2 of 5 floors in the Main Building. This failure could result in the potential increase risk of a fire causing harm to patients, staff and visitors.

Findings:

During the facility tour with the Director of Facilities on March 14, 2011 through March 18, 2011, the ABHR dispensers were observed in corridors and patients rooms.


Patient Tower - Fourth Floor on 3/15/11:
At 12:38 p.m., the ABHR dispenser was installed above an electrical outlet in room 401.
Patient Tower - Third Floor on 3/15/11:
At 3:09 p.m., the ABHR dispenser was installed above an electrical outlet in room 308.
At 3:14 p.m., the ABHR dispenser was installed above an electrical outlet in room 304.
At 3:27 p.m., the ABHR dispenser was installed above a light switch in the Physical Therapy office.
Patient Tower - Second Floor on 3/16/11:
At 9:50 a.m., the ABHR dispenser was installed above an electrical outlet in room 208.
At 9:53 a.m., the ABHR dispenser was installed above an electrical outlet in room 204.
At 9:54 a.m., the ABHR dispenser was installed above an electrical outlet in room 201.
Main Building - First Floor on 3/16/11:
At 11:24 a.m., the ABHR dispenser was installed adjacent to a light switch in the Dirty side of Central Supplies.
Main Building - Fourth Floor on 3/17/11:
At 10:50 a.m., an ABHR dispenser was installed above an emergency (red) electrical outlet in the corridor outside of operating room 2.

Based on observation, the facility failed to ensure that alcohol based hand rub dispensers (ABHR) are not installed over ignition sources. This was evidenced by five ABHR dispensers that were installed over light switches and electrical outlets. This affected two of two floors in the Southwest hospital, and could result in the increased risk of a fire.

Findings:

During the facility tour with the Supervisor of Plant Operations on March 15, 2011 and March 16, 2011, the ABHR dispensers were observed.

Southwest Hospital - Second Floor on 3/15/11:
At 11:14 a.m., there was an ABHR dispenser installed directly above a light switch, in the front wall of the respiratory therapy room.

At 11:24 a.m., there was an ABHR dispenser installed approximately 3 feet directly above an electrical outlet, in the corridor outside Room 2103.

At 11:40 a.m., there was an ABHR dispenser installed approximately 3 feet directly above an electrical outlet, in the right wall of Room 2348, next to the sink.

Southwest Hospital - First Floor on 3/15/11:
At 3:24 p.m., there was an ABHR dispenser installed directly above an electrical outlet, near the sink in the pre-op patient holding room.

At 4:37 p.m., there was an ABHR dispenser installed approximately 3 feet above an electrical outlet, in Room 1234.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations in the facility to prevent the spread of fire and smoke. This failure affected 1 of 5 floors in the Patient Tower and 3 of 5 floors in the Main Building. This could result in potential harm to patients, staff and visitors in the event of a fire.

Findings:

During the facility tour with the Director of Facilities and the Director of Security on March 14, 2011 through March 18, 2011, the facility walls and ceilings were observed.

Patient Tower - Fifth Floor on 3/15/11:
At 11:18 a.m., in the CDC Kitchen/Supply room there was a 1 inch penetration in the wall behind the door where the door closure hits the wall.

Main Building - Fifth Floor on 3/15/11:
At 11:48 a.m., the Storage room filled with boxes next to the stair well had a 1/ 2 inch penetration in the back wall.
Main Building - Fourth Floor on 3/15/11:
At 12:00 p.m., the Storage room filled with supply's next to the stair well had a 3/4 inch penetration in the back wall.

Main Building - First Floor on 3/16/11:
At 10:25 a.m., next to the desk in Respiratory there was a discontinue phone jack that was removed and revealed a 2 inch by 4 inch penetration in the wall.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected two of two floors in the Southwest Hospital, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with the Supervisor of Plant Operations on March 15, 2011 and March 16, 2011, the walls and ceilings in the Southwest hospital were observed.

Southwest Hospital - Second Floor on 3/15/11:
At 9:51 a.m., there was an approximately 1/4 inch by 5 inch penetration in the ceiling, adjacent to the shower light fixture, in the bathroom of Room 2158.

At 9:54 a.m., there was an approximately 1/2 inch by 3 inch penetration in the ceiling, adjacent to the shower light fixture, in the bathroom of Room 2156.

At 10:24 a.m., there were two approximately 1/4 inch penetrations in the back wall of the staff lounge, of the Med Surge nurses ' station, near the refrigerator.

At 10:35 a.m., there was an approximately 2 inch by 4 inch penetration in the back wall of the I.S. Room, on the right-hand side, around an electrical conduit.

At 11:04 a.m., there were four approximately 1/4 inch penetrations in the left wall of the Women ' s Care Center janitor ' s closet, near the mop sink. There was an approximately 1 1/2 inch penetration in the right wall, near the door.

First Floor:

At 2:51 p.m., there was an approximately 1/2 inch penetration in the left wall, near the front corner, of the biomedical engineering office.

At 3:45 p.m., there were two approximately 1 inch penetrations in the front wall of Room 1139, behind the x-ray viewing machine.

Based on observation, the facility failed to maintain its doors to close and resist the passage of smoke and the integrity of the doors to provide an effective smoke barrier in the event of a fire. This failure affected 1 of 5 floors in the Main Building and 2 of 5 floors in the Patient Tower. This could result in the potential harm to patients, staff and visitors.
Findings:

During the facility tour with the Director of Facilities and the Director of Security on March 14, 2011 through March 18, 2011, the corridor doors were observed.

Main Building - Fourth Floor on 3/15/11:
At 11:53 a.m., the door to Patient room 424 failed to latch when closed.
At 12:07 p.m., the door to Patient room 425 was equipped with a self closure device that was disassembled.

Patient Tower - Fourth Floor on 3/15/11:
At 12:15 p.m., the door to patient room 405 failed to latch when closed.
Patient Tower - Third Floor on 3/15/11:
At 3:11 p.m., the door to Patient room 306 failed to latch when closed.
At 3:29 p.m., the door to Patient room 317 failed to latch when closed.
At 3:32 p.m., the door to Patient room 309 failed to latch when closed.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by penetrations in doors, and doors that failed to latch. This affected two of two floors in the Southwest hospital, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with the Supervisor of Plant Operations on March 15, 2011 and March 16, 2011 , the doors were observed.

Southwest Hospital - Second Floor on 3/15/11:
At 10:37 a.m., the door to the I.S. Room, equipped with a self-closing device, closed but failed to latch.

At 10:44 a.m., the door to the rehab services mailroom, equipped with a self-closing device, closed but failed to latch.

At 11:01 a.m., there was an approximately 1/2 inch penetration, in the upper right-hand corner of the quality nurse ' s office door, in the Women ' s Care Center.

At 11:35 a.m., there was an approximately 1/4 inch penetration, in the upper right-hand corner of the door to Room 2337.


First Floor:
At 2:16 p.m., the door to the Room 1367, equipped with a self-closing device, closed but failed to latch.

At 2:45 p.m., the door to the supply closet across from the administration office, equipped with a self-closing device, closed but failed to latch.

At 3:08 p.m., the door to the admitting supervisor ' s office, equipped with a self-closing device, closed but failed to latch.

At 3:51 p.m., the door to the Room 1160, equipped with a self-closing device, closed but failed to latch.

At 4:00 p.m., the door to the security office, equipped with a self-closing device, closed but failed to latch.


First Floor on 3/16/11:
At 10:45 a.m., the corridor double doors, outside the pharmacy, closed but failed to latch, upon release from a magnetic hold-open device, during fire alarm testing.

Based on observation, the facility failed to maintain door devices connected to the fire alarm system to release doors upon activation of fire alarms. This was evidenced by doors that failed to release from held open devices during the testing of the fire alarm system. This could result in the failure to contain smoke to a compartment and affected patients, staff and visitors in 5 of 5 floors in the Patient Tower.

Findings:

During the testing of the fire alarm system with the Director of Facilities, Director of Security, and Supervisor of Plant Operations on March 16, 2011 and March 17, 2011, doors held open by devices were observed.

Patient Tower - First Floor through Fifth Floor on 3/16/11:
At 3:10 p.m., the smoke barrier doors on the first floor entering the cafeteria and the smoke barrier doors in the corridors (two sets of doors) failed to release from the held open devices during the testing of the fire alarm system.
At 3:20 p.m., 3 of 3 smoke barrier doors on the second floor failed to release from the held open devices during the testing of the fire alarm system.
At 3:30 p.m., During interview, facility staff confirmed the smoke barrier doors on the first floor through the fifth floor in the Patient Tower (also known as the 81 Building) were not releasing upon activation of the fire alarm system. During interview with the Director of Facilities and Director of Security both stated they were not aware of any problems with doors not closing.
At 4:00 p.m., the Director of Facilities stated a Fire Watch for the Patient Towers would be implemented and the fire alarm vendor would be contacted.
Total Census for Patient Tower: 60

Patient Tower - First Floor through Firth Floor on 3/17/11:
At 9:15 a.m., the fire alarm vendor stated they were in the process of repairing the problem with the door devices.
At 9:40 a.m., the fire alarm vendor stated they had found wires that were not connected and stated that they did not know why or who may have disconnected the wires and stated this was the reason the doors were not releasing.
At 9:50 a.m., smoke barrier doors entering the first floor Cafeteria and the two sets of smoke barrier doors all release and latched during fire alarm testing.
At 9:55 a.m., 3 of 3 smoke barrier doors on the second floor Patient Tower released and latched.

At 10:15 a.m., Staff confirmed the smoke barrier doors in the Patient Tower floors 1 through 5 were releasing from their devices during fire alarm testing.

At 12:00 p.m., on 3/17/11, after the completion of the fire alarm testing on floors 1 through 5 in the Patient Tower and the doors were observed to be releasing from their devices the Patient Tower Fire Watch was abated.

Based on observation, the facility failed to maintain doors held open by approved hold-open devices. This was evidenced by one door, in an elevator enclosure, that failed to release from a hold-open device, during fire alarm testing. This affected one of two floors in the Southwest hospital, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with the Supervisor of Plant Operations on March 16, 2011, in the Southwest hospital, doors held open with magnetic devices were observed.

Southwest Hospital - First Floor on 3/16/11:
At 10:45 a.m., the left leaf of the double doors, enclosing the elevators across from the pharmacy, did not release from the magnetic hold-open device, during fire alarm testing. The right leaf released and closed.

Based on observation, the facility failed to maintain the integrity of its fire rated smoke barrier construction as evidenced by unsealed penetrations in the smoke barrier walls. This affected 2 of 5 floors on the Patient Tower and 1 of 4 Floors in the Treatment and Diagnostic Building. The failure to maintain the integrity of the walls would allow the spread of fire and smoke from one compartment to another resulting in potential harm to patients, staff and visitors.

Findings:

During the facility tour with the Director of Facilities and Director of Security on March 14, 2011 through March 18, 2011, the smoke barrier walls were observed.

Patient Tower - Fifth Floor on 3/15/11:
At 11:00 a.m., the East smoke barrier wall had a 3/4 inch penetration around grey wires in the center of the wall and two unsealed conduits on the left side of the wall.
At 11:05 a.m., the West smoke barrier wall had two unsealed flexible conduits with a 1/4 inch penetration around two flexible conduits in the center of the wall and an unsealed conduit with wires running through.

Patient Tower - Third Floor on 3/15/11:
At 3:04 p.m., the East smoke barrier wall had a 1/2 inch penetration around grey wires in the right side of the wall.

Treatment and Diagnostic - Second Floor on 3/15/11:
At 4:33 p.m., the smoke barrier wall entering the Emergency Department (ER) had a two inch unsealed conduit with grey wires running through and a 4 inch by 6 inch penetration in the left side of the wall.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls, as evidenced by penetrations in one smoke barrier wall. This affected one of two floors in the Southwest hospital, and could result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During the facility tour with staff, from 3/15/11 - 3/16/11, the smoke barrier walls in the Southwest hospital were observed.

Southwest Hospital - Second Floor on 3/15/11:
At 10:02 a.m., there was an approximately 5 inch by 5 inch penetration, in the center of the smoke barrier wall, by Room 2154, around an electrical conduit.

Based on observation, the facility failed to maintain its fire rated smoke barriers doors on hold open devices to latch and resist the passage of smoke upon activation of the fire alarm system as evidenced by smoke barrier doors that failed to latch on 2 of 5 Floors in the Main Building and 2 of 5 floors in the Patient Tower Building. The failure to maintain doors could result in the potential spread of smoke from one compartment to another in the event of a fire causing harm to patients, staff and visitors.

Findings:

During the testing of the fire alarm system with the Director of Facilities, Director of Security and Plant Operations Supervisor on March 16, 2011 and March 17, 2011, the smoke barrier doors were observed.

Main Building - Third Floor on 3/17/11:
At 10:13 a.m., the smoke barrier door entering the Main Building from the Treatment and Diagnostic Building failed to latch shut during the activation of the fire alarms.
Main Building - Fourth Floor on 3/17/11:
At 11:04 a.m., the smoke barrier door entering the Main Building from the Treatment and Diagnostic Building failed to latch shut during the activation of the fire alarms.

Patient Tower - Third Floor on 3/17/11:
At 10:26 a.m., the left leaf of the smoke barrier door next to the Charge Nurse office failed to latch upon activation of the fire alarms.
Patient Tower - Fifth Floor on 3/17/11:
At 11:30 a.m., the left leaf of the smoke barrier door next to the Charge Nurse office failed to latch upon activation of the fire alarms.

Based on observation, the facility failed to maintain their smoke barrier doors, as evidenced by one smoke barrier door that failed to latch. This affected one of two floors in the Southwest hospital, and could result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During fire alarm testing with the Supervisor of Plant Operations on March 16, 2011, the smoke barrier doors were observed.

Southwest Hospital - Second Floor on 3/16/11:
At 9:40 a.m., the right leaf of the smoke barrier double doors, outside Room 2108, closed but failed to latch, upon release from a magnetic hold-open device, during fire alarm testing.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by one door to a hazardous area that did not latch, and by one hazardous area that has penetrations in the walls, and is not protected by self-closing door. This affected two of two floors in the Southwest hospital, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with the Supervisor of Plant Operations on March 15, 2011 and March 16, 2011 , the hazardous areas were observed.

Southwest Hospita - Second Floor on 3/15/11:
At 10:23 a.m., the door to the biohazard waste room, near the Med Surge nurses ' station, equipped with a self-closing device, closed but failed to latch.

First Floor on 3/15/11:
At 2:02 p.m., the interior door of the gift shop storage room was observed. The room is greater than 50 square feet in size and contained shelves of cardboard boxes, decorations, stuffed animals, and other combustibles. The door was not equipped with a self-closing device.

At 2:08 p.m., there were three approximately 1/2 inch penetrations, and one approximately 1 inch penetration, in the back wall of the gift shop storage room, above the flower refrigerator.

Based on observation, document review, interview and fire alarm testing, the facility failed to maintain it's fire alarm system, in accordance with the NFPA 72, National Fire Alarm Code as evidenced by: 1) failing to provide documentation of repairing or replacing devices that failed during the past four quarterly testing; 2) failing to maintain and repair a fire alarm system "trouble" reported on the main fire alarm panel and sub-panels; 3) failing to provide documented evidence of acknowledging trouble alarms and investigating the problems for repairs; and 4) failure of audible devices. The failure to maintain the fire alarm system could result in the system not functioning as required in the event of a fire or other emergency. This affected the entire facility and could result in potential harm to patients, staff and visitors.

Findings:

During document review with the Director of Facilities on March 15, 2011, between 2:00 p.m., and 4:30 p.m., the past four quarterly test and inspection reports dated May 2010, August 2010, November 2010 and February 2011, from a licensed vendor were reviewed. The reports noted failures. During interview, the Director of Facilities was asked for the documentation for the repairs that were noted in the quarterly reports. The Director of Facilities stated he did not have any documentation and did not know if any repairs had been completed.

During the tour of the facility with the Director of Facilities and Director of Security on March 16, 2011, at 10:55 a.m., the fire alarm sub panel outside of CDC 5th floor Patient Tower noted trouble mode "Node 5" and at 11:20 the fire alarm panel located in CDC Kitchen noted the same trouble "Node 5". During interview, the Director of Facilities and the Director of Security both stated they were not aware that the fire alarm panel was in a trouble mode and did not have any documentation of acknowledging when the fire alarm panel is in trouble modes.

During observation of the main fire alarm panel with the Director of Facilities and the Director of Security, on March 16, 2011, the main fire alarm panel located on the first floor in PBX noted two troubles for "Node 4 and Node 5". During interview, staff in PBX stated they log all fire alarms including troubles on a note pad and also stated they would call engineering.

During interview with Director of Facilities and Director of Security on March 16, 2011, at 4:45 p.m., the facility failed to provide documentation of acknowledging and documentation of repairing fire alarm system issues. The Director of Facilities stated the fire alarm vendor was contacted and would be onsite tomorrow morning.

During the testing of the fire alarm system with the Director of Facilities, Director of Security, and Supervisor of Plant Operations on March 16, 2011 and March 17, 2011, the audible and visual devices were observed.

Main Building - First Floor on 3/16/11:
At 2:30 p.m., the chime next to the Nurse Station in the Endoscopy Department failed to activate an audible alarm during testing.
At 2:35 p.m., chime in the Respiratory Therapy corridor failed to activate an audible alarm during testing.

Treatment and Diagnostic - First Floor on 3/16/11:
At 2:40 p.m., the strobe across the Dietary Freezers failed to activate during alarm testing.

Patient Tower - Fourth Floor on 3/17/11:
At 10:37 a.m., the chime located next to the House Keeping closet failed to activate an audible alarm during testing.

Main Building - Fourth Floor on 3/17/11:
At 11:00 a.m., chime next to room 423 and room 433 failed to activate an audible alarm during testing.

During interview with the fire alarm vendor with the Director of Facilities on March 17, 2011, at 9:30 a.m., the vendor stated he found and corrected the problem for the doors not releasing and was trouble shooting the "Node 4 and 5" problem in the fire alarm panel. Fire alarm testing was continued due to the activation of alarms would override the Node problems according to the fire alarm vendor. This was confirmed by the activation of smoke detectors, manual pulls and water flow devices that reported to the main fire alarm panel and the fire alarm activity report that was provided by the outside monitoring company.

On March 18, 2011, at 8:10 a.m., the main fire alarm panel in PBX and the fire alarm panel in the control room were observed to be in trouble mode.

On March 18, 2011, at 8:55 a.m., the facility provided a copy of a memo from the fire alarm vendor dated March 18, 2011, stating they would be back on site to continue working on the fire alarm. The memo also stated "these troubles will not affect the way the Fire Alarm system reports".

Based on observation and interview, the facility failed to maintain their fire alarm system. This was evidenced by one area with no alarm annunciator. This affected one of two floors in the Southwest hospital, and could result in a delay of notification, in the event of a fire.

Findings:

During fire alarm testing with the Supervisor of Plant Operations on March 16, 2011, the fire alarm annunciators were observed.

Southwest Hospital - First Floor on 3/16/11:
At 10:50 a.m., there was no audible or visual fire alarm device in the pharmacy. Near the back of the pharmacy, no alarm can be seen or heard during fire alarm testing.
During an interview at 10:51 a.m., a pharmacy staff member, working in the back of the pharmacy, stated that he had not heard any alarms since he started his shift at 10:00 a.m. Fire alarm testing began at 9:05 a.m. that day, and five alarm devices were activated between 10:00 a.m. and 10:50 a.m. The device activated at 10:10 a.m. alarmed for more than seven minutes. The pharmacy staff member did not hear any of the alarms.

Based on observation and interview, the facility failed to maintain its fire alarm system as evidenced by a smoke detector that was disassembled and missing its base. This failure affected 1 of 5 floors in the Main Building and could result in failure to activate the fire alarm system and notify the facility of a fire in the facility. This had potential to cause harm to patients, staff and visitors.

Findings:

During the facility tour with the Director of Facilities and Director of Security on March 14, 2011 through March 18, 2011, the fire alarm devices were observed.

Main Building - Fourth Floor on 3/15/11:
At 12:04 p.m., the smoke detector located in the Nurse Station was missing. During interview nursing staff stated they did not know how long ago the smoke detector was removed.
At 12:05 p.m., During interview, the Director of Facilities stated the smoke detector was removed due to water damage, but did not know when. The Director of Facilities found a report from the fire alarm vender stating the smoke detector was removed on 3/11/11 and the Facility Director did not know why it had not been replaced.

Based on observation, the facility failed to ensure the automatic sprinkler system was maintained and inspected periodically as evidenced by sprinklers there were contaminated with paint, corroded, sprinkler escutcheon rings that were not flush with the ceiling had gaps or were missing. This failure could result in the sprinkler system not functioning as designed and affected 1 of 5 floor in the Patient Tower, 1 of 5 floors in the Main Building and 1 of 4 floors in Treatment and Diagnostic Building.

NFPA 25, 1998 Edition
2-2 Inspection. 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During the facility tour with the Director of Facilities and Director of Security on March 14, 2011 through March 18, 2011, the sprinkler system was observed.

Patient Tower - Fifth Floor on 3/15/11:
At 11:25 a.m., in the Staff locker room\Time clock room 3 of 3 sprinkler escutcheon ring had gaps and were not flush with the ceiling.

Treatment and Diagnostic - Second Floor on 3/15/11:
At 4:19 p.m., the sprinkler in Radiology room 6 had signs of corrosion.
At 4:36 p.m., the sprinkler in the Emergency Department corridor next to room 229 was contaminated with paint.

Main Building - First Floor on 3/16/11:
10:35 a.m., the sprinkler escutcheon ring was missing in the corridor entering the Respiratory break room.
10:44 a.m., the sprinkler escutcheon ring was missing in the Dialysis Storage room that is located next to Housekeeping break room.
11:30 a.m., the sprinkler escutcheon ring was missing in the Loading dock corridor.
At 11:44 a.m., 1 of 6 sprinkler escutcheon rings was missing in the Dietary break room.
At 11:46 a.m., the sprinkler escutcheon ring was missing in the Dietary office corridor.
At 12:01 p.m., 1 of 2 sprinkler escutcheon rings was missing in the Dietary Dry Storage room.

.

Based on record review and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by three sprinkler tamper switches that failed inspections since November 2009, by one water flow detector that failed inspections since November 2010, and by no documents for quarterly testing of the sprinkler system for two of four quarters. This affected two of two floors in the Southwest hospital, and could result in a delay in extinguishing a fire, in the event of a fire.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition.

1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Findings:

During document review from March 14, 2011 through March 17, 2011, the sprinkler system maintenance documents for the Southwest hospital were requested.

Southwest Hospital on 3/14/11:
At 4:15 p.m., the sprinkler system testing documents were provided for November 2010 and February 2011. The sprinkler system testing was performed by a vendor, which tests the facilities fire alarm system quarterly. The documents indicated that one tamper switch in the North Pump Room, two tamper switches in the Core Hall 1404, and the main water flow detector, failed during inspections on November 2010 and February 2011.

Southwest Hospital on 3/15/11:
At 8:31 a.m., the records of the vendor ' s inspections of the fire alarm system on May 2010, and August 2010, were provided. The records indicated that the sprinkler system was not tested during these inspections.
During an interview at 8:32 a.m., the Supervisor of Plant Operations stated that the vendor does all the inspections.

Southwest Hospital on 3/17/11:
At 2:20 p.m., the records of the vendor ' s November 2009 inspection indicated that one tamper switch in the North Pump Room, and two tamper switches in Core Hall 1404, failed during the inspection.

There was no documentation provided, dated from November 2009 to March 14, 2011, indicating that the facility attempted to repair the tamper switches that failed. Documentation provided indicated that the tamper switches in Core Hall 1404, and the main water flow detector, were repaired on 3/16/11 by the vendor, and the tamper switch in the North Pump Room was repaired on 3/17/11.

Based on observation, and interview, the facility failed to maintain their portable fire extinguishers as evidenced by fire extinguishers that were obscured from view. This affected 1 of 5 floors in the Main Building and 1 of 5 floor in the Patient Tower. This had the potential for inaccessibility to the fire extinguisher in the event of a fire, which could result in potential harm to patients and staff.

NFPA 10, Standard for Portable Fire Extinguishers (1998 Edition)
1-6 General Requirements.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14kg) shall be installed so the the top of the fire extinguisher is not more than 5ft (1.53 m) above the floor.

Findings:

During the tour of the facility with the Director of Facilities and Director of Security on March 14, 2011 through March 18, 2011, the fire extinguishers were observed.

Main Building - First Floor on 3/16/11:
At 11:27 a.m., the fire extinguisher in Pharmacy next to the exit door was mounted less than 12 inches from the floor and was visually obstructed by the counter. There was no sign to indicate there was a fire extinguisher.

Patient Tower - Fourth Floor on 3/17/11:
At 10:54 a.m., the fire extinguisher in ICU 1 was mounted less that 10 inches from the floor and was not visible to staff. There was no sign to indicated there was a fire extinguisher. During an interview, the Registered Nurse stated she did not know there was a fire extinguisher across from the nurse station because its was mounted very low and was obscured by a collum.

Based on observation, the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This was evidenced by one fire extinguisher that was obstructed, and by one fire extinguisher that had not been serviced for more than one year. This affected one of two floors in the Southwest hospital, and could result in a delay in extinguishing a fire.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1.6.3 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.
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.

4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Findings:

During the facility tour with the Supervisor of Plant Operations on March 15, 2011 and March 16, 2011, the fire extinguishers in were observed.

Southwest Hospital - First Floor on 3/16/11:
At 9:54 a.m., the fire extinguisher, mounted on the front wall of O.R. 2, was obstructed by a biohazard bin.

At 10:01 a.m., the fire extinguisher in the sterile storage room was last serviced on 10/5/09. There were three monthly checks on the tag dated 11/10, 04/10, and 12/09.

Based on observation and interview, the facility failed to ensure the storage of medical gas is in accordance with NFPA 99, as evidenced by oxygen stored with combustible material such as plastic supplies, clean linen and wheel chairs in a non sprinklered room. This affected 1 of 5 floors in the Main Building and could result in potential harm to patients, staff and visitors in the event of a fire.

NFPA 99, 1999 (Edition)
8-3.1.11 Storage Requirements.
8-3.1.11.2 Storage for non Flammable gases less than 3000 ft (85 m 3)
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustible or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 12, standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of on-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Findings:

During the facility tour with the Director of Facilities and Director of Security on March 14, 2011 through March 18, 2011, oxygen storage in the facility was observed.

Main Building - Fourth Floor on 3/15/11:
At 12:02 p.m., 12 oxygen "E" tanks were observed to be stored in a shower room that was converted for storage. The storage room was not sprinklered and the door was prop open. During interview, the Registered Nurse stated that the room was used for storage including the storage of oxygen tanks.

Based on document review and interview the facility failed to maintain an emergency generator inspection and maintenance program documenting weekly visual inspection for 2 of 2 generators in accordance with NFPA 99 and NFPA 110. This failure affected the entire facility and could result in the emergency generator not functioning as required.

NFPA 110, 1999 Edition Standard for Emergency and Standby Power Systems
6-3.6 Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

6-4 Operational Inspection and Testing.
6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Findings:

During document review with the Director of Facilities and Plant Operations Supervisor on March 14, 2011, the emergency generator maintenance logs were requested.

At 4:00 p.m., the facility failed to provide written documentation of conducting weekly visual inspections for its two emergency generators. During interview the Plant Operations Supervisor stated only the monthly load test is documented. He was not aware of the required weekly inspections.

Based on record review and interview, the facility failed to maintain their generator, as evidenced by no documentation of weekly visual inspections. This affected two of two floors in the Southwest hospital, and could result in the potential failure of the generator during a power outage.

Findings:

During record review with the Director of Facilities on March 14, 2011, the maintenance records for the Southwest hospital generator were requested.

Southwest Hospital:
At 4:26 p.m., the generator maintenance records were provided. There was no documentation of weekly visual inspections.
During an interview on 3/15/11 at 8:40 a.m., the Supervisor of Plant Operations stated that staff does not document weekly visual inspections of the generator. They document generator inspections during monthly load tests.

Based on observation the facility failed to maintain the electrical equipment and wiring in accordance with NFPA 70, National Electrical Code, as evidenced by microwave ovens and/or refrigerators that were not plugged directly into a wall outlet and the unauthorized use of electrical equipment such as power strips plugged into power strips and the use of extension cords with no overcurrent protection. This failure affected 2 of 5 floors in the Main Building and 2 of 5 floors in the Patient Tower. This failure could increase the potential risk of an electrical fire causing harm to patients, staff and visitors.

NFPA 70 National Electrical Code (1999 Edition), Chapter 4 Article 400-Flexible Cords and Cables
Section 400-8.
Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cable shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceiling, dropped ceiling, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind buildings walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

NFPA 70, (1999 Edition) Article 240-4, and HFCA Transmittal Notice 22-99, prohibits the use of extension cords without overcurrent protection.
Section 240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

Findings:

During the facility tour with the Director of Facilities and Director of Security on March 14, 2011, through March 18, 2011, the electrical equipment and wiring was observed.

Patient Tower - Fifth Floor on 3/15/11:
At 11:14 a.m., a white extension cord in use with no overcurrent protection was plugged into a power strip in the Lieutenant Office.
At 11:23 a.m., a power strip was plugged into a power strip observed to be in use in the Charge Nurse office.
At 11:27 a.m., a white extension cord with no overcurrent protection observed in use at the Nurse Station.
At 11:28 a.m., a power strip was plugged into a power strip observed to be in use at the Tele monitor desk.
Main Building - Third Floor on 3/15/11:
At 2:30 p.m., a power strip was plugged into a three outlet adapter with no overcurrent protection and a refrigerator was plugged into the adapter in the Home Health Liaison office.
At 2:35 p.m., there were two white extension cords with no overcurrent protection in use behind the desk of the Case Management office.
At 2:40 p.m., in the Nurse Staffing office there was a green extension cord, a white extension cord and a three outlet adapter with no overcurrent protection in use. The Refrigerator and microwave was plugged into a power strip and not directly into the wall receptacle.
At 2:55 p.m., microwave and refrigerator plugged into a power strip and not directly into the wall receptacle in the Transfer Center office.
At 2:58 p.m., in the Case Manager office there was a three outlet adapter with no overcurrent protection in use behind the fish tank.
Patient Tower - Third Floor on 3/15/11:
At 3:06 p.m., three power strips were observed to be plugged into one power strip in the Charge Nurse office.
Main Building - First Floor on 3/16/11:
At 10:25 a.m., a three outlet wall adapter and extension cord with no overcurrent protection was in use in the Respiratory break room.
At 10:35 a.m., a microwave and refrigerator observed to be plugged into a power strip and not directly into the wall receptacle.
At 10:50 a.m., a microwave was observed to be plugged into a power strip and not directly into the wall receptacle in the Enterostomal Therapy office.
At 11:49 a.m., the refrigerator in the Dietary break room was plugged into a power strip and not directly into a wall receptacle.

Based on observation, the facility failed to maintain their electrical wiring, as evidenced by a refrigerator plugged into a six-plug surge protector. This affected one of two floors of the Southwest hospital, and could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During the facility tour with the Supervisor of Plant Operations on March 15, 2011 and March 16, 2011, the electrical wiring was observed.

Southwest Hospital - Second Floor on 3/15/11:
At 11:07 a.m., there was a refrigerator plugged into a six-plug surge protector in Room 2155.