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Based on observation, the facility failed to ensure there were no impediments to closing the corridor doors. This was evidenced by a self closing corridor door for the triage room in the emergency department that was obstructed from closing by a wooden wedge. This affected one of five smoke compartments and could result in a delay in containing smoke or fire, in the event of a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

Findings:

During the facility tour with Maintenance 3 on 6/2/13, the corridor doors were observed and tested.

1. At 3:33 p.m., the corridor door to the triage room in the emergency department was obstructed from closing by a wooden wedge that was placed between the bottom of the door and the floor in the fully open position. This corridor door was equipped with a self closing device.

Based on observation and interview, the facility failed to maintain doors in the smoke barrier wall. This was evidenced by a pair of smoke barrier doors that were obstructed from closing by kick-down hold-open hardware. This affected two of five smoke compartments and could result in the spread of fire or smoke, in the event of a fire emergency.

NFPA 101, Life Safety Code 2000 edition
19.3.7.6* Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

Findings:

During the facility tour and interview with Maintenance 2 on 6/2/15, the smoke barrier doors were observed.

1. At 9:10 a.m., the north leaf and the south leaf of the cross corridor smoke barrier doors, between the surgery department and the acute care area, were obstructed from closing by kick-down hardware that held the doors in a fully open position. Maintenance 2 explained that the kick-down hardware was used to hold the doors in the open position when transporting patients to the adjacent recovery room and for equipment such as the portable x-ray machine.

Based on observation and interview, the facility failed to maintain their hazardous areas. This was evidenced by a corridor door for the medical records storage area that failed to self close due to a broken door closer. This affected one of five smoke compartments and could result in the spread of smoke or fire during a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During the facility tour with Maintenance 2 and interview with Medical Records Staff 1 on 6/2/15, the medical records storage areas were observed.

1. At 11:13 a.m., the door to Medical Records was in the fully open position and the door failed to self close when tested. The self closing mechanism arm was missing and the hardware on the door frame was bent upwards. Medical Records Staff 1 confirmed that the door was usually open during business hours and that the door closer had been damaged several months ago. The room was greater than 100 square feet in area and was filled with open file storage of paper records on shelving from floor to ceiling along the north wall.

Based on record review and interview, the facility failed to maintain their emergency lighting units. This was evidenced by the facility's failure to complete an annual 90 minute test on twelve emergency lighting units equipped with battery-backup. This affected four of five smoke compartments and could result in limited visibility in the event of a power failure.

NFPA 101 Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During document review and interview with Maintenance 2 on 6/1/15, the test records for battery back-up egress lighting were requested.

1. At 6:18 p.m., there were no records of annual 90 minute testing of battery operated egress lighting for twelve locations. The "Emergency Light Report" indicated monthly 30 second testing was performed on twelve lighting fixtures located in the hospital at the following locations: CT (Computerized Tomography) South, CT West, CT North, ER(Emergency Room), Acute, Main West, Main East, Main South, X-Ray Lobby, X-Ray Room, and Operating Room.

During an interview at 6:20 p.m., Maintenance 2 explained that there had been annual 90 minute tests performed in previous years.

Based on observation and interview, the facility failed to maintain their fire alarm system. This was evidenced by three fire alarm notification devices that were abandoned and not maintained or removed. This affected one of five smoke compartments and could result in a delayed notification of a fire alarm system activation

NFPA 101 Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
4.6.12.2* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings:

During the facility tour and fire alarm testing with Maintenance 2 on 6/2/15, the fire alarm annunciating devices were observed.

1. At 10:43 a.m., there was no audible alarm emitting from the bell in the kitchen during fire alarm testing.

2. At 10:53 a.m., there was no audible alarm emitting from the bell in the Social Dining Room during fire alarm testing.

3. At 10:57 a.m., there was no audible alarm emitting from the bell in the main hall next to the women's locker room during fire alarm testing.

During an interview on 6/2/15 at 10:44 a.m., Maintenance 2 explained that the old fire alarm system bells that used the vibrating plates were abandoned in place when the combination audible and visuals devices were added.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by two sprinkler heads that were obstructed by storage items and by one sprinkler with a dislodged escutcheon fitting. This affected two of five smoke compartments and could result in a delayed response of the automatic sprinkler system.

NFPA 101 Life Safety Code 2000 Edition
9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
19.7.6 Maintenance and Testing. (See 4.6.12.)

NFPA 13 Standard for Installation of Sprinkler Systems, 1999 Edition
5-5.6* Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 inch (457 mm) or greater

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems,1998 Edition
2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During the facility tour with Maintenance 2 on 6/2/15, the automatic sprinkler system was observed.

1. At 11:11 a.m., there was a 1/2 inch by one inch penetration in the ceiling tile around the sprinkler head escutcheon in the corridor for HIM (Health Information Management).

2. At 2:42 p.m., there was an obstructed sprinkler head in the X-Ray file storage room. There was less than 14 inches of clearance between records stored on the top shelf and the sprinkler head. The sprinkler did not have 18 inches of clearance.

3. At 4:13 p.m., there was an obstructed sprinkler head in the isolation utility room. There was less than 8 inches of clearance between the ceiling mounted sprinkler head and a portable HEPA (High Efficiency Particulate Air) filtration unit. The sprinkler did not have 18 inches of clearance.

Based on observation, the facility failed to maintain the means of egress free from obstructions. This was evidenced by equipment that was stored in the egress corridors. This affected one of five smoke compartments and could result in a delayed evacuation during a fire emergency.

NFPA 101 Life Safety Code 2000 Edition
7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During the facility tour with Maintenance 3 on 6/2/15, the corridor egress was observed.

1. At 3:29 p.m., the corridor from the OR (Operating Room) to the Acute area was obstructed by a gurney and a portable x-ray machine that were located on opposite sides of the corridor. The eight foot wide corridor was reduced to less than four feet of clear width.

2. At 3:43 p.m., the corridor from the ER (Emergency Room) department was obstructed by miscellaneous monitoring equipment located on opposite sides of the corridor. The eight foot wide corridor was reduced to less than five feet of clear width.

Based on observation and interview, the facility failed to ensure the integrity of their smoke barrier walls. This was evidenced by five unsealed wall penetrations around recently installed sprinkler system piping and an electrical conduit that passed through the smoke barrier walls above ceilings. This affected two of five smoke compartments and could result in the spread of smoke or fire to other smoke compartments.

NFPA 101, Life Safety Code 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour and interview with Maintenance 2 on 6/2/15, the smoke barrier walls were observed.

1. At 9:15 a.m., there was a 4 inch diameter wall penetration around a one inch automatic sprinkler system pipe. This was located above the ceiling in the south wall of the alcove between Recovery and the OR (Operating Room) office. During an interview at 9:16 a.m., Maintenance 2 explained that the sprinkler system was recently installed and that their contractor must have missed sealing that penetration.

2. At 9:24 a.m., there was a 2 inch diameter wall penetration around a one inch conduit. This was located in the north wall above the ceiling of the Imaging Office.

3. At 9:31 a.m., there was 4 inch diameter wall penetration around a 1-1/4 inch sprinkler pipe. This was located above the ceiling of the corridor wall for the men's locker room.

4. At 9:48 a.m., there was 4 inch diameter wall penetration around a 1-1/4 inch sprinkler pipe. This was located above the ceiling of the corridor wall for the women's locker room.

5. At 9:53 a.m., there was 4 inch by 8 inch oblong wall penetration around a 3 inch sprinkler pipe. This was located above the ceiling of the corridor over the smoke barrier doors between the Acute area and the ER (Emergency Room).

Based on record review and interview, the facility failed to maintain their emergency generator. This was evidenced by incomplete weekly emergency generator inspection records for 39 of the past 52 weeks and incomplete records of monthly 30 minute load testing for one of the past 12 months. This affected the entire facility and could result in a malfunctioning emergency generator and a loss of emergency power in the event of a power failure.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches. (a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

NFPA 110, Standard for Emergency and Standby Power Systems 1999 Edition.
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
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.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Findings:

During record review and interview with Maintenance 2 on 6/1/15, the weekly and monthly emergency generator inspection and test records were requested.

1. At 5:50 p.m., there was no documentation of a monthly 30 minute load test for the month of April 2015. Maintenance 2 explained that this test was completed but not logged as indicated by the hour meter readings on the emergency generator.

2. At 5:55 p.m., there was no documentation of weekly visual inspections of the generator for three of the last four quarters. The last month documented was August of 2014. Maintenance 2 explained that the task had been mistakenly dropped during staffing reductions.

Based on observation and interview, the facility failed to maintain their electrical wiring connections. This was evidenced by the use of extension cords and surge protected multi-outlet extension cords as a substitute for fixed wiring. This affected three of five smoke compartments and could result in an electrical fire.

NFPA 101 Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(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 and interview with Maintenance 3 on 6/2/15, the electrical devices and wiring connections were observed.

1. At 11:51 a.m., there was a coffee maker plugged into surge protector which was plugged into the wall outlet. This was located along the west wall of HIM (Health Information Management).

2. At 3:03 p.m., there was a blanket warmer plugged into a surge protector which was plugged into a wall outlet. This was located along the south wall of the clean utility room in the acute area.

3. At 3:07 p.m., there was a wall mounted light plugged into an extension cord which was plugged into a wall outlet. This was located along the west wall of the mammography room.

4. At 3:48 p.m., there was a microwave oven plugged into a surge protector which was plugged into a wall outlet. This was located along the north wall of the ER (Emergency Room) Doctor's Office.

5. At 4:38 p.m., there was desktop equipment plugged into a surge protector which was plugged into an extension cord which was plugged into a wall outlet. This was located along the south wall of HIM Room 2. Maintenance 3 explained that the extension cord had been installed behind the desks years ago to provide power for one of the desks.

Based on observation and interview, the facility failed to maintain their alcohol based hand rub (ABHR) dispensers. This was evidenced by two ABHR dispensers that were mounted above ignition sources in the Emergency Room. This affected one of five smoke compartments and could result in an ABHR ignited fire emergency.

Findings:

During the facility tour with Maintenance 3 on 6/3/15, the ABHR (Alcohol Based Hand Rub) dispenser locations were observed.

1. At 9:27 a.m., there was an ABHR dispenser located over the light switch for ER (Emergency Room) E2. The ABHR dispenser was mounted directly above and within five inches of the light switch.

2. At 9:28 a.m., there was an ABHR dispenser located over the light switch for ER (Emergency Room) A. The ABHR dispenser was mounted directly above and within five inches of the light switch.

During an interview on 6/3/15 at 9:35 a.m., EVS1 provided the label information on one of the ABHR dispenser refill containers. EVS1 stated that the ABHR was 70 percent ethyl alcohol by volume.

Based on observation, the facility failed to ensure there were no impediments to closing the corridor doors. This was evidenced by a self closing corridor door for the triage room in the emergency department that was obstructed from closing by a wooden wedge. This affected one of five smoke compartments and could result in a delay in containing smoke or fire, in the event of a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

Findings:

During the facility tour with Maintenance 3 on 6/2/13, the corridor doors were observed and tested.

1. At 3:33 p.m., the corridor door to the triage room in the emergency department was obstructed from closing by a wooden wedge that was placed between the bottom of the door and the floor in the fully open position. This corridor door was equipped with a self closing device.

Based on observation and interview, the facility failed to maintain doors in the smoke barrier wall. This was evidenced by a pair of smoke barrier doors that were obstructed from closing by kick-down hold-open hardware. This affected two of five smoke compartments and could result in the spread of fire or smoke, in the event of a fire emergency.

NFPA 101, Life Safety Code 2000 edition
19.3.7.6* Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

Findings:

During the facility tour and interview with Maintenance 2 on 6/2/15, the smoke barrier doors were observed.

1. At 9:10 a.m., the north leaf and the south leaf of the cross corridor smoke barrier doors, between the surgery department and the acute care area, were obstructed from closing by kick-down hardware that held the doors in a fully open position. Maintenance 2 explained that the kick-down hardware was used to hold the doors in the open position when transporting patients to the adjacent recovery room and for equipment such as the portable x-ray machine.

Based on observation and interview, the facility failed to maintain their hazardous areas. This was evidenced by a corridor door for the medical records storage area that failed to self close due to a broken door closer. This affected one of five smoke compartments and could result in the spread of smoke or fire during a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During the facility tour with Maintenance 2 and interview with Medical Records Staff 1 on 6/2/15, the medical records storage areas were observed.

1. At 11:13 a.m., the door to Medical Records was in the fully open position and the door failed to self close when tested. The self closing mechanism arm was missing and the hardware on the door frame was bent upwards. Medical Records Staff 1 confirmed that the door was usually open during business hours and that the door closer had been damaged several months ago. The room was greater than 100 square feet in area and was filled with open file storage of paper records on shelving from floor to ceiling along the north wall.

Based on record review and interview, the facility failed to maintain their emergency lighting units. This was evidenced by the facility's failure to complete an annual 90 minute test on twelve emergency lighting units equipped with battery-backup. This affected four of five smoke compartments and could result in limited visibility in the event of a power failure.

NFPA 101 Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During document review and interview with Maintenance 2 on 6/1/15, the test records for battery back-up egress lighting were requested.

1. At 6:18 p.m., there were no records of annual 90 minute testing of battery operated egress lighting for twelve locations. The "Emergency Light Report" indicated monthly 30 second testing was performed on twelve lighting fixtures located in the hospital at the following locations: CT (Computerized Tomography) South, CT West, CT North, ER(Emergency Room), Acute, Main West, Main East, Main South, X-Ray Lobby, X-Ray Room, and Operating Room.

During an interview at 6:20 p.m., Maintenance 2 explained that there had been annual 90 minute tests performed in previous years.

Based on observation and interview, the facility failed to maintain their fire alarm system. This was evidenced by three fire alarm notification devices that were abandoned and not maintained or removed. This affected one of five smoke compartments and could result in a delayed notification of a fire alarm system activation

NFPA 101 Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
4.6.12.2* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings:

During the facility tour and fire alarm testing with Maintenance 2 on 6/2/15, the fire alarm annunciating devices were observed.

1. At 10:43 a.m., there was no audible alarm emitting from the bell in the kitchen during fire alarm testing.

2. At 10:53 a.m., there was no audible alarm emitting from the bell in the Social Dining Room during fire alarm testing.

3. At 10:57 a.m., there was no audible alarm emitting from the bell in the main hall next to the women's locker room during fire alarm testing.

During an interview on 6/2/15 at 10:44 a.m., Maintenance 2 explained that the old fire alarm system bells that used the vibrating plates were abandoned in place when the combination audible and visuals devices were added.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by two sprinkler heads that were obstructed by storage items and by one sprinkler with a dislodged escutcheon fitting. This affected two of five smoke compartments and could result in a delayed response of the automatic sprinkler system.

NFPA 101 Life Safety Code 2000 Edition
9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
19.7.6 Maintenance and Testing. (See 4.6.12.)

NFPA 13 Standard for Installation of Sprinkler Systems, 1999 Edition
5-5.6* Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 inch (457 mm) or greater

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems,1998 Edition
2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During the facility tour with Maintenance 2 on 6/2/15, the automatic sprinkler system was observed.

1. At 11:11 a.m., there was a 1/2 inch by one inch penetration in the ceiling tile around the sprinkler head escutcheon in the corridor for HIM (Health Information Management).

2. At 2:42 p.m., there was an obstructed sprinkler head in the X-Ray file storage room. There was less than 14 inches of clearance between records stored on the top shelf and the sprinkler head. The sprinkler did not have 18 inches of clearance.

3. At 4:13 p.m., there was an obstructed sprinkler head in the isolation utility room. There was less than 8 inches of clearance between the ceiling mounted sprinkler head and a portable HEPA (High Efficiency Particulate Air) filtration unit. The sprinkler did not have 18 inches of clearance.

Based on observation, the facility failed to maintain the means of egress free from obstructions. This was evidenced by equipment that was stored in the egress corridors. This affected one of five smoke compartments and could result in a delayed evacuation during a fire emergency.

NFPA 101 Life Safety Code 2000 Edition
7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During the facility tour with Maintenance 3 on 6/2/15, the corridor egress was observed.

1. At 3:29 p.m., the corridor from the OR (Operating Room) to the Acute area was obstructed by a gurney and a portable x-ray machine that were located on opposite sides of the corridor. The eight foot wide corridor was reduced to less than four feet of clear width.

2. At 3:43 p.m., the corridor from the ER (Emergency Room) department was obstructed by miscellaneous monitoring equipment located on opposite sides of the corridor. The eight foot wide corridor was reduced to less than five feet of clear width.

Based on observation and interview, the facility failed to ensure the integrity of their smoke barrier walls. This was evidenced by five unsealed wall penetrations around recently installed sprinkler system piping and an electrical conduit that passed through the smoke barrier walls above ceilings. This affected two of five smoke compartments and could result in the spread of smoke or fire to other smoke compartments.

NFPA 101, Life Safety Code 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour and interview with Maintenance 2 on 6/2/15, the smoke barrier walls were observed.

1. At 9:15 a.m., there was a 4 inch diameter wall penetration around a one inch automatic sprinkler system pipe. This was located above the ceiling in the south wall of the alcove between Recovery and the OR (Operating Room) office. During an interview at 9:16 a.m., Maintenance 2 explained that the sprinkler system was recently installed and that their contractor must have missed sealing that penetration.

2. At 9:24 a.m., there was a 2 inch diameter wall penetration around a one inch conduit. This was located in the north wall above the ceiling of the Imaging Office.

3. At 9:31 a.m., there was 4 inch diameter wall penetration around a 1-1/4 inch sprinkler pipe. This was located above the ceiling of the corridor wall for the men's locker room.

4. At 9:48 a.m., there was 4 inch diameter wall penetration around a 1-1/4 inch sprinkler pipe. This was located above the ceiling of the corridor wall for the women's locker room.

5. At 9:53 a.m., there was 4 inch by 8 inch oblong wall penetration around a 3 inch sprinkler pipe. This was located above the ceiling of the corridor over the smoke barrier doors between the Acute area and the ER (Emergency Room).

Based on record review and interview, the facility failed to maintain their emergency generator. This was evidenced by incomplete weekly emergency generator inspection records for 39 of the past 52 weeks and incomplete records of monthly 30 minute load testing for one of the past 12 months. This affected the entire facility and could result in a malfunctioning emergency generator and a loss of emergency power in the event of a power failure.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches. (a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.

NFPA 110, Standard for Emergency and Standby Power Systems 1999 Edition.
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
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.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Findings:

During record review and interview with Maintenance 2 on 6/1/15, the weekly and monthly emergency generator inspection and test records were requested.

1. At 5:50 p.m., there was no documentation of a monthly 30 minute load test for the month of April 2015. Maintenance 2 explained that this test was completed but not logged as indicated by the hour meter readings on the emergency generator.

2. At 5:55 p.m., there was no documentation of weekly visual inspections of the generator for three of the last four quarters. The last month documented was August of 2014. Maintenance 2 explained that the task had been mistakenly dropped during staffing reductions.

Based on observation and interview, the facility failed to maintain their electrical wiring connections. This was evidenced by the use of extension cords and surge protected multi-outlet extension cords as a substitute for fixed wiring. This affected three of five smoke compartments and could result in an electrical fire.

NFPA 101 Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(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 and interview with Maintenance 3 on 6/2/15, the electrical devices and wiring connections were observed.

1. At 11:51 a.m., there was a coffee maker plugged into surge protector which was plugged into the wall outlet. This was located along the west wall of HIM (Health Information Management).

2. At 3:03 p.m., there was a blanket warmer plugged into a surge protector which was plugged into a wall outlet. This was located along the south wall of the clean utility room in the acute area.

3. At 3:07 p.m., there was a wall mounted light plugged into an extension cord which was plugged into a wall outlet. This was located along the west wall of the mammography room.

4. At 3:48 p.m., there was a microwave oven plugged into a surge protector which was plugged into a wall outlet. This was located along the north wall of the ER (Emergency Room) Doctor's Office.

5. At 4:38 p.m., there was desktop equipment plugged into a surge protector which was plugged into an extension cord which was plugged into a wall outlet. This was located along the south wall of HIM Room 2. Maintenance 3 explained that the extension cord had been installed behind the desks years ago to provide power for one of the desks.