HospitalInspections.org

Building M
On 6/4/13, at 2:06 p.m., the walls in the Air Handler Room were observed. There was a two inch round unsealed penetration in the east wall located approximately ten feet above the floor. This penetration was through the gypsum board sheeting that covered the structural column. Engineering Staff 2 confirmed the penetration.












27254

Based on observation and interview, the facility failed to maintain the building free of penetrations, as evidenced by unsealed pipe penetrations, and by unsealed junction boxes. These conditions affected smoke compartments in in Buildings C, K, and M, and could result in the passage of smoke from one part of the facility to another in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire 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 fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following
conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
Findings:

During a tour of the facility with the Director of Facilities, between 6/3/13 and 6/7/13, the walls and ceilings were observed.

Building K
1. On 6/4/13, at 2:25 p.m., on the Basement Level, in Room BK007 there were three pipes, each approximately between 1.5 inches and 3 inches in diameter, that were passing through the finished ceiling. There was a two inch opening around each pipe that had not been sealed.

Building E
2. On 6/5/13, at 9:46 a.m., on the Basement Level, in the Psychology Services Office Room #BEC04, the cover for the junction box by the office door was missing.

Building C
3. On 6/5/13, at 10:58 a.m., on the 7th floor in room 7C021, a clock had been removed, and the junction box for the clock had not been sealed.

Based on observation, the facility failed to maintain its corridor construction with a one half hour fire rating as evidenced by unsealed penetrations in the corridor walls. This finding affected one of six floors in Building M, and one of eight floors of Building C, and could result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager on 6/4/13, corridor walls were observed.

Building M - Basement Level
1. At 3:25 p.m., there were two unsealed pipe sleeves above the drop-down ceiling near the Basement North Exit. The three quarter inch pipe sleeves were located in the north and west walls above the exit sign.

Building C- Second Floor
2. At 12:11 p.m., there was a one inch metal conduit traveling through the wall near the ceiling. There was an approximately one quarter inch unsealed penetration around the outside of the conduit.

Main Hospital Second Floor Building M
During a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager on 6/4/13, corridor doors were observed.

8. At 2:10 p.m., the roll down fire door in the Imaging Library had a bell and clipboard sitting on the counter top that obstructed the path of the fire door.








27254

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that did not latch when closed, and by doors that were impeded from closing. This affected three of four floors in Building E, and one floor in the Main Building, and VHC Bascom, and could result in the migration of smoke.

Findings:

During a tour of the facility with the Director of Facilities between 6/3/13 and 6/17/13, the corridor doors were observed.

Building E
1. On 6/4/13 at 3:48 p.m., 3rd floor Room 3E051, the corridor door to the patient room failed to positively latch when fully closed.

2. On 6/4/13 at 4:05 p.m., 2nd floor Room 2E031, the corridor door to the patient room failed to positively latch when fully closed.

3. On 6/4/13 at 4:08 p.m., 2nd floor Room 2E022, the corridor door to the patient room failed to positively latch when fully closed.

4. On 6/4/13 at 4:10 p.m., 2nd floor Room 2E005, the corridor door to the Staff Lounge failed to positively latch when fully closed.

5. On 6/5/13 at 9:32 a.m., 1st floor Room 1E029, the corridor door to the patient room was impeded from closing by the foot of the bed.

6. On 6/5/13 at 9:35 a.m., 1st floor Room 1E023, the corridor door to the patient room was obstructed from closing by a trash can.

VHC Bascom
7. On 6/7/13 at 9:40 a.m., 3rd floor OB Suite 300, the self closing door between the waiting room and the corridor failed to fully close and positively latch when closed.

Based on observation and interview, the facility failed to maintain all doors in exit passageways and horizontal exits to close automatically when the fire alarm system was activated by the automatic sprinkler system, manual fire alarm system, or smoke detectors. This was evidenced by doors that were held open by magnetic hold-open devices that failed to automatically close upon activation of the manual fire alarm system and automatic sprinkler system. This affected eight of eight smoke compartments in Building G Barbara Arons Pavilion, and could result in the spread of smoke and/or fire

Findings:

During fire alarm testing with Engineering Staff between 6/5/13 and 6/6/13, the cross-corridor doors were observed.

Building G Barbara Arons Pavilion
1. Between 1:35 p.m., and 2:08 p.m., the fire alarm system manual pull and automatic sprinkler system water flow devices were tested. Doors that were being held open by automatic hold-open devices did not release by zone or throughout the facility when the fire alarm devices activated the fire alarm control panel.

2. At 1:45 p.m., door 1G145 did not activate the fire alarm when artificial smoke was sprayed into the door smoke detector/closure assembly. The doors closed, but did not positively latch. No audible alarm was heard.

When asked, Staff 6 stated that all of the automatic door closures in the Unit 400 and Unit 500 were only designed to close by activating the smoke detector built into the door closure. Staff stated that the doors do not release when the corridor smoke detectors, automatic sprinkler system, or the fire alarm manual pulls are activated. When asked, Staff stated that the smoke detectors that are built into the door closures do not activate the fire alarm control panel or produce an audible alarm, and that they only close the doors.


27254

Building G
1. On 6/5/13, at 1:40 p.m., in the 500 Wing, 4 sets of fire doors failed to release and close upon activation of the fire alarm system. The two sets of fire doors to the meeting room, 1 set of fire doors by Room 1G224, and 1 set of fire doors by Room 1G221 only closed when the local smoke detector for the door was activated.

2. On 6/5/13, at 2:02 p.m., the right hand fire door by Room 1G224 failed to magnetize and remain closed.

Based on observation, the facility failed to maintain the construction of its smoke/fire barrier walls. This was evidenced by an unsealed penetration in a smoke barrier wall. This affected one of three smoke compartments on the third floor of Building M, and could result in smoke and/or fire spreading from one smoke compartment to another.

NFPA 101, 2000 Edition
8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube 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 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 of 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:
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 a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager on 6/4/13, smoke/fire barrier walls were observed.

At 3:55 p.m., there was an approximately one half inch by three inch unsealed penetration inside a pipe sleeve that traveled through the smoke barrier wall located above the drop down ceiling near Room 3M101.

During testing of the fire alarm system with the Engineering Supervisor and the Quality Improvement Manager between 6/5/13 and 6/6/13, the fire alarm system devices were observed.

Building K - Second Floor
1. At 11:10 a.m., the one and one half hour fire rated corridor door number 6006F2-CC01 seperating the West Wing form the Old Main was tested by spraying artificial smoke into the smoke detector built into the door closing hardware. The right leaf facing west did not close and latch leaving a twelve inch gap.

2. At 2:17 p.m., smoke detector SD82-22 was tested with artificial smoke. The cross corridor fire doors between Buildings C and F failed to close completely and latch leaving a one inch gap.

Building E
3. At 2:09 p.m., the one and one half hour fire rated door near Room 1E050 leading to the Spinal Cord Rehabilitation Unit was observed during fire alarm testing. The left door leaf facing east failed to close.

4. At 2:19 p.m., during fire alarm testing, the corridor doors near 1E065 did not close. The door had released from its hold open device, but did not self-close.

5. At 2:53 p.m., during fire alarm testing, the corridor fire doors to the cafeteria did not positive latch when tested by activating the smoke detector.

Valley Specialty Clinic Basement level (Building Q)
6. At 3:15 p.m., the one and one half hour fire rated cross corridor doors separating building Q from Building M the Main Hospital did not close when the fire alarm system was activated. These doors were near stairwell number 1.

7. The fire doors near Room B0J01 released from there hold open devices, but failed to close.





27254

Based on observation and interview, the facility failed to maintain fire doors as evidenced by fire doors that did not fully close and latch, and by fire doors that remained open. These deficient conditions affected smoke compartments in Buildings M, K, Q, and could result in the spread of smoke in the event of a fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door.
Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.


Findings
During a tour of the facility with the Director of Facilities, between 6/3/13 and 6/7/13, the facility fire doors were observed and tested.
Building M
1. On 6/4/13, at 11:15 a.m., on the 4th floor across from Room 4M056, Fire Door #6009-F4-CC22, the left hand door failed to fully close and latch when tested.

2. On 6/5/13, at 11:45 a.m., on the 4th floor, fire door #6009-F4-CC09, the left hand door to the MICU entrance failed to positively latch when closed. When the push hardware on the doors was not fully pushed in when opening, the door latching mechanism did not reset so that it can latch again when closed.

3. On 6/5/13, at 3:02 p.m., on the 5th floor, by Room 5M101 the right hand door of fire door #6009-F5-CC08 failed to positively latch when closed.

4. On 6/5/13, at 3:05 p.m., on the 4th floor, the right hand door of fire door #6009-F5-CC05 remained fully open when the fire alarm was activated.

Building K
5. On 6/6/13, at 10:55 a.m., on the 2nd floor, the fire door #6006-F2-CC06 by the Rehabilitation Trauma Center failed to release and close upon activation of the fire alarm system.

Based on observation, the facility failed to protect its hazardous area enclosures. This was evidenced by a room which contained combustible storage and was not equipped with a self-closing mechanism on the door. This deficient practice affected one of eight smoke compartments in Building G, and could result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager rooms with combustible storage were observed.

Building G
On 6/5/13 at 1:10 p.m., the corridor door to Office 1G153 had the arm to the door closure removed. Approximately 20 percent of the room contained papers, boxes, and other combustible storage.

Building M - Second Floor
1. At 1:35 p.m., the corridor between the Anesthesia Offices had medical equipment stored for the full length of the corridor. The clear width at the narrowest point in this area was 38 inches wide.









27254

Based on observation and interview, the facility failed to maintain the emergency exits, as evidenced by items stored along egress corridors, and by signs posted on Egress Doors that stated "Not an Exit" or "STOP". This could lead to a delayed evacuation in the event of an emergency, and affected smoke compartments in Building C, K, and M.

NFPA 101 Life Safety Code, 2000 edition
4.5.3 Means of Egress.
4.5.3.2 Unobstructed Egress. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. No lock or fastening shall be permitted that prevents free escape from the inside of any building other than in health care occupancies and detention and correctional occupancies where staff are continually on duty and effective provisions are made to remove occupants in case of fire or other emergency. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.
7.1.3.2.3* An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
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.
7.1.10.2.2 There shall be no obstructions by railings, barriers, or gates that divide the open space into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment.

Findings:

During a tour of the facility with the Director of Facilities, between 6/3/07 and 6/7/07, the exit corridors were observed.

Building K
1. On 6/4/13, at 3:40 p.m., on the 2nd floor in TICU, the two fire doors from the Unit to the corridor had signs the read "STOP" posted on each door. The signs were each 8 inches by 11 inches. During an interview, staff stated that the signs had been posted to deter individuals from pushing the doors open. The doors were controlled by a hand motion detector.

Building M
2. On 6/5/13, at 4:00 p.m., by Room 2M035, three carts and a lift were stored along the egress corridor in front of the egress door. There was a sign posted on the door that read "NOT AN EXIT". The door was marked with an illuminated emergency exit sign above the doorway. Staff stated during an interview that the signs had been posted so that employees would not exit the surgical unit during breaks and at end of shift through the doors.

Building C
3. On 6/5/13, at 11:11 a.m., on the 6th floor by room 6C094, a table and shredder were placed in the corridor. During staff interview, staff stated that the items were always in that location.

4. On 6/5/13, at 11:15 a.m., on the 6th floor by room 6C095, a filing cabinet, a paper cabinet and a recycle bin were stored along the corridor wall. During staff interview, staff stated that the items were always in that location.

5. On 6/5/13, at 11:18 a.m., on the 6th floor by room 6C058, a printer/copier was observed in the corridor. During staff interview, staff stated that the items were always in that location.

Based on interview and observation, the facility failed to maintain the emergency lighting, as evidenced by battery operated lights that failed to illuminate when tested, and by no records for the monthly and annual testing of the emergency back up lights in the facility. This could lead to the emergency lighting malfunctioning in the event of an emergency, and affected the second floor of Building F, and the VHC Bascom Building.

NFPA 101, Life Safety Code,
SECTION 7.9 EMERGENCY LIGHTING
7.9.1 General.
Section 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 battery-powered emergency lighting system for not less than 1 ? 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 a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager on 6/5/13 and 6/7/13, the battery-powered egress lights were observed.

6/5/13
Building F
1. At 10:45 a.m., two battery-powered egress lights in the Cafeteria did not function when tested. One light was located in the Vending Machine area. This light was located to provide light if exiting from the east side of the Cafeteria. The other light was located across the Cafeteria from the ice machine, and was one of two lights that would provide light in the main part of the Cafeteria itself.

Documentation was requested for the testing of the battery-powered lights in the Cafeteria on 6/6/13, at 9:35 a.m. No documentation was provided for review.


VHC Bascom
1. On 6/7/13, at 9:00 a.m., battery emergency lighting units were observed in all the clinic suites. Records for the monthly and annual testing of the emergency lighting were requested. Upon interview, staff stated that the lights were tested and that the documents would be provided. As of 6/13/13, no documents were provided.

2. On 6/5/13, at 9:51 a.m., on the 3rd floor in suite 335, the battery back up light by Room 335-03 failed to illuminate when tested by staff.

3. On 6/5/13, at 9:59 a.m., on the 2nd floor in suite 240, the battery back up light by Room 240-01 failed to illuminate when tested by staff.

4. On 6/5/13, at 10:11 a.m., on the 2nd floor in suite 200, the battery back up light by Room 200-1B failed to illuminate when tested by staff.

5. On 6/5/13, at 10:21 p.m., on the 1st floor in suite 140, the battery back up light by Room 140-01 failed to illuminate when tested by staff.

Based on observation and interview, the facility failed to maintain exit and directional signs as evidenced by no exit or directional sign located in the corridor outside of the cafeteria. This condition affected the second floor of Building F, and could result in a delay in egress in the event of an emergency evacuation.

Findings

During a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager on 6/5/13, exit signs were observed.

Building F - First Floor
At 10:50 a.m., the exit path located in the corridor outside of the Vending Machine Room did not have the direction of egress marked. When exiting into the corridor, the door to the right at the end of the dead-end corridor had a sign on it stating "Not An Exit". If exiting to the the left into the corridor, there was no sign located above the cross-corridor doors. If the doors were to close during activation of the fire alarm, no exit sign would be visible in that direction. When asked, Engineering Staff 2 agreed that it could be confusing.

Base on observation and interview the facility failed to maintain all fire alarm system devices, as evidenced by a door smoke detector that failed to activate the fire alarm system when tested. This finding affected one of five floors in Building K, and could result in a delay in response to the buildings occupants in the event of a fire emergency.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

Findings:

During testing of the fire alarm system with the Engineering Supervisor and the Quality Improvement Manager on 6/6/13, the fire alarm system devices were observed.

West Wing Basement Building K
1. At 10:35 a.m., the smoke detector device number 6005F0CC02 that was built into the door closing mechanism was sprayed with artificial smoke. The door closed, but no audible alarm could be heard, and no other door closed throughout the facility. Staff 5 was interviewed at that time, and stated that the fire alarm control panel did not activate when the door smoke detector was tested. Staff stated that the device had recently been changed, and that it needed to be fixed. This door was a one and one half hour fire rated door between buildings B and K.

2. At 11:02 a.m., the corridor doors to the Rehabilitation/Trama Room doors by the Consultation Room were observed during testing. The smoke detector that was built into the door closing mechanism was sprayed with artificial smoke. The door closed, but no audible alarm could be heard.

Based on record review and interview, the facility failed to maintain the smoke detectors. This was evidenced by failing to provide documentation for the smoke detectors sensitivity testing. This affected Buildings E, K, G, F, and could result in the failure of the smoke detectors in the event of a fire, or in a delay in notification in the event of a fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

NFPA 72, 1999 Edition
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer 's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review with the Engineering Supervisor on 6/3/13, at 2:45 p.m., the facility failed to provide documentation indicating that the smoke detectors had been tested for sensitivity within the past two years, for the Main Campus Rehabilitation, West Wing, Barbara Arons Pavillion, and Services Buildings E, K, G, and F.

When asked if all of the smoke detectors in all areas of the facility were smart detectors, Staff 6 stated that Buildings E, K, G, and F did not have smart detectors or newer fire alarm control panels that would sense if the detector was outside of it listed sensitivity range.

On 6/6/13, at 9:35 a.m., when asked what the date was for the last sensitivity test in Buildings E, K, G, and F, Staff 1 stated that they did not think they had been tested for sensitivity.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by sprinkler head escutcheons that had dropped of the ceiling surface or had shifted off to the side, and by an Inspector's Test Valve opening that was not the size of the smallest installed sprinkler head. These conditions affected smoke compartments in Building M, K, E, and could result in the passage of smoke from one smoke compartment to another.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

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.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems., 1998 edition.
2-2.1 Sprinklers.
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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
2-2.2 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.
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.
2-3.3.1* Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspectors test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used.

Findings

During a tour of the facility with the Director of Facilities between 6/3/13 and 6/7/13, the automatic sprinkler heads and Inspector's Test Valve (ITV) were observed.

Building M
1. On 6/4/13, at 1:50 p.m., on the Basement Level, in Room BB05A, the ITV exit orifice was not the size of the smallest installed sprinkler head. The exit orifice for the sprinkler measured approximately 2 1/2 inches.

Building K
2. On 6/4/13, at 3:25 p.m., on the 4th floor, in Room 4K124, the sprinkler head escutcheon had dropped off the ceiling surface approximately one inch, and exposed a two inch penetration in the ceiling.

Building K
3. On 6/4/13, at 4:06 p.m., on the 2nd floor, in Room 2E021, the sprinkler head escutcheon had dropped off the ceiling surface approximately one inch, and exposed a two inch penetration in the ceiling.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by portable fire extinguishers that were stored unsecured, and by portable fire extinguishers that were obstructed. This deficient practice affected staff and patients in Building C, M, K, and could result in a delay in access to the portable fire extinguishers, resulting in the spread of smoke and/or fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

NFPA 10, 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.

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

Findings:

During a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager, the portable fire extinguishers were observed.

Building M - Basement Level
1. On 6/5/13, at 9:30 a.m., there were portable fire extinguishers stored on the floor unsecured in the two IT Rooms near Room BMTD1. There were tags on the portable fire extinguishers with instructions to install the extinguishers in those rooms.

2. On 6/5/13, at 11:45 a.m., outside of Building M, there was a portable fire extinguisher stored unsecured on the ground in the outside medical gas cylinder storage location.


27254

During a tour of the facility with the Director of Facilities between 6/3/13 and 6/7/13, the portable fire extinguishers were observed.
Building K
1. On 6/4/13, at 3:45 p.m., in RICU next to the Nurse Station, the portable fire extinguisher was blocked by rolling carts.

2. On 6/4/13, at 3:10 p.m., on the 4th floor by Room 4K112, a Work station On Wheels (WOW) was stored charging in front of a portable fire extinguisher.

Building C
3. On 6/5/13, at 11:20 a.m., on the 6th floor, in Room 6C058, the portable fire extinguisher was blocked by three IV poles and a blanket cart.

Building M
4. On 6/5/13, at 4 p.m., on the 2nd floor across from OR 11, the portable fire extinguisher was blocked by a cart.

Based on record review and interview, the facility failed to maintain its heating, ventilation, and air conditioning system in accordance with NFPA 90A, as evidenced by duct detectors and smoke fire dampers that were documented as not functioning properly, and that had not been repaired. This finding affected six of six floors in Building M, and could result in the spread of smoke and/or fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.


Findings:

Building M
During a review of the facility's documentation with the Engineering Supervisor and Quality Improvement Manager on 6/4/13, documentation provided for the fire /smoke damper inspection report was requested.

Documentation indicated that a total of 49 fire smoke dampers (SFD) did not function properly when tested. Documentation titled "SCCVMC Building M FSD Failure" documented damper failure on the following floors of the Main Hopsital:

Six dampers on the basement level, six dampers on the first floor, nineteen dampers on the second floor, three dampers on the third floor, nine dampers on the fourth floor, and six dampers on the fifth floor.

When asked, Engineering Staff 1 confirmed that the dampers were not functioning properly and that the facility had been working on repairing them. Documentation provided titled "Work Requests", recorded 109 dampers/duct detectors that had failed, and had been repaired at the Main Hospital since November of 2012.

Based on document review, the facility failed to monitor the relative humidity in its anesthetizing locations. This was evidenced by humidity levels that were not documented on each shift. This deficient practice had the potential to affect staff and patients in twelve of twelve operating rooms in Building M, by increasing the risk of fire.

Findings:

During record review with the Engineering Supervisor on 6/4/13, documentation for monitoring humidity levels in the operating room was reviewed. Documentation provided titled "Temperature and Humidity Log Main Operating Rooms", had fields on the form that the time, temperature, and humidity could be documented for all twelve operating rooms for the Night, Day, and PM shifts.

The following days had shifts that were missing documentation for the time, temperature, and humidity in Operating Rooms 1 throught 12:

2/6/13 was missing the PM Shift
2/14/13 was missing the Night Shift
2/15/13 was missing the PM Shift
2/18/13 was missing the Night Shift
2/20/13 was missing the Day Shift
2/24/13 was missing the Day Shift
3/1/13 was missing the Day Shift
3/6/13 was missing the Day Shift
3/11/13 was missing the Day Shift
3/12/13 was missing the Daty Shift
3/14/13 was missing the Day Shift
3/18/13 was missing the Day Shift
3/20/13 Was missing the Day Shift
4/11/13 was missing the PM Shift
4/16/13 was missing the Night Shift (forgot to do it)
4/21/13 was missing the Day Shift
5/1/13 was missing the PM Shift
5/20/13 was missing the day shift (No time)
5/23/13 was missing the Day Shift (No time Busy)
6/1/13 was missing the Night Shift
6/3/13 was missing the Day and PM Shift

The Policy and Procedure number 822.0 for the Operating Room ventilation system states "The humidity and temperature of each operating room will be checked at the begininning of each shift and documented on the Humidity/Temperature Log Sheet."

Building M - Third Floor
1. There were two power strips chained together in the Labor and Delivery Conference Room 104.

Main Hospital Second Floor Building M
2. At 1:37 p.m., Room 2M074 had a power strip suspended above the floor



VHC Bascom
1. On 6/7/13, at 9:47 a.m., on the 3rd floor in Suite 330, there was an ultra sound machine, bed and electrosurgical machine plugged into a single power strip in room 330-13.

2. On 6/7/13, at 10:25 a.m., on the 1st floor in Suite 100, there was a refrigerator and a microwave plugged into a power strip in the Mail Room.




27254

Based on interview and observation, the facility failed to maintain the electrical wiring and equipment, as evidenced by the use of surge protectors as a substitute for fixed wiring, and by surge protectors plugged into other surge protectors. This affected smoke compartments in Buildings C, M and E, and could result in the ignition of an electrical fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4)Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection\
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b)& 305-4 c)
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.


Findings:

During a tour of the facility with the Director of Facilities, between 6/3/13 and 6/7/13, the electrical wiring in the facility was observed.

Building C
1. On 6/5/13, at 11:00 a.m., on the 7th floor in Room 7C015, in the Special Procedures Room there were three suction machines plugged into a power strip instead of directly into the wall outlet.

2. On 6/5/13, at 11:01 a.m., on the 7th floor in Room 7C001, in the Staff locker Room, an air conditioning unit was plugged into a power strip instead of directly into the wall outlet.

Building M
3. On 6/4/13, at 11:50 a.m., on the 3rd floor in Room 3M104, the training computers were all plugged into power strips, and the power strips were plugged into one another.

4. On 6/4/13, at 1:10 p.m., on the Basement Level in Room 3B010, the training computers were all plugged into power strips, and the power strips were plugged into one another.

Building E
5. On 6/5/13, at 9:22 a.m., on the 1st floor in Room 1E070, in the Cardiac Rehab room, two treadmills were plugged into a single power strip instead of directly into the wall outlet.

6. On 6/5/13, at 9:34 a.m., on the 1st floor in Room 1E028, six ventilator batteries were plugged into a power strip for charging.

7. On 6/5/13, at 9:37 a.m., on the 1st floor in Room 1E052, in the Staff Lounge, a coffee maker was plugged into a power strip instead of direclty into the wall outelt.

Based on document review and interview, the facility failed to provide a written protocol to insure that if the automatic sprinkler system was out of service for four or more hours in a 24 hour period, that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation for this requirement. This affected all staff and patients in the Buildings B,C, E, F, G, K, M, and Q, and could result in the AHJ (the Department of Public Health) being unable to exercise oversight during the shutdown.


Findings:

During record review on 6/3/13 at 2:00 p.m., documentation provided for an approved fire watch did not give guidance to notify the Department of Public Health if the automatic sprinkler system was out of service for four or more hours in a 24 hour period.

Based on document review and interview, the facility failed to provide a written protocol to insure that if the fire alarm system was out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation for this requirement. This affected all staff and patients in the Buildings B,C, E, F, G, K, M, and Q, and could result in the AHJ (the Department of Public Health) being unable to exercise oversight during the shutdown.


Findings:

During record review on 6/3/13 at 2:00 p.m., documentation provided for an approved fire watch did not give guidance to notify the Department of Public Health if the fire alarm system was out of service for four or more hours in a 24 hour period.

Building M
On 6/4/13, at 2:06 p.m., the walls in the Air Handler Room were observed. There was a two inch round unsealed penetration in the east wall located approximately ten feet above the floor. This penetration was through the gypsum board sheeting that covered the structural column. Engineering Staff 2 confirmed the penetration.












27254

Based on observation and interview, the facility failed to maintain the building free of penetrations, as evidenced by unsealed pipe penetrations, and by unsealed junction boxes. These conditions affected smoke compartments in in Buildings C, K, and M, and could result in the passage of smoke from one part of the facility to another in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire 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 fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following
conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
Findings:

During a tour of the facility with the Director of Facilities, between 6/3/13 and 6/7/13, the walls and ceilings were observed.

Building K
1. On 6/4/13, at 2:25 p.m., on the Basement Level, in Room BK007 there were three pipes, each approximately between 1.5 inches and 3 inches in diameter, that were passing through the finished ceiling. There was a two inch opening around each pipe that had not been sealed.

Building E
2. On 6/5/13, at 9:46 a.m., on the Basement Level, in the Psychology Services Office Room #BEC04, the cover for the junction box by the office door was missing.

Building C
3. On 6/5/13, at 10:58 a.m., on the 7th floor in room 7C021, a clock had been removed, and the junction box for the clock had not been sealed.

Based on observation, the facility failed to maintain its corridor construction with a one half hour fire rating as evidenced by unsealed penetrations in the corridor walls. This finding affected one of six floors in Building M, and one of eight floors of Building C, and could result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager on 6/4/13, corridor walls were observed.

Building M - Basement Level
1. At 3:25 p.m., there were two unsealed pipe sleeves above the drop-down ceiling near the Basement North Exit. The three quarter inch pipe sleeves were located in the north and west walls above the exit sign.

Building C- Second Floor
2. At 12:11 p.m., there was a one inch metal conduit traveling through the wall near the ceiling. There was an approximately one quarter inch unsealed penetration around the outside of the conduit.

Main Hospital Second Floor Building M
During a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager on 6/4/13, corridor doors were observed.

8. At 2:10 p.m., the roll down fire door in the Imaging Library had a bell and clipboard sitting on the counter top that obstructed the path of the fire door.








27254

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that did not latch when closed, and by doors that were impeded from closing. This affected three of four floors in Building E, and one floor in the Main Building, and VHC Bascom, and could result in the migration of smoke.

Findings:

During a tour of the facility with the Director of Facilities between 6/3/13 and 6/17/13, the corridor doors were observed.

Building E
1. On 6/4/13 at 3:48 p.m., 3rd floor Room 3E051, the corridor door to the patient room failed to positively latch when fully closed.

2. On 6/4/13 at 4:05 p.m., 2nd floor Room 2E031, the corridor door to the patient room failed to positively latch when fully closed.

3. On 6/4/13 at 4:08 p.m., 2nd floor Room 2E022, the corridor door to the patient room failed to positively latch when fully closed.

4. On 6/4/13 at 4:10 p.m., 2nd floor Room 2E005, the corridor door to the Staff Lounge failed to positively latch when fully closed.

5. On 6/5/13 at 9:32 a.m., 1st floor Room 1E029, the corridor door to the patient room was impeded from closing by the foot of the bed.

6. On 6/5/13 at 9:35 a.m., 1st floor Room 1E023, the corridor door to the patient room was obstructed from closing by a trash can.

VHC Bascom
7. On 6/7/13 at 9:40 a.m., 3rd floor OB Suite 300, the self closing door between the waiting room and the corridor failed to fully close and positively latch when closed.

Based on observation and interview, the facility failed to maintain all doors in exit passageways and horizontal exits to close automatically when the fire alarm system was activated by the automatic sprinkler system, manual fire alarm system, or smoke detectors. This was evidenced by doors that were held open by magnetic hold-open devices that failed to automatically close upon activation of the manual fire alarm system and automatic sprinkler system. This affected eight of eight smoke compartments in Building G Barbara Arons Pavilion, and could result in the spread of smoke and/or fire

Findings:

During fire alarm testing with Engineering Staff between 6/5/13 and 6/6/13, the cross-corridor doors were observed.

Building G Barbara Arons Pavilion
1. Between 1:35 p.m., and 2:08 p.m., the fire alarm system manual pull and automatic sprinkler system water flow devices were tested. Doors that were being held open by automatic hold-open devices did not release by zone or throughout the facility when the fire alarm devices activated the fire alarm control panel.

2. At 1:45 p.m., door 1G145 did not activate the fire alarm when artificial smoke was sprayed into the door smoke detector/closure assembly. The doors closed, but did not positively latch. No audible alarm was heard.

When asked, Staff 6 stated that all of the automatic door closures in the Unit 400 and Unit 500 were only designed to close by activating the smoke detector built into the door closure. Staff stated that the doors do not release when the corridor smoke detectors, automatic sprinkler system, or the fire alarm manual pulls are activated. When asked, Staff stated that the smoke detectors that are built into the door closures do not activate the fire alarm control panel or produce an audible alarm, and that they only close the doors.


27254

Building G
1. On 6/5/13, at 1:40 p.m., in the 500 Wing, 4 sets of fire doors failed to release and close upon activation of the fire alarm system. The two sets of fire doors to the meeting room, 1 set of fire doors by Room 1G224, and 1 set of fire doors by Room 1G221 only closed when the local smoke detector for the door was activated.

2. On 6/5/13, at 2:02 p.m., the right hand fire door by Room 1G224 failed to magnetize and remain closed.

Based on observation, the facility failed to maintain the construction of its smoke/fire barrier walls. This was evidenced by an unsealed penetration in a smoke barrier wall. This affected one of three smoke compartments on the third floor of Building M, and could result in smoke and/or fire spreading from one smoke compartment to another.

NFPA 101, 2000 Edition
8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube 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 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 of 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:
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 a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager on 6/4/13, smoke/fire barrier walls were observed.

At 3:55 p.m., there was an approximately one half inch by three inch unsealed penetration inside a pipe sleeve that traveled through the smoke barrier wall located above the drop down ceiling near Room 3M101.

During testing of the fire alarm system with the Engineering Supervisor and the Quality Improvement Manager between 6/5/13 and 6/6/13, the fire alarm system devices were observed.

Building K - Second Floor
1. At 11:10 a.m., the one and one half hour fire rated corridor door number 6006F2-CC01 seperating the West Wing form the Old Main was tested by spraying artificial smoke into the smoke detector built into the door closing hardware. The right leaf facing west did not close and latch leaving a twelve inch gap.

2. At 2:17 p.m., smoke detector SD82-22 was tested with artificial smoke. The cross corridor fire doors between Buildings C and F failed to close completely and latch leaving a one inch gap.

Building E
3. At 2:09 p.m., the one and one half hour fire rated door near Room 1E050 leading to the Spinal Cord Rehabilitation Unit was observed during fire alarm testing. The left door leaf facing east failed to close.

4. At 2:19 p.m., during fire alarm testing, the corridor doors near 1E065 did not close. The door had released from its hold open device, but did not self-close.

5. At 2:53 p.m., during fire alarm testing, the corridor fire doors to the cafeteria did not positive latch when tested by activating the smoke detector.

Valley Specialty Clinic Basement level (Building Q)
6. At 3:15 p.m., the one and one half hour fire rated cross corridor doors separating building Q from Building M the Main Hospital did not close when the fire alarm system was activated. These doors were near stairwell number 1.

7. The fire doors near Room B0J01 released from there hold open devices, but failed to close.





27254

Based on observation and interview, the facility failed to maintain fire doors as evidenced by fire doors that did not fully close and latch, and by fire doors that remained open. These deficient conditions affected smoke compartments in Buildings M, K, Q, and could result in the spread of smoke in the event of a fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door.
Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.


Findings
During a tour of the facility with the Director of Facilities, between 6/3/13 and 6/7/13, the facility fire doors were observed and tested.
Building M
1. On 6/4/13, at 11:15 a.m., on the 4th floor across from Room 4M056, Fire Door #6009-F4-CC22, the left hand door failed to fully close and latch when tested.

2. On 6/5/13, at 11:45 a.m., on the 4th floor, fire door #6009-F4-CC09, the left hand door to the MICU entrance failed to positively latch when closed. When the push hardware on the doors was not fully pushed in when opening, the door latching mechanism did not reset so that it can latch again when closed.

3. On 6/5/13, at 3:02 p.m., on the 5th floor, by Room 5M101 the right hand door of fire door #6009-F5-CC08 failed to positively latch when closed.

4. On 6/5/13, at 3:05 p.m., on the 4th floor, the right hand door of fire door #6009-F5-CC05 remained fully open when the fire alarm was activated.

Building K
5. On 6/6/13, at 10:55 a.m., on the 2nd floor, the fire door #6006-F2-CC06 by the Rehabilitation Trauma Center failed to release and close upon activation of the fire alarm system.

Based on observation, the facility failed to protect its hazardous area enclosures. This was evidenced by a room which contained combustible storage and was not equipped with a self-closing mechanism on the door. This deficient practice affected one of eight smoke compartments in Building G, and could result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager rooms with combustible storage were observed.

Building G
On 6/5/13 at 1:10 p.m., the corridor door to Office 1G153 had the arm to the door closure removed. Approximately 20 percent of the room contained papers, boxes, and other combustible storage.

Building M - Second Floor
1. At 1:35 p.m., the corridor between the Anesthesia Offices had medical equipment stored for the full length of the corridor. The clear width at the narrowest point in this area was 38 inches wide.









27254

Based on observation and interview, the facility failed to maintain the emergency exits, as evidenced by items stored along egress corridors, and by signs posted on Egress Doors that stated "Not an Exit" or "STOP". This could lead to a delayed evacuation in the event of an emergency, and affected smoke compartments in Building C, K, and M.

NFPA 101 Life Safety Code, 2000 edition
4.5.3 Means of Egress.
4.5.3.2 Unobstructed Egress. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. No lock or fastening shall be permitted that prevents free escape from the inside of any building other than in health care occupancies and detention and correctional occupancies where staff are continually on duty and effective provisions are made to remove occupants in case of fire or other emergency. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.
7.1.3.2.3* An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
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.
7.1.10.2.2 There shall be no obstructions by railings, barriers, or gates that divide the open space into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment.

Findings:

During a tour of the facility with the Director of Facilities, between 6/3/07 and 6/7/07, the exit corridors were observed.

Building K
1. On 6/4/13, at 3:40 p.m., on the 2nd floor in TICU, the two fire doors from the Unit to the corridor had signs the read "STOP" posted on each door. The signs were each 8 inches by 11 inches. During an interview, staff stated that the signs had been posted to deter individuals from pushing the doors open. The doors were controlled by a hand motion detector.

Building M
2. On 6/5/13, at 4:00 p.m., by Room 2M035, three carts and a lift were stored along the egress corridor in front of the egress door. There was a sign posted on the door that read "NOT AN EXIT". The door was marked with an illuminated emergency exit sign above the doorway. Staff stated during an interview that the signs had been posted so that employees would not exit the surgical unit during breaks and at end of shift through the doors.

Building C
3. On 6/5/13, at 11:11 a.m., on the 6th floor by room 6C094, a table and shredder were placed in the corridor. During staff interview, staff stated that the items were always in that location.

4. On 6/5/13, at 11:15 a.m., on the 6th floor by room 6C095, a filing cabinet, a paper cabinet and a recycle bin were stored along the corridor wall. During staff interview, staff stated that the items were always in that location.

5. On 6/5/13, at 11:18 a.m., on the 6th floor by room 6C058, a printer/copier was observed in the corridor. During staff interview, staff stated that the items were always in that location.

Based on interview and observation, the facility failed to maintain the emergency lighting, as evidenced by battery operated lights that failed to illuminate when tested, and by no records for the monthly and annual testing of the emergency back up lights in the facility. This could lead to the emergency lighting malfunctioning in the event of an emergency, and affected the second floor of Building F, and the VHC Bascom Building.

NFPA 101, Life Safety Code,
SECTION 7.9 EMERGENCY LIGHTING
7.9.1 General.
Section 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 battery-powered emergency lighting system for not less than 1 ? 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 a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager on 6/5/13 and 6/7/13, the battery-powered egress lights were observed.

6/5/13
Building F
1. At 10:45 a.m., two battery-powered egress lights in the Cafeteria did not function when tested. One light was located in the Vending Machine area. This light was located to provide light if exiting from the east side of the Cafeteria. The other light was located across the Cafeteria from the ice machine, and was one of two lights that would provide light in the main part of the Cafeteria itself.

Documentation was requested for the testing of the battery-powered lights in the Cafeteria on 6/6/13, at 9:35 a.m. No documentation was provided for review.


VHC Bascom
1. On 6/7/13, at 9:00 a.m., battery emergency lighting units were observed in all the clinic suites. Records for the monthly and annual testing of the emergency lighting were requested. Upon interview, staff stated that the lights were tested and that the documents would be provided. As of 6/13/13, no documents were provided.

2. On 6/5/13, at 9:51 a.m., on the 3rd floor in suite 335, the battery back up light by Room 335-03 failed to illuminate when tested by staff.

3. On 6/5/13, at 9:59 a.m., on the 2nd floor in suite 240, the battery back up light by Room 240-01 failed to illuminate when tested by staff.

4. On 6/5/13, at 10:11 a.m., on the 2nd floor in suite 200, the battery back up light by Room 200-1B failed to illuminate when tested by staff.

5. On 6/5/13, at 10:21 p.m., on the 1st floor in suite 140, the battery back up light by Room 140-01 failed to illuminate when tested by staff.

Based on observation and interview, the facility failed to maintain exit and directional signs as evidenced by no exit or directional sign located in the corridor outside of the cafeteria. This condition affected the second floor of Building F, and could result in a delay in egress in the event of an emergency evacuation.

Findings

During a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager on 6/5/13, exit signs were observed.

Building F - First Floor
At 10:50 a.m., the exit path located in the corridor outside of the Vending Machine Room did not have the direction of egress marked. When exiting into the corridor, the door to the right at the end of the dead-end corridor had a sign on it stating "Not An Exit". If exiting to the the left into the corridor, there was no sign located above the cross-corridor doors. If the doors were to close during activation of the fire alarm, no exit sign would be visible in that direction. When asked, Engineering Staff 2 agreed that it could be confusing.

Base on observation and interview the facility failed to maintain all fire alarm system devices, as evidenced by a door smoke detector that failed to activate the fire alarm system when tested. This finding affected one of five floors in Building K, and could result in a delay in response to the buildings occupants in the event of a fire emergency.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

Findings:

During testing of the fire alarm system with the Engineering Supervisor and the Quality Improvement Manager on 6/6/13, the fire alarm system devices were observed.

West Wing Basement Building K
1. At 10:35 a.m., the smoke detector device number 6005F0CC02 that was built into the door closing mechanism was sprayed with artificial smoke. The door closed, but no audible alarm could be heard, and no other door closed throughout the facility. Staff 5 was interviewed at that time, and stated that the fire alarm control panel did not activate when the door smoke detector was tested. Staff stated that the device had recently been changed, and that it needed to be fixed. This door was a one and one half hour fire rated door between buildings B and K.

2. At 11:02 a.m., the corridor doors to the Rehabilitation/Trama Room doors by the Consultation Room were observed during testing. The smoke detector that was built into the door closing mechanism was sprayed with artificial smoke. The door closed, but no audible alarm could be heard.

Based on record review and interview, the facility failed to maintain the smoke detectors. This was evidenced by failing to provide documentation for the smoke detectors sensitivity testing. This affected Buildings E, K, G, F, and could result in the failure of the smoke detectors in the event of a fire, or in a delay in notification in the event of a fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

NFPA 72, 1999 Edition
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer 's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review with the Engineering Supervisor on 6/3/13, at 2:45 p.m., the facility failed to provide documentation indicating that the smoke detectors had been tested for sensitivity within the past two years, for the Main Campus Rehabilitation, West Wing, Barbara Arons Pavillion, and Services Buildings E, K, G, and F.

When asked if all of the smoke detectors in all areas of the facility were smart detectors, Staff 6 stated that Buildings E, K, G, and F did not have smart detectors or newer fire alarm control panels that would sense if the detector was outside of it listed sensitivity range.

On 6/6/13, at 9:35 a.m., when asked what the date was for the last sensitivity test in Buildings E, K, G, and F, Staff 1 stated that they did not think they had been tested for sensitivity.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by sprinkler head escutcheons that had dropped of the ceiling surface or had shifted off to the side, and by an Inspector's Test Valve opening that was not the size of the smallest installed sprinkler head. These conditions affected smoke compartments in Building M, K, E, and could result in the passage of smoke from one smoke compartment to another.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

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.
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems., 1998 edition.
2-2.1 Sprinklers.
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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
2-2.2 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.
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.
2-3.3.1* Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspectors test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used.

Findings

During a tour of the facility with the Director of Facilities between 6/3/13 and 6/7/13, the automatic sprinkler heads and Inspector's Test Valve (ITV) were observed.

Building M
1. On 6/4/13, at 1:50 p.m., on the Basement Level, in Room BB05A, the ITV exit orifice was not the size of the smallest installed sprinkler head. The exit orifice for the sprinkler measured approximately 2 1/2 inches.

Building K
2. On 6/4/13, at 3:25 p.m., on the 4th floor, in Room 4K124, the sprinkler head escutcheon had dropped off the ceiling surface approximately one inch, and exposed a two inch penetration in the ceiling.

Building K
3. On 6/4/13, at 4:06 p.m., on the 2nd floor, in Room 2E021, the sprinkler head escutcheon had dropped off the ceiling surface approximately one inch, and exposed a two inch penetration in the ceiling.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by portable fire extinguishers that were stored unsecured, and by portable fire extinguishers that were obstructed. This deficient practice affected staff and patients in Building C, M, K, and could result in a delay in access to the portable fire extinguishers, resulting in the spread of smoke and/or fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

NFPA 10, 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.

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

Findings:

During a tour of the facility with the Engineering Supervisor and the Quality Improvement Manager, the portable fire extinguishers were observed.

Building M - Basement Level
1. On 6/5/13, at 9:30 a.m., there were portable fire extinguishers stored on the floor unsecured in the two IT Rooms near Room BMTD1. There were tags on the portable fire extinguishers with instructions to install the extinguishers in those rooms.

2. On 6/5/13, at 11:45 a.m., outside of Building M, there was a portable fire extinguisher stored unsecured on the ground in the outside medical gas cylinder storage location.


27254

During a tour of the facility with the Director of Facilities between 6/3/13 and 6/7/13, the portable fire extinguishers were observed.
Building K
1. On 6/4/13, at 3:45 p.m., in RICU next to the Nurse Station, the portable fire extinguisher was blocked by rolling carts.

2. On 6/4/13, at 3:10 p.m., on the 4th floor by Room 4K112, a Work station On Wheels (WOW) was stored charging in front of a portable fire extinguisher.

Building C
3. On 6/5/13, at 11:20 a.m., on the 6th floor, in Room 6C058, the portable fire extinguisher was blocked by three IV poles and a blanket cart.

Building M
4. On 6/5/13, at 4 p.m., on the 2nd floor across from OR 11, the portable fire extinguisher was blocked by a cart.

Based on record review and interview, the facility failed to maintain its heating, ventilation, and air conditioning system in accordance with NFPA 90A, as evidenced by duct detectors and smoke fire dampers that were documented as not functioning properly, and that had not been repaired. This finding affected six of six floors in Building M, and could result in the spread of smoke and/or fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.


Findings:

Building M
During a review of the facility's documentation with the Engineering Supervisor and Quality Improvement Manager on 6/4/13, documentation provided for the fire /smoke damper inspection report was requested.

Documentation indicated that a total of 49 fire smoke dampers (SFD) did not function properly when tested. Documentation titled "SCCVMC Building M FSD Failure" documented damper failure on the following floors of the Main Hopsital:

Six dampers on the basement level, six dampers on the first floor, nineteen dampers on the second floor, three dampers on the third floor, nine dampers on the fourth floor, and six dampers on the fifth floor.

When asked, Engineering Staff 1 confirmed that the dampers were not functioning properly and that the facility had been working on repairing them. Documentation provided titled "Work Requests", recorded 109 dampers/duct detectors that had failed, and had been repaired at the Main Hospital since November of 2012.

Based on document review, the facility failed to monitor the relative humidity in its anesthetizing locations. This was evidenced by humidity levels that were not documented on each shift. This deficient practice had the potential to affect staff and patients in twelve of twelve operating rooms in Building M, by increasing the risk of fire.

Findings:

During record review with the Engineering Supervisor on 6/4/13, documentation for monitoring humidity levels in the operating room was reviewed. Documentation provided titled "Temperature and Humidity Log Main Operating Rooms", had fields on the form that the time, temperature, and humidity could be documented for all twelve operating rooms for the Night, Day, and PM shifts.

The following days had shifts that were missing documentation for the time, temperature, and humidity in Operating Rooms 1 throught 12:

2/6/13 was missing the PM Shift
2/14/13 was missing the Night Shift
2/15/13 was missing the PM Shift
2/18/13 was missing the Night Shift
2/20/13 was missing the Day Shift
2/24/13 was missing the Day Shift
3/1/13 was missing the Day Shift
3/6/13 was missing the Day Shift
3/11/13 was missing the Day Shift
3/12/13 was missing the Daty Shift
3/14/13 was missing the Day Shift
3/18/13 was missing the Day Shift
3/20/13 Was missing the Day Shift
4/11/13 was missing the PM Shift
4/16/13 was missing the Night Shift (forgot to do it)
4/21/13 was missing the Day Shift
5/1/13 was missing the PM Shift
5/20/13 was missing the day shift (No time)
5/23/13 was missing the Day Shift (No time Busy)
6/1/13 was missing the Night Shift
6/3/13 was missing the Day and PM Shift

The Policy and Procedure number 822.0 for the Operating Room ventilation system states "The humidity and temperature of each operating room will be checked at the begininning of each shift and documented on the Humidity/Temperature Log Sheet."

Building M - Third Floor
1. There were two power strips chained together in the Labor and Delivery Conference Room 104.

Main Hospital Second Floor Building M
2. At 1:37 p.m., Room 2M074 had a power strip suspended above the floor



VHC Bascom
1. On 6/7/13, at 9:47 a.m., on the 3rd floor in Suite 330, there was an ultra sound machine, bed and electrosurgical machine plugged into a single power strip in room 330-13.

2. On 6/7/13, at 10:25 a.m., on the 1st floor in Suite 100, there was a refrigerator and a microwave plugged into a power strip in the Mail Room.




27254

Based on interview and observation, the facility failed to maintain the electrical wiring and equipment, as evidenced by the use of surge protectors as a substitute for fixed wiring, and by surge protectors plugged into other surge protectors. This affected smoke compartments in Buildings C, M and E, and could result in the ignition of an electrical fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing
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.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4)Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection\
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b)& 305-4 c)
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.


Findings:

During a tour of the facility with the Director of Facilities, between 6/3/13 and 6/7/13, the electrical wiring in the facility was observed.

Building C
1. On 6/5/13, at 11:00 a.m., on the 7th floor in Room 7C015, in the Special Procedures Room there were three suction machines plugged into a power strip instead of directly into the wall outlet.

2. On 6/5/13, at 11:01 a.m., on the 7th floor in Room 7C001, in the Staff locker Room, an air conditioning unit was plugged into a power strip instead of directly into the wall outlet.

Building M
3. On 6/4/13, at 11:50 a.m., on the 3rd floor in Room 3M104, the training computers were all plugged into power strips, and the power strips were plugged into one another.

4. On 6/4/13, at 1:10 p.m., on the Basement Level in Room 3B010, the training computers were all plugged into power strips, and the power strips were plugged into one another.

Building E
5. On 6/5/13, at 9:22 a.m., on the 1st floor in Room 1E070, in the Cardiac Rehab room, two treadmills were plugged into a single power strip instead of directly into the wall outlet.

6. On 6/5/13, at 9:34 a.m., on the 1st floor in Room 1E028, six ventilator batteries were plugged into a power strip for charging.

7. On 6/5/13, at 9:37 a.m., on the 1st floor in Room 1E052, in the Staff Lounge, a coffee maker was plugged into a power strip instead of direclty into the wall outelt.

Based on document review and interview, the facility failed to provide a written protocol to insure that if the automatic sprinkler system was out of service for four or more hours in a 24 hour period, that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation for this requirement. This affected all staff and patients in the Buildings B,C, E, F, G, K, M, and Q, and could result in the AHJ (the Department of Public Health) being unable to exercise oversight during the shutdown.


Findings:

During record review on 6/3/13 at 2:00 p.m., documentation provided for an approved fire watch did not give guidance to notify the Department of Public Health if the automatic sprinkler system was out of service for four or more hours in a 24 hour period.

Based on document review and interview, the facility failed to provide a written protocol to insure that if the fire alarm system was out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation for this requirement. This affected all staff and patients in the Buildings B,C, E, F, G, K, M, and Q, and could result in the AHJ (the Department of Public Health) being unable to exercise oversight during the shutdown.


Findings:

During record review on 6/3/13 at 2:00 p.m., documentation provided for an approved fire watch did not give guidance to notify the Department of Public Health if the fire alarm system was out of service for four or more hours in a 24 hour period.