HospitalInspections.org

Based on observation and document review, the facility failed to maintain the fire-rated walls and doors in the two hour fire barrier. This was evidenced by two doors that did not have a fire rating label, and by a penetrations in the occupancy separation wall. This affected all staff and patients in two of two smoke compartments in the Hyperbaric Chamber Room and could potentially result in the spread of smoke and fire.

NFPA 101 Life Safety Code, 2000 Edition
3.2.4 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.

19.1.1.4.2 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with
the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.

8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows: (1) 2-hour fire barrier - 1 1/2-hour fire protection rating.

NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition
1-6 Classifications and Types of Doors.
1-6.1* Only labeled fire doors shall be used.
1-6.2 The label on doors covers only the design and construction of the door.

Findings:

During a tour of the Hyperbaric Clinic Wound/Ostomy Center, with facility staff, on 5/16/2013, the fire barriers were observed.

Hyperbaric Clinic Wound/Ostomy at 1026 Mangrove
1. At 9:52 a.m., the one and one-half hour fire rating tag could not be found on the southwest exit door and the door to Room 131 identified on the facility diagram as the Toilet. Engineering Staff were unable to locate the fire rating tags on the doors. These doors were identified on the construction drawings as being in two hour fire-rated walls and should be one and one-half hour fire rated doors.

2. At 10:15 a.m., there was an approximately one-half inch unsealed penetration around a flexible electrical conduit in the two hour fire-rated wall above the drop down ceiling near the Bathroom.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls. This could result in the spread of fire and smoke in the event of a fire. This affected 2 of 5 floors in the Magnolia Tower, 1 of 4 smoke compartments in Enloe Rehabilitation, 1 of 3 floors in the Lake Side Commons, and 2 of 2 smoke compartments in the Hyperbaric Clinic.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, and Director of Facilities, from 5/13/13 through 5/16/13, the facility construction was observed.

Magnolia Tower - 5/13/13
1. At 3:20 p.m., there were two 1/2 inch unsealed pipes in the east wall of the second floor data closet.

Fifth Ave - 5/13/13
At 4:10 p.m., there was an approximately 2 inch round hole, in the wall under the desk, in the emergency department manager's office on the first floor.

Magnolia Tower - 5/14/13
2. At 10:03 a.m., there were four approximately 3 inch unsealed pipes, in the east wall, in Room 4024.


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Enloe Rehabilitation - 5/14/13
3. At 2:20 p.m., there was an approximately one by six inch unsealed penetration in the east wall, near the floor, in the soiled linen room.

Lake Side Commons - First Floor Surgery Center - 5/15/13
4. At 3:15 p.m., there was an approximately one inch penetration in the ceiling of the housekeeping closet.

Hyperbaric Clinic Wound/Ostomy - 5/16/13
5. At 10:15 a.m., there were five penetrations, in the walls above the drop ceiling, at the north wall and near the ceiling of the east wall, near the two hour fire-rated Chamber Room wall. On the north wall, the penetrations were approximately 2 by 4 inches in size and were caused by open junction boxes and pipe sleeves in the wall. The other penetration was approximately 3 by 8 inches, where the fire-rated sheeting was removed. On the east wall, there was an approximately 2 1/2 by 2 inch penetration near the ceiling.

Based on observation, the facility failed to maintain corridor doors, as evidenced by corridor doors that were impeded from closing and doors that failed to latch. This affected 1 of 5 floors in Magnolia Tower, 1 of 4 floors at Fifth Ave, 3 of 11 smoke compartments of the Enloe Medical Center-Cohasset, and 1 of 8 smoke compartments of the EOC Buildings. This had the potential to allow the spread of smoke and fire from one area to another.

NFPA 101 Life Safety Code, 2000 edition
19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, and the Director of Facilities, from 5/13/13 through 5/16/13, the corridor doors were observed.

Magnolia Tower - 5/14/13
1. At 2:40 p.m., the self-closing corridor door to Operating Room 10 did not latch when closed. The latching mechanism was stuck in the open position.

2. At 3:55 p.m., the self-closing corridor door to the janitor's closet, in the Emergency Room, was impeded from closing by a rubber wedge under the door and by a clipboard hanging on the door frame. When the wedge and clipboard were removed, the door hit the door frame and was obstructed from closing.

Fifth Ave Tower - 5/15/13
3. At 9:51 a.m., the self-closing corridor door to the Hopper Room, in the Cathlab, did not latch when closed.

4. At 1:16 p.m., the self-closing corridor door, at the entrance to X-Ray, did not latch when closed.

5. At 4:10 p.m., the self-closing corridor door did not latch when closed, at the entrance to Central Supply, in the Basement.


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Enloe Medical Center-Cohasset - 5/15/13
6. At 9:28 a.m., the corridor door to Exam Room 6 did not positive latch when released from an open position.

7. At 10:08 a.m., the door to the Break Room did not positive latch, in Behavioral Health.

8. At 10:42 a.m., the four self-closing corridor office doors, in the County Behavioral Health unit, were held open with door wedges.

EOC Buildings A, B and, C First Floor - 5/15/13
9. At 2:45 p.m., there was a bed located within the swing area of the corridor door to the Post Op/Recovery Room. The door was held open by a device designed to release upon activation of the fire alarm system. When tested by manually releasing, the door could only close half way before it was obstructed by the bed.

Based on observation and interview, the facility failed to ensure their cross-corridor doors close automatically. This was evidenced by one cross-corridor fire door that was held open by a trash can. This affected all staff and patients in one of seven offsite buildings and could potentially result in the spread of smoke and fire from one smoke compartment to another.

NFPA 101, Life Safety Code, 2000 Edition,
9.6.5.1. A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

Findings:

During a tour of the facility with Engineering Staff, on 5/15/13, the separation doors were observed.

Enloe Medical Center-Cohasset - 5/15/13
At 10:40 a.m., the three hour fire-rated door, separating the County Behavioral Health from the CSU, was held open with a recycling can.

During an interview at 10:41 a.m., Staff explained that the magnetic hold-open device was not long enough to hold the door open.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of its smoke/fire barrier walls. This was evidenced by penetrations in smoke barriers accessed above the ceiling. This affected all staff and patients in five of eleven smoke compartments at the Enloe Medical Center Cohasset building, one of three floors at the 251 Cohasset Medical building, and 1 of 5 floors in the Magnolia Tower. This could potentially result in smoke and fire spreading from one smoke compartment to another.

NFPA 101, Life Safety Code, 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 Director of Plant Operations, Lead Maintenance, Engineering Staff, the Director of Facilities, and Engineering Staff, from 5/14/13 to 5/16/13, the smoke/fire barrier walls were observed.

Medical Building at 251 Cohasset Suites 110, 120, 130, 150, and 300 - 5/14/13
1. At 11:40 a.m., there were three penetrations in the smoke barrier wall, above the drop-down ceiling, on the third floor, at the north end of the building, near Suite 300. There was an approximately 3 by 3 inch penetration, a 4 by 4 inch penetration, and an approximately 1/4 inch penetration around a six inch diameter pipe.

Enloe Medical Center Cohasset - 5/15/13
2. At 11:59 a.m., there was an approximately 1/2 inch metal sleeve passing through the wall, that was not sealed on the end, above the drop-down ceiling between operating Room 4 and the Recovery Room.

3. At 1:55 p.m., the fire rated sheeting was missing, exposing the structural wood on the two-hour fire wall, above the drop-down ceiling, near the Fire Alarm Control Panel. There was also an approximately two inch gap where the fire barrier should have continued up to the ceiling rafters. There were two 1 1/2 inch round holes cut through the wood around wires.

4. At 2:08 p.m., there was an approximately three inch round penetration around conduit, in the three-hour fire barrier wall, above the drop-down ceiling near Patient Room 609 .

5. At 2:12 p.m., Engineering Staff AS 3 confirmed the penetrations in the smoke barriers, during an interview.


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Magnolia Tower - 5/14/13
6. At 9:40 a.m., there was an approximately 1 inch unsealed conduit pipe in the smoke barrier wall above Room 4014 and four tiles east of the room.

Based on observation, the facility failed to maintain its fire doors to prevent the spread of smoke and fire. This was evidenced by rolling fire doors that failed to close and by cross-corridor fire doors which were equipped with latching hardware that failed to close completely and latch. This affected all staff and residents in the Medical Building at 251 Cohasset, and 2 of 5 floors in the Magnolia Tower. This could potentially result in the spread of smoke and fire from one smoke compartment to another.


Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, and the Director of Facilities, from 5/13/13 through 5/16/13, the fire doors were inspected throughout the facility.

Medical Building at 251 Cohasset Suite 110 - 5/14/13
1. At 9:08 a.m., the smoke detector located in Suite 110 produced an audible alarm. The rolling fire door at the Receptionist Area, was not activated by the smoke detector.

2. At 9:09 a.m., the smoke detector at the cross-corridor door, near the elevator, was tested and produced an audible alarm. The door released from its hold-open device, but the door coordinator did not work. The door failed to close completely, creating an approximately four inch vertical gap the entire height of the door.

3. At 9:10 a.m., the nine foot rolling fire doors, near the elevator, did not drop down after the smoke detector was activated.


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Magnolia Tower - 5/14/13
4. At 9:59 a.m., the north smoke barrier door did not latch when released from the magnetic hold open device, in the Cathlab near the elevator .

5. At 1:43 p.m., the third floor cross corridor, smoke barrier doors, between Magnolia Tower and Fifth Ave, failed to latch when tested.

Based on observation, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible storage and were not equipped with a self-closing mechanism on the door. This affected 1 of 4 floors in the Fifth Ave Tower, and could result in the spread of smoke and fire through compartments.

NFPA 101 Life Safety Code 2000 Edition
19.7.5.5. Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64 ft2 (5.9 m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, and the Director of Facilities, on 5/14/13, the hazardous area enclosures were observed. Soiled Linen and Trash Collection rooms are identified as hazardous areas and are required to have self-closing doors.

Fifth Ave Tower - 5/14/13
At 9:41 a.m., the door to the Bio-Hazard area, in the Cathlab, did not have a self-closing mechanism on it. The room contained two trash receptacles that were approximately 100 gallons each.

Based on observation, the facility failed to ensure that exits were readily accessible at all times. This was evidenced by exit doors that were equipped with double-action latching devices and by equipment placed in one exit corridor. This affected all staff and patients in the Neurology at Neurodiagnostic Clinic, and one of five smoke compartments in the Cancer Center (two of seven offsite buildings). This could result in delayed evacuation in the event of afire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition
39.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
39.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

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.

7.2.1.5 Locks and Latches.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.

Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

During a tour of the facility with Engineering Staff on 5/13/13 and 5/16/13, the exit doors were observed at the off site locations.

The Cancer Center - 5/13/13
At 4 p.m., there was a paper shedder stored against the wall in the exit access corridor near Room 218 (Manager's Office). The clear width of the corridor was partially obstructed.

Neurology at Neurodiagnostic Clinic - 5/16/013
At 10:55 a.m., the front and back exit doors had door latching hardware and dead bolt type locks that could be locked from the inside without a key. There was no sign on the door indicating that the door should remain unlocked when the building was occupied.

Based on observation, document review, and interview, the facility failed to provide and maintain emergency lighting. This was evidenced by battery-powered emergency lighting units that failed to illuminate, by no documents for testing emergency lights, and by no emergency lighting in exit corridors. This affected staff and patients in 7 of 8 off site buildings and 12 of 12 OR suites. This could result in delayed evacuation in the event of a fire or other emergency.

NFPA 101. Life Safety Code, 2000 Edition

39.2.8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7.8.

7.8.1.1* Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.

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 1 1/2 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.

Findings:

During a tour of the off site facilities, with the Director of Plant Operations, Lead Maintenance, Engineering Staff, Administrative Services, and the Director of Facilities, from 5/13/2013 through 5/16/2013, the emergency lights were observed and emergency light testing documents were requested.

251 Cohasset Medical Building - 5/13/13
First Floor Surgical and Procedural Assessment Center Suite 110
1. At 2:15 p.m., the battery-powered emergency light failed to illuminate when tested, in the corridor near the Break room.

2. At 2:20 p.m., there was no emergency egress lighting provided in the exit corridors.

Mother Baby Education Center Suite 120 - 5/13/13
3. At 2:35 p.m., there was no emergency egress lighting in the exit corridor.

Ortho Joint Clinic Suite 130 - 5/13/13
4. At 2:40 p.m., there was no emergency lighting in the exit corridor. The lights were turned out and the doors were closed in the suite. The corridor was completely dark.

Radiology at Radiology Suite 150 - 5/13/13
5. At 2:55 p.m., there was no emergency lighting in the exit corridor.

Digestive Diseases Clinic Suite 300 - 5/13/13
6. At 3:03 p.m., the corridor emergency light, 3G, failed to illuminate when tested.

This building does not have an emergency back-up power supply (generator). During a power outage the battery-powered egress lights would provide emergency lighting in the exit corridors.

Cancer Center 256 Cohasset - 5/13/13
7. At 3:31 p.m., the battery-powered emergency light in the Men's Dressing Room failed to illuminate when tested.

8. At 3:40 p.m., the exit corridor battery-powered emergency light failed to illuminate when tested, in the corridor leading from the Lenac True Beam Room.

9. At 3:45 p.m., the 21EX Lenac Room emergency battery-powered light failed to illuminate when tested.

10. At 3:48 p.m., the battery-powered emergency light failed to illuminate when tested, in the corridor leading from the 21EX Lenac Room.

There was no emergency back-up power supply (generator or uninterrupted power supply) in the Cancer Building. During a power outage the battery-powered emergency lights would provide lighting for the exit corridors.

5/16/13
11. During record review, at 10:30 a.m., the facility failed to provide documented evidence for testing the emergency lights.

During an interview at 11:34 a.m., the AS 2 stated that there was no documentation for monthly or annual testing of the battery backed up emergency lights.

Enloe Medical Center-Cohasset - 5/15/13
12. At 9:47 a.m., the battery-powered emergency light, located in the Linen Room, failed to illuminate when tested.

Surveyor: Leggett, Jerry
Magnolia Tower - 5/14/13
13. At 10:16 a.m., the facility failed to provide documented evidence of testing the emergency lights in 12 of 12 Operating Rooms in the OR and 2 of 2 Operating Rooms in the Labor and Delivery Room.

14. During an interview at 10:18 a.m., the Director of Plant Operations reported that there was no documented testing of the emergency lights in the operating rooms.

Surveyor: Leggett, Jerry


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Based on observation, the facility failed to ensure exit signs were readily visible. This was evidenced by exit signs that were not illuminated or by missing signs to mark the way to exits. This affected 6 of 8 buildings and could result in a delayed evacuation in the event of an emergency.

7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, Administrative Services, and the Director of Facilities, from 5/13/13, through 5/16/13, the exit signs were observed.

251 Cohasset Medical Building - 5/13/13
First Floor, Surgical and Procedural Assessment Center Suite 110
1. At 2:20 p.m., there were no illuminated exit directional signs at each turn in the corridor, leading to the West exit, or at the East exit leading into to the Lobby from the suite.

Mother Baby Education Center Suite 120 - 5/13/13
2. At 2:35 p.m., there were no illuminated exit directional signs pointing the direction to the rear hall exit or to the front exit.

Ortho Joint Clinic Suite 130 - 5/13/13
3. At 2:40 p.m., there were no illuminated exit signs in the exit corridor leading the way to the rear or front exit.

Enloe Medical Center-Cohasset - 5/15/13
4. At 8:43 a.m., the exit sign located near the Human Resources door was not illuminated.

5. Between 8:50 and 9:05 a.m., there were six exit signs that were not illuminated. The signs were not illuminated at the storage area near Surgery 6, at the store room in Engineering, at Central Storage, at the store room, at the file cabinet storage area, and at the west door of the "Old Surgery Suite."

6. At 9:10 a.m., the west exit sign, in the Ambulance Crew quarters, was not illuminated.

7. At 9:27 a.m., both exits in the Prompt Care area, were not clearly marked with illuminated exit signs.

8. At 10:30 a.m., the exit sign Z9-5, located in the Conference Room, was partially lit.

EOC Buildings A, B and, C at 888 Lakeside Commons
9. On 5/15/13, at 3:30 p.m., two photoluminescent exit signs, located in the "spine" between buildings A-B and C, had a replacement date of 8/2001.


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Magnolia Tower - 5/13/13
10. At 3:49 p.m., the exit sign outside of Room 2209 (second floor) was not illuminated.

Based on interview, the facility failed to ensure staff are trained in emergency fire procedures. This was evidenced by contracted staff that did not know the procedures for a fire drill. This affected 2 of 8 buildings and could result in a delay in notification of a fire, in an area where a contractor was working.

NFPA 101, Life Safety Code 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, and Director of Facilities, on 5/15/13, staff were interviewed regarding fire drill procedures.

Fifth Ave Tower - 5/15/13
At 1:20 p.m., 5 contractors were interviewed at the worksite of a remodeling project in the Fifth Avenue Tower. Three of five staff reported they would run away from the area if a fire occurred. They could not locate a fire alarm activation device, and did not indicate that they would use a fire extinguisher that was readily available. The three staff did not know the code phrase for fire (Code Red), and did not indicate that they would notify personnel of a fire within a construction area with disabled fire alarm devices.

During an interview, the contractor supervisor said that any staff that had not received life safety training would be under direct supervision. He said that the staff that who were interviewed should have been under direct supervision, and must have been missed.

Based on observation and document review, the facility failed to maintain its fire alarm system. This was evidenced by no current annual fire alarm system test and inspection, by alarm devices that failed, and by areas where there was no audible fire alarm. This affected all staff and patients on three of three floors, in three of eight buildings. This could cause a delay in notification to the building's occupants and first responders in the event of a fire.

Findings:

During fire alarm testing and record review, with the Director of Plant Operations, Lead Engineer, and Engineering Staff, from 5/14/13 through 5/16/13, the fire alarm systems were tested, and testing records were reviewed.

Medical Building at 251 Cohasset First Floor - 5/14/13
During fire alarm testing with Engineering Staff, smoke detectors were tested.
1. At 9:15 a.m., a smoke detector did not activate an audible alarm or release the smoke barrier door from its magnetic hold open device. The smoke detector was located in the main exit corridor near the south waiting room area.

During record review with Engineering Staff, documentation was requested for testing the fire alarm system.
2. On 5/16/13, at 11:30 a.m., the facility failed to provide documented evidence for testing and certification of the complete fire alarm system for the five suites in the 251 Cohasset Building.

EOC Building C at 888 Lakeside Commons - 5/16/13
3. At 8:38 a.m., the fire alarm was activated. There was no audible alarm in the Staff Break room/Storage Room area in Building C. No fire alarm could be heard from inside the Staff Break room in Building C.


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Fifth Avenue - 5/15/13
4. At 3 p.m., the fire alarm system was activated. No alarm could be heard in the Decontamination Room. There were several decontamination machines running and a radio was playing music.

Based on record review and interview, the facility failed to provide documentation for complete maintenance, inspection, and testing of the smoke detectors. This was evidenced by no documentation for smoke-sensitivity testing in one building. This affected all staff and patients in one of eight buildings and could potentially result in nuisance alarms or no alarms if the detectors were outside of their listed sensitivity range.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
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.

NFPA 72 National Fire Alarm Code 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 Administrative Staff, on 5/16/13, the smoke sensitivity documents were reviewed for the Medical Building at 251 Cohasset. This affected Suites 110, 120, 130, 150, and 300.

At 11:30 a.m., the facility failed to provide documentation indicating that the smoke detectors were tested for sensitivity within the past two years. No documentation was provided for the last sensitivity test.

At 11:34 a.m., during an interview, AS 2 stated that the sensitivity testing was not done.

Based on observation, the facility failed to ensure a local alarm sounded when the water to the automatic sprinkler system was turned off. This was evidenced by one supervisory alarm, which did not sound a local alarm, when the water valve was closed. This affected staff and patients in 1 of 8 offsite buildings. This could result in a delay in activation of the automatic sprinkler system if the water supply was turned off.

NFPA 72, National Fire Alarm Code, 1999 Edition
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During fire alarm testing with Engineering Staff, on 5/15/13, the fire alarm system components were tested.

Enloe Medical Center Cohasset
At 12:03 p.m., the supervised sprinkler riser main shut-off valve was closed. The fire alarm panel supervisory trouble alarm failed to activate. Engineering Staff turned the valve wheel back and forth and the alarm was activated. The supporting bracket for the supervising switch was loose.

The supervisory alarm switch was re-tested multiple times, and did not consistently send a supervisory trouble signal to the fire alarm control panel.

Based on observation, the facility failed to maintain all fire extinguishers, as evidenced by one extinguisher that was past due for its annual inspection. This affected all staff and patients on one of three floors, in one of eight buildings. This could result in a failure of the fire extinguisher resulting in the spread of smoke and fire.

NFPA 10, Standard For Portable Fire Extinguishers, 1998 Edition
4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

4-1.2 The procedure for inspection and maintenance of fire extinguishers varies considerably. Minimal knowledge is necessary to perform a monthly " quick check " or inspection in order to follow the inspection procedure as outlined in Section 4-3. A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer ' s service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 4-4.

Findings:

During a tour of the facility with Engineering Staff, on 5/13/13, the fire extinguishers were observed.

Medical Building at 251 Cohasset Suite 300 Third Floor - 5/13/13
At 3:23 p.m., the ABC fire extinguisher located in the exit corridor, near the northwest corner stairwell, had an annual inspection date of November 2011. The fire extinguisher expired on 11/2012.

Based on observation and interview, the facility failed to maintain its smoking areas. This was evidenced by failing to provide safety-type ashtrays and metal containers to dispose of cigarette butts. This affected one of two smoking areas outside of the facility, at one of eight buildings, and could potentially result in the ignition of a fire.

Findings:

During a tour of the facility with Engineering Staff, on 5/15/13, the smoking areas were observed.

Enloe Medical Center-Cohasset - 5/15/13
At 10:11 a.m., an open top ash tray was sitting on a table, in the designated smoking area, located outside of the Behavioral Health Patio.

At 10:14 a.m., during an interview, Engineering Staff reported that there was no metal self-closing container for emptying the ashtray.

Based on observation and interview, the facility failed to ensure portable space heaters met the regulations and manufacturer's recommendations. This was evidenced by one portable heater placed within two inches of a trash can. This affected one of five smoke compartments within one of eight buildings, and could result in the ignition of a fire.

39.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.

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.

1999 NFPA 70 National Electrical Code
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a tour of the facility with Engineering Staff, electrical equipment was observed in the Medical Building at 251 Cohasset, on 5/13/13.

At 3:11 p.m., there was a portable electric heater within two inches of a trash can, in the northeast corner doctor's office. The trash can had paper hanging over the top. The heater had a label warning "high temperature maintain three feet of clearance from all sides."

At 3:14 p.m., during an interview, Engineering Staff said that the heater had not been tested or accepted by the facility.

Based on observation and interview, the facility failed to maintain all oxygen storage areas. This was evidenced by one cylinder which was stored free standing, and by combustible material in an oxygen storage area. This could cause damage to a cylinder, if knocked over, and increase the fuel supply in the event of a fire. This affected two of eight buildings.

NFPA 99, Standards for Health Care Facilities, 1999 Edition
8-3.1.11 Storage Requirements.
8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet (85 cubic meters).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustible or incompatible materials by either:
1. A minimum distance of 20 feet (6.1 m), or
2. A minimum distance of 5 feet (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

4-3.5.2.1
(b) 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, Administrative Services, and the Director of Facilities, from 5/13/13, through 5/16/13, the oxygen storage areas were observed.

Enloe Medical Center 560 Cohasset Road - 5/16/13
1. At 9:10 a.m., there was one free standing E size oxygen cylinder, on the floor, in the Ambulance Crew Area.



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Fifth Ave Tower - 5/16/13
2. At 9:15 a.m., there was a cardboard box, containing an E-type cylinder, in the Fifth Ave medical gas (bulk) oxygen storage area.

At 9:16 a.m., during an interview, the Director of Plant Operations reported that the cardboard should not be in the oxygen area.

Based on observation and interview, the facility failed to maintain its generator in accordance with NFPA 110. This was evidenced by the failure to provide a battery-powered task light at it generator set location. This deficient practice affected all staff and patients in five of five smoke compartments within the facility and could potentially result in a delay in visibility in the generator enclosure during a loss of normal and emergency power.

NFPA 99 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
5-3 Lighting.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.


Findings:

During a tour of the facility with Engineering Staff, the generator enclosure was observed.

Enloe Rehabilitation Center - 5/14/13
At 3:15 p.m., there was no emergency battery powered task light mounted in the generator enclosure.

At 3:17 p.m., during an interview, AS 4 confirmed that the room did not have a battery-powered emergency light.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by appliances and medical equipment that were plugged into surge protectors, by electrical panels that were obstructed, by the use of extension cords, and by surge protectors that were plugged into surge protectors and a multi-outlet adapter. This affected 6 of 8 buildings, and could result in an electrical fire.

NFPA 70, National Electrical Code, 1999 edition
Article 110-26(a)(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

Article 110-26(3)(b) Clear Spaces. Working space required by this section shall not be used for storage.

240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

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

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, and the Director of Facilities, from 5/13/13, through 5/16/13, the electrical equipment and wiring were observed.

Fifth Ave Tower - 5/13/13
1. At 3:13 p.m., there was a microwave plugged into a surge protector in the Staff Break Room on the 3rd floor.

2. At 3:40 p.m., there was a surge protector plugged into a second surge protector at the Nursing Station near Room 2209.

3. At 4:04 p.m., there was a surge protector plugged into a second surge protector at the Area 2 Emergency Department (ER) nursing station.

Magnolia Tower - 5/14/13
4. 2:07 p.m., there was medical equipment plugged into a surge protector in Operating Room 2.

5. 2:12 p.m., there was medical equipment plugged into a surge protector in Operating Room 3.

Fifth Ave Tower - 5/14/13
6. At 3:35 p.m., the electrical panel in Emergency Treatment Area 1 was impeded from access and obstructed from view by a four tier cart placed in front of the panel.

Fifth Ave Tower - 5/15/13
7. At 8:55 a.m., there was a tan extension cord in use in the Laboratory Manager's office.

8. At 9:20 a.m., Electrical Panel E, near the Nuclear Medication reading room, was obstructed by a cart in front of the panel.

9. At 10:36 a.m., there was a surge protector plugged into another surge protector in the Nursing Administrative Supervisor's Office.

10. At 10:59 a.m., there was a four plug adapter in the Pharmacy Quite Order entry Room.

11. At 11:16 a.m., there was a missing cover plate on an outlet in the Pharmacy Back Office.

12. At 1:46 p.m., there was a surge protector that was plugged into another surge protector in the Medical Records Request Office.

13. At 2 p.m., there was an extension cord, connected to a surge protector, in the supervisor's cubicle, Medical Records back office.

Magnolia Tower - 5/15/13
14. At 3:21 p.m., there was a yellow extension cord in use in the Kitchen Assistant Director's Office.

Fifth Ave Tower - 5/15/13
16. At 4:13 p.m., there was a yellow extension cord plugged into a surge protector that was plugged into another surge protector in the Respiratory Therapy Room. Multiple devices were plugged into the surge protectors.


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Medical Building at 251 Cohasset Suites 110, 120, 130, 150, and 300, Suite 110 - 5/13/13
17. At 2:17 p.m., there was a surge protector suspended above the floor in the office across from Room 3. A refrigerator was plugged into it.

18. At 2:19 p.m., there was a coffee pot, plugged into an extension cord, connected to a surge protector in the Staff Break Room.

Suite 150
19. At 2:55 p.m., there was a bread machine, a toaster, and a refrigerator plugged into a surge protector, suspended above the floor in Break Room 1.

20. At 2:57 p.m., there was an extension cord in use in Staff Break Room 2.

Enloe Rehabilitation Center 340 W East Ave - 5/14/13
21. At 2:12 p.m., there was a surge protector plugged into another surge protector in the Staff Office (Room 830).

22. At 2:19 p.m., there was a surge protector suspended above the floor in the Therapy Room.

23. At 2:45 p.m., there was an extension cord in use in the Physician's Office.

24. At 3:16 p.m., there was a gas barbecue with a propane tank stored against the facility's main transformer. The label warning on the outside of the transformer read, "requires three feet of clearance from the sides."

Enloe Medical Center-Cohasset - 5/15/13
25. At 9:12 a.m., there was an extension cord in the First Sleep Bay of the Ambulance Quarters.

EOC Buildings A, B and, C at 888 Lakeside Commons - 5/16/13
26. At 8:09 a.m., there was a toaster plugged into a surge protector in the Building C Break room.

27. At 8:12 a.m., there was a microwave oven plugged into a surge protector in Housekeeping Storage.

28. At 8:20 a.m., there was an oxygen concentrator plugged into a surge protector in the Rehabilitation Exercise Room.

29. At 8:22, there was an extension cord supplying power to a fan in the Exercise Room.

Neurology at Neurodiagnostic Clinic at 1421 Magnolia Ave - 5/16/13
30. At 10:55 a.m.,there was a surge protector plugged into another surge protector, under a desk in the office.

Based on observation, the facility failed to maintain the Alcohol Based Hand Rub (ABHR) dispensers, as evidence by dispensers installed adjacent to an ignition source. This affected 2 of 5 floors in Magnolia Tower, and 1 of 4 floors at Fifth Ave Tower. This could result in an increased risk of an alcohol based fire.
Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, and Director of Facilities from 5/13/13 through 5/16/13, the facility ABHR dispensers were observed.

Magnolia Tower - 5/13/13
1. At 2:08 p.m., there was an ABHR dispenser located in in the hallway near Room 5551, (fifth floor). The dispenser was mounted directly above an electrical receptacle.

2. At 3:05 p.m., there was an ABHR dispenser located in the hallway near
Room 3312, (third floor). The dispenser was mounted directly above an electrical receptacle.

3. At 3:09 p.m., there was an ABHR dispenser located in the hallway near Room 3320, (third floor). The dispenser was mounted directly above an electrical receptacle.

Fifth Ave Tower - 5/14/13
4. At 4:12 p.m., there was an ABHR dispenser located in the Administration hallway near Room 177, (first floor). The dispenser was mounted directly above an electrical receptacle.

Fifth Ave Tower - 5/15/13
5. At 10:23 a.m., there was an ABHR dispenser located in the Emergency Room hallway near Room 40, (first floor). The dispenser was mounted directly above an electrical receptacle.

Based on observation and document review, the facility failed to maintain the fire-rated walls and doors in the two hour fire barrier. This was evidenced by two doors that did not have a fire rating label, and by a penetrations in the occupancy separation wall. This affected all staff and patients in two of two smoke compartments in the Hyperbaric Chamber Room and could potentially result in the spread of smoke and fire.

NFPA 101 Life Safety Code, 2000 Edition
3.2.4 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.

19.1.1.4.2 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with
the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.

8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows: (1) 2-hour fire barrier - 1 1/2-hour fire protection rating.

NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition
1-6 Classifications and Types of Doors.
1-6.1* Only labeled fire doors shall be used.
1-6.2 The label on doors covers only the design and construction of the door.

Findings:

During a tour of the Hyperbaric Clinic Wound/Ostomy Center, with facility staff, on 5/16/2013, the fire barriers were observed.

Hyperbaric Clinic Wound/Ostomy at 1026 Mangrove
1. At 9:52 a.m., the one and one-half hour fire rating tag could not be found on the southwest exit door and the door to Room 131 identified on the facility diagram as the Toilet. Engineering Staff were unable to locate the fire rating tags on the doors. These doors were identified on the construction drawings as being in two hour fire-rated walls and should be one and one-half hour fire rated doors.

2. At 10:15 a.m., there was an approximately one-half inch unsealed penetration around a flexible electrical conduit in the two hour fire-rated wall above the drop down ceiling near the Bathroom.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls. This could result in the spread of fire and smoke in the event of a fire. This affected 2 of 5 floors in the Magnolia Tower, 1 of 4 smoke compartments in Enloe Rehabilitation, 1 of 3 floors in the Lake Side Commons, and 2 of 2 smoke compartments in the Hyperbaric Clinic.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, and Director of Facilities, from 5/13/13 through 5/16/13, the facility construction was observed.

Magnolia Tower - 5/13/13
1. At 3:20 p.m., there were two 1/2 inch unsealed pipes in the east wall of the second floor data closet.

Fifth Ave - 5/13/13
At 4:10 p.m., there was an approximately 2 inch round hole, in the wall under the desk, in the emergency department manager's office on the first floor.

Magnolia Tower - 5/14/13
2. At 10:03 a.m., there were four approximately 3 inch unsealed pipes, in the east wall, in Room 4024.


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Enloe Rehabilitation - 5/14/13
3. At 2:20 p.m., there was an approximately one by six inch unsealed penetration in the east wall, near the floor, in the soiled linen room.

Lake Side Commons - First Floor Surgery Center - 5/15/13
4. At 3:15 p.m., there was an approximately one inch penetration in the ceiling of the housekeeping closet.

Hyperbaric Clinic Wound/Ostomy - 5/16/13
5. At 10:15 a.m., there were five penetrations, in the walls above the drop ceiling, at the north wall and near the ceiling of the east wall, near the two hour fire-rated Chamber Room wall. On the north wall, the penetrations were approximately 2 by 4 inches in size and were caused by open junction boxes and pipe sleeves in the wall. The other penetration was approximately 3 by 8 inches, where the fire-rated sheeting was removed. On the east wall, there was an approximately 2 1/2 by 2 inch penetration near the ceiling.

Based on observation, the facility failed to maintain corridor doors, as evidenced by corridor doors that were impeded from closing and doors that failed to latch. This affected 1 of 5 floors in Magnolia Tower, 1 of 4 floors at Fifth Ave, 3 of 11 smoke compartments of the Enloe Medical Center-Cohasset, and 1 of 8 smoke compartments of the EOC Buildings. This had the potential to allow the spread of smoke and fire from one area to another.

NFPA 101 Life Safety Code, 2000 edition
19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, and the Director of Facilities, from 5/13/13 through 5/16/13, the corridor doors were observed.

Magnolia Tower - 5/14/13
1. At 2:40 p.m., the self-closing corridor door to Operating Room 10 did not latch when closed. The latching mechanism was stuck in the open position.

2. At 3:55 p.m., the self-closing corridor door to the janitor's closet, in the Emergency Room, was impeded from closing by a rubber wedge under the door and by a clipboard hanging on the door frame. When the wedge and clipboard were removed, the door hit the door frame and was obstructed from closing.

Fifth Ave Tower - 5/15/13
3. At 9:51 a.m., the self-closing corridor door to the Hopper Room, in the Cathlab, did not latch when closed.

4. At 1:16 p.m., the self-closing corridor door, at the entrance to X-Ray, did not latch when closed.

5. At 4:10 p.m., the self-closing corridor door did not latch when closed, at the entrance to Central Supply, in the Basement.


25385

Enloe Medical Center-Cohasset - 5/15/13
6. At 9:28 a.m., the corridor door to Exam Room 6 did not positive latch when released from an open position.

7. At 10:08 a.m., the door to the Break Room did not positive latch, in Behavioral Health.

8. At 10:42 a.m., the four self-closing corridor office doors, in the County Behavioral Health unit, were held open with door wedges.

EOC Buildings A, B and, C First Floor - 5/15/13
9. At 2:45 p.m., there was a bed located within the swing area of the corridor door to the Post Op/Recovery Room. The door was held open by a device designed to release upon activation of the fire alarm system. When tested by manually releasing, the door could only close half way before it was obstructed by the bed.

Based on observation and interview, the facility failed to ensure their cross-corridor doors close automatically. This was evidenced by one cross-corridor fire door that was held open by a trash can. This affected all staff and patients in one of seven offsite buildings and could potentially result in the spread of smoke and fire from one smoke compartment to another.

NFPA 101, Life Safety Code, 2000 Edition,
9.6.5.1. A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

Findings:

During a tour of the facility with Engineering Staff, on 5/15/13, the separation doors were observed.

Enloe Medical Center-Cohasset - 5/15/13
At 10:40 a.m., the three hour fire-rated door, separating the County Behavioral Health from the CSU, was held open with a recycling can.

During an interview at 10:41 a.m., Staff explained that the magnetic hold-open device was not long enough to hold the door open.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of its smoke/fire barrier walls. This was evidenced by penetrations in smoke barriers accessed above the ceiling. This affected all staff and patients in five of eleven smoke compartments at the Enloe Medical Center Cohasset building, one of three floors at the 251 Cohasset Medical building, and 1 of 5 floors in the Magnolia Tower. This could potentially result in smoke and fire spreading from one smoke compartment to another.

NFPA 101, Life Safety Code, 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 Director of Plant Operations, Lead Maintenance, Engineering Staff, the Director of Facilities, and Engineering Staff, from 5/14/13 to 5/16/13, the smoke/fire barrier walls were observed.

Medical Building at 251 Cohasset Suites 110, 120, 130, 150, and 300 - 5/14/13
1. At 11:40 a.m., there were three penetrations in the smoke barrier wall, above the drop-down ceiling, on the third floor, at the north end of the building, near Suite 300. There was an approximately 3 by 3 inch penetration, a 4 by 4 inch penetration, and an approximately 1/4 inch penetration around a six inch diameter pipe.

Enloe Medical Center Cohasset - 5/15/13
2. At 11:59 a.m., there was an approximately 1/2 inch metal sleeve passing through the wall, that was not sealed on the end, above the drop-down ceiling between operating Room 4 and the Recovery Room.

3. At 1:55 p.m., the fire rated sheeting was missing, exposing the structural wood on the two-hour fire wall, above the drop-down ceiling, near the Fire Alarm Control Panel. There was also an approximately two inch gap where the fire barrier should have continued up to the ceiling rafters. There were two 1 1/2 inch round holes cut through the wood around wires.

4. At 2:08 p.m., there was an approximately three inch round penetration around conduit, in the three-hour fire barrier wall, above the drop-down ceiling near Patient Room 609 .

5. At 2:12 p.m., Engineering Staff AS 3 confirmed the penetrations in the smoke barriers, during an interview.


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Magnolia Tower - 5/14/13
6. At 9:40 a.m., there was an approximately 1 inch unsealed conduit pipe in the smoke barrier wall above Room 4014 and four tiles east of the room.

Based on observation, the facility failed to maintain its fire doors to prevent the spread of smoke and fire. This was evidenced by rolling fire doors that failed to close and by cross-corridor fire doors which were equipped with latching hardware that failed to close completely and latch. This affected all staff and residents in the Medical Building at 251 Cohasset, and 2 of 5 floors in the Magnolia Tower. This could potentially result in the spread of smoke and fire from one smoke compartment to another.


Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, and the Director of Facilities, from 5/13/13 through 5/16/13, the fire doors were inspected throughout the facility.

Medical Building at 251 Cohasset Suite 110 - 5/14/13
1. At 9:08 a.m., the smoke detector located in Suite 110 produced an audible alarm. The rolling fire door at the Receptionist Area, was not activated by the smoke detector.

2. At 9:09 a.m., the smoke detector at the cross-corridor door, near the elevator, was tested and produced an audible alarm. The door released from its hold-open device, but the door coordinator did not work. The door failed to close completely, creating an approximately four inch vertical gap the entire height of the door.

3. At 9:10 a.m., the nine foot rolling fire doors, near the elevator, did not drop down after the smoke detector was activated.


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Magnolia Tower - 5/14/13
4. At 9:59 a.m., the north smoke barrier door did not latch when released from the magnetic hold open device, in the Cathlab near the elevator .

5. At 1:43 p.m., the third floor cross corridor, smoke barrier doors, between Magnolia Tower and Fifth Ave, failed to latch when tested.

Based on observation, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible storage and were not equipped with a self-closing mechanism on the door. This affected 1 of 4 floors in the Fifth Ave Tower, and could result in the spread of smoke and fire through compartments.

NFPA 101 Life Safety Code 2000 Edition
19.7.5.5. Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64 ft2 (5.9 m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, and the Director of Facilities, on 5/14/13, the hazardous area enclosures were observed. Soiled Linen and Trash Collection rooms are identified as hazardous areas and are required to have self-closing doors.

Fifth Ave Tower - 5/14/13
At 9:41 a.m., the door to the Bio-Hazard area, in the Cathlab, did not have a self-closing mechanism on it. The room contained two trash receptacles that were approximately 100 gallons each.

Based on observation, the facility failed to ensure that exits were readily accessible at all times. This was evidenced by exit doors that were equipped with double-action latching devices and by equipment placed in one exit corridor. This affected all staff and patients in the Neurology at Neurodiagnostic Clinic, and one of five smoke compartments in the Cancer Center (two of seven offsite buildings). This could result in delayed evacuation in the event of afire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition
39.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
39.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

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.

7.2.1.5 Locks and Latches.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.

Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

During a tour of the facility with Engineering Staff on 5/13/13 and 5/16/13, the exit doors were observed at the off site locations.

The Cancer Center - 5/13/13
At 4 p.m., there was a paper shedder stored against the wall in the exit access corridor near Room 218 (Manager's Office). The clear width of the corridor was partially obstructed.

Neurology at Neurodiagnostic Clinic - 5/16/013
At 10:55 a.m., the front and back exit doors had door latching hardware and dead bolt type locks that could be locked from the inside without a key. There was no sign on the door indicating that the door should remain unlocked when the building was occupied.

Based on observation, document review, and interview, the facility failed to provide and maintain emergency lighting. This was evidenced by battery-powered emergency lighting units that failed to illuminate, by no documents for testing emergency lights, and by no emergency lighting in exit corridors. This affected staff and patients in 7 of 8 off site buildings and 12 of 12 OR suites. This could result in delayed evacuation in the event of a fire or other emergency.

NFPA 101. Life Safety Code, 2000 Edition

39.2.8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7.8.

7.8.1.1* Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.

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 1 1/2 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.

Findings:

During a tour of the off site facilities, with the Director of Plant Operations, Lead Maintenance, Engineering Staff, Administrative Services, and the Director of Facilities, from 5/13/2013 through 5/16/2013, the emergency lights were observed and emergency light testing documents were requested.

251 Cohasset Medical Building - 5/13/13
First Floor Surgical and Procedural Assessment Center Suite 110
1. At 2:15 p.m., the battery-powered emergency light failed to illuminate when tested, in the corridor near the Break room.

2. At 2:20 p.m., there was no emergency egress lighting provided in the exit corridors.

Mother Baby Education Center Suite 120 - 5/13/13
3. At 2:35 p.m., there was no emergency egress lighting in the exit corridor.

Ortho Joint Clinic Suite 130 - 5/13/13
4. At 2:40 p.m., there was no emergency lighting in the exit corridor. The lights were turned out and the doors were closed in the suite. The corridor was completely dark.

Radiology at Radiology Suite 150 - 5/13/13
5. At 2:55 p.m., there was no emergency lighting in the exit corridor.

Digestive Diseases Clinic Suite 300 - 5/13/13
6. At 3:03 p.m., the corridor emergency light, 3G, failed to illuminate when tested.

This building does not have an emergency back-up power supply (generator). During a power outage the battery-powered egress lights would provide emergency lighting in the exit corridors.

Cancer Center 256 Cohasset - 5/13/13
7. At 3:31 p.m., the battery-powered emergency light in the Men's Dressing Room failed to illuminate when tested.

8. At 3:40 p.m., the exit corridor battery-powered emergency light failed to illuminate when tested, in the corridor leading from the Lenac True Beam Room.

9. At 3:45 p.m., the 21EX Lenac Room emergency battery-powered light failed to illuminate when tested.

10. At 3:48 p.m., the battery-powered emergency light failed to illuminate when tested, in the corridor leading from the 21EX Lenac Room.

There was no emergency back-up power supply (generator or uninterrupted power supply) in the Cancer Building. During a power outage the battery-powered emergency lights would provide lighting for the exit corridors.

5/16/13
11. During record review, at 10:30 a.m., the facility failed to provide documented evidence for testing the emergency lights.

During an interview at 11:34 a.m., the AS 2 stated that there was no documentation for monthly or annual testing of the battery backed up emergency lights.

Enloe Medical Center-Cohasset - 5/15/13
12. At 9:47 a.m., the battery-powered emergency light, located in the Linen Room, failed to illuminate when tested.

Surveyor: Leggett, Jerry
Magnolia Tower - 5/14/13
13. At 10:16 a.m., the facility failed to provide documented evidence of testing the emergency lights in 12 of 12 Operating Rooms in the OR and 2 of 2 Operating Rooms in the Labor and Delivery Room.

14. During an interview at 10:18 a.m., the Director of Plant Operations reported that there was no documented testing of the emergency lights in the operating rooms.

Surveyor: Leggett, Jerry


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Based on observation, the facility failed to ensure exit signs were readily visible. This was evidenced by exit signs that were not illuminated or by missing signs to mark the way to exits. This affected 6 of 8 buildings and could result in a delayed evacuation in the event of an emergency.

7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, Administrative Services, and the Director of Facilities, from 5/13/13, through 5/16/13, the exit signs were observed.

251 Cohasset Medical Building - 5/13/13
First Floor, Surgical and Procedural Assessment Center Suite 110
1. At 2:20 p.m., there were no illuminated exit directional signs at each turn in the corridor, leading to the West exit, or at the East exit leading into to the Lobby from the suite.

Mother Baby Education Center Suite 120 - 5/13/13
2. At 2:35 p.m., there were no illuminated exit directional signs pointing the direction to the rear hall exit or to the front exit.

Ortho Joint Clinic Suite 130 - 5/13/13
3. At 2:40 p.m., there were no illuminated exit signs in the exit corridor leading the way to the rear or front exit.

Enloe Medical Center-Cohasset - 5/15/13
4. At 8:43 a.m., the exit sign located near the Human Resources door was not illuminated.

5. Between 8:50 and 9:05 a.m., there were six exit signs that were not illuminated. The signs were not illuminated at the storage area near Surgery 6, at the store room in Engineering, at Central Storage, at the store room, at the file cabinet storage area, and at the west door of the "Old Surgery Suite."

6. At 9:10 a.m., the west exit sign, in the Ambulance Crew quarters, was not illuminated.

7. At 9:27 a.m., both exits in the Prompt Care area, were not clearly marked with illuminated exit signs.

8. At 10:30 a.m., the exit sign Z9-5, located in the Conference Room, was partially lit.

EOC Buildings A, B and, C at 888 Lakeside Commons
9. On 5/15/13, at 3:30 p.m., two photoluminescent exit signs, located in the "spine" between buildings A-B and C, had a replacement date of 8/2001.


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Magnolia Tower - 5/13/13
10. At 3:49 p.m., the exit sign outside of Room 2209 (second floor) was not illuminated.

Based on interview, the facility failed to ensure staff are trained in emergency fire procedures. This was evidenced by contracted staff that did not know the procedures for a fire drill. This affected 2 of 8 buildings and could result in a delay in notification of a fire, in an area where a contractor was working.

NFPA 101, Life Safety Code 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, and Director of Facilities, on 5/15/13, staff were interviewed regarding fire drill procedures.

Fifth Ave Tower - 5/15/13
At 1:20 p.m., 5 contractors were interviewed at the worksite of a remodeling project in the Fifth Avenue Tower. Three of five staff reported they would run away from the area if a fire occurred. They could not locate a fire alarm activation device, and did not indicate that they would use a fire extinguisher that was readily available. The three staff did not know the code phrase for fire (Code Red), and did not indicate that they would notify personnel of a fire within a construction area with disabled fire alarm devices.

During an interview, the contractor supervisor said that any staff that had not received life safety training would be under direct supervision. He said that the staff that who were interviewed should have been under direct supervision, and must have been missed.

Based on observation and document review, the facility failed to maintain its fire alarm system. This was evidenced by no current annual fire alarm system test and inspection, by alarm devices that failed, and by areas where there was no audible fire alarm. This affected all staff and patients on three of three floors, in three of eight buildings. This could cause a delay in notification to the building's occupants and first responders in the event of a fire.

Findings:

During fire alarm testing and record review, with the Director of Plant Operations, Lead Engineer, and Engineering Staff, from 5/14/13 through 5/16/13, the fire alarm systems were tested, and testing records were reviewed.

Medical Building at 251 Cohasset First Floor - 5/14/13
During fire alarm testing with Engineering Staff, smoke detectors were tested.
1. At 9:15 a.m., a smoke detector did not activate an audible alarm or release the smoke barrier door from its magnetic hold open device. The smoke detector was located in the main exit corridor near the south waiting room area.

During record review with Engineering Staff, documentation was requested for testing the fire alarm system.
2. On 5/16/13, at 11:30 a.m., the facility failed to provide documented evidence for testing and certification of the complete fire alarm system for the five suites in the 251 Cohasset Building.

EOC Building C at 888 Lakeside Commons - 5/16/13
3. At 8:38 a.m., the fire alarm was activated. There was no audible alarm in the Staff Break room/Storage Room area in Building C. No fire alarm could be heard from inside the Staff Break room in Building C.


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Fifth Avenue - 5/15/13
4. At 3 p.m., the fire alarm system was activated. No alarm could be heard in the Decontamination Room. There were several decontamination machines running and a radio was playing music.

Based on record review and interview, the facility failed to provide documentation for complete maintenance, inspection, and testing of the smoke detectors. This was evidenced by no documentation for smoke-sensitivity testing in one building. This affected all staff and patients in one of eight buildings and could potentially result in nuisance alarms or no alarms if the detectors were outside of their listed sensitivity range.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
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.

NFPA 72 National Fire Alarm Code 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 Administrative Staff, on 5/16/13, the smoke sensitivity documents were reviewed for the Medical Building at 251 Cohasset. This affected Suites 110, 120, 130, 150, and 300.

At 11:30 a.m., the facility failed to provide documentation indicating that the smoke detectors were tested for sensitivity within the past two years. No documentation was provided for the last sensitivity test.

At 11:34 a.m., during an interview, AS 2 stated that the sensitivity testing was not done.

Based on observation, the facility failed to ensure a local alarm sounded when the water to the automatic sprinkler system was turned off. This was evidenced by one supervisory alarm, which did not sound a local alarm, when the water valve was closed. This affected staff and patients in 1 of 8 offsite buildings. This could result in a delay in activation of the automatic sprinkler system if the water supply was turned off.

NFPA 72, National Fire Alarm Code, 1999 Edition
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During fire alarm testing with Engineering Staff, on 5/15/13, the fire alarm system components were tested.

Enloe Medical Center Cohasset
At 12:03 p.m., the supervised sprinkler riser main shut-off valve was closed. The fire alarm panel supervisory trouble alarm failed to activate. Engineering Staff turned the valve wheel back and forth and the alarm was activated. The supporting bracket for the supervising switch was loose.

The supervisory alarm switch was re-tested multiple times, and did not consistently send a supervisory trouble signal to the fire alarm control panel.

Based on observation, the facility failed to maintain all fire extinguishers, as evidenced by one extinguisher that was past due for its annual inspection. This affected all staff and patients on one of three floors, in one of eight buildings. This could result in a failure of the fire extinguisher resulting in the spread of smoke and fire.

NFPA 10, Standard For Portable Fire Extinguishers, 1998 Edition
4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

4-1.2 The procedure for inspection and maintenance of fire extinguishers varies considerably. Minimal knowledge is necessary to perform a monthly " quick check " or inspection in order to follow the inspection procedure as outlined in Section 4-3. A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer ' s service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 4-4.

Findings:

During a tour of the facility with Engineering Staff, on 5/13/13, the fire extinguishers were observed.

Medical Building at 251 Cohasset Suite 300 Third Floor - 5/13/13
At 3:23 p.m., the ABC fire extinguisher located in the exit corridor, near the northwest corner stairwell, had an annual inspection date of November 2011. The fire extinguisher expired on 11/2012.

Based on observation and interview, the facility failed to maintain its smoking areas. This was evidenced by failing to provide safety-type ashtrays and metal containers to dispose of cigarette butts. This affected one of two smoking areas outside of the facility, at one of eight buildings, and could potentially result in the ignition of a fire.

Findings:

During a tour of the facility with Engineering Staff, on 5/15/13, the smoking areas were observed.

Enloe Medical Center-Cohasset - 5/15/13
At 10:11 a.m., an open top ash tray was sitting on a table, in the designated smoking area, located outside of the Behavioral Health Patio.

At 10:14 a.m., during an interview, Engineering Staff reported that there was no metal self-closing container for emptying the ashtray.

Based on observation and interview, the facility failed to ensure portable space heaters met the regulations and manufacturer's recommendations. This was evidenced by one portable heater placed within two inches of a trash can. This affected one of five smoke compartments within one of eight buildings, and could result in the ignition of a fire.

39.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.

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.

1999 NFPA 70 National Electrical Code
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a tour of the facility with Engineering Staff, electrical equipment was observed in the Medical Building at 251 Cohasset, on 5/13/13.

At 3:11 p.m., there was a portable electric heater within two inches of a trash can, in the northeast corner doctor's office. The trash can had paper hanging over the top. The heater had a label warning "high temperature maintain three feet of clearance from all sides."

At 3:14 p.m., during an interview, Engineering Staff said that the heater had not been tested or accepted by the facility.

Based on observation and interview, the facility failed to maintain all oxygen storage areas. This was evidenced by one cylinder which was stored free standing, and by combustible material in an oxygen storage area. This could cause damage to a cylinder, if knocked over, and increase the fuel supply in the event of a fire. This affected two of eight buildings.

NFPA 99, Standards for Health Care Facilities, 1999 Edition
8-3.1.11 Storage Requirements.
8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet (85 cubic meters).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustible or incompatible materials by either:
1. A minimum distance of 20 feet (6.1 m), or
2. A minimum distance of 5 feet (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

4-3.5.2.1
(b) 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, Administrative Services, and the Director of Facilities, from 5/13/13, through 5/16/13, the oxygen storage areas were observed.

Enloe Medical Center 560 Cohasset Road - 5/16/13
1. At 9:10 a.m., there was one free standing E size oxygen cylinder, on the floor, in the Ambulance Crew Area.



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Fifth Ave Tower - 5/16/13
2. At 9:15 a.m., there was a cardboard box, containing an E-type cylinder, in the Fifth Ave medical gas (bulk) oxygen storage area.

At 9:16 a.m., during an interview, the Director of Plant Operations reported that the cardboard should not be in the oxygen area.

Based on observation and interview, the facility failed to maintain its generator in accordance with NFPA 110. This was evidenced by the failure to provide a battery-powered task light at it generator set location. This deficient practice affected all staff and patients in five of five smoke compartments within the facility and could potentially result in a delay in visibility in the generator enclosure during a loss of normal and emergency power.

NFPA 99 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
5-3 Lighting.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.


Findings:

During a tour of the facility with Engineering Staff, the generator enclosure was observed.

Enloe Rehabilitation Center - 5/14/13
At 3:15 p.m., there was no emergency battery powered task light mounted in the generator enclosure.

At 3:17 p.m., during an interview, AS 4 confirmed that the room did not have a battery-powered emergency light.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by appliances and medical equipment that were plugged into surge protectors, by electrical panels that were obstructed, by the use of extension cords, and by surge protectors that were plugged into surge protectors and a multi-outlet adapter. This affected 6 of 8 buildings, and could result in an electrical fire.

NFPA 70, National Electrical Code, 1999 edition
Article 110-26(a)(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

Article 110-26(3)(b) Clear Spaces. Working space required by this section shall not be used for storage.

240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

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

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Engineering Staff, and the Director of Facilities, from 5/13/13, through 5/16/13, the electrical equipment and wiring were observed.

Fifth Ave Tower - 5/13/13
1. At 3:13 p.m., there was a microwave plugged into a surge protector in the Staff Break Room on the 3rd floor.

2. At 3:40 p.m., there was a surge protector plugged into a second surge protector at the Nursing Station near Room 2209.

3. At 4:04 p.m., there was a surge protector plugged into a second surge protector at the Area 2 Emergency Department (ER) nursing station.

Magnolia Tower - 5/14/13
4. 2:07 p.m., there was medical equipment plugged into a surge protector in Operating Room 2.

5. 2:12 p.m., there was medical equipment plugged into a surge protector in Operating Room 3.

Fifth Ave Tower - 5/14/13
6. At 3:35 p.m., the electrical panel in Emergency Treatment Area 1 was impeded from access and obstructed from view by a four tier cart placed in front of the panel.

Fifth Ave Tower - 5/15/13
7. At 8:55 a.m., there was a tan extension cord in use in the Laboratory Manager's office.

8. At 9:20 a.m., Electrical Panel E, near the Nuclear Medication reading room, was obstructed by a cart in front of the panel.

9. At 10:36 a.m., there was a surge protector plugged into another surge protector in the Nursing Administrative Supervisor's Office.

10. At 10:59 a.m., there was a four plug adapter in the Pharmacy Quite Order entry Room.

11. At 11:16 a.m., there was a missing cover plate on an outlet in the Pharmacy Back Office.

12. At 1:46 p.m., there was a surge protector that was plugged into another surge protector in the Medical Records Request Office.

13. At 2 p.m., there was an extension cord, connected to a surge protector, in the supervisor's cubicle, Medical Records back office.

Magnolia Tower - 5/15/13
14. At 3:21 p.m., there was a yellow extension cord in use in the Kitchen Assistant Director's Office.

Fifth Ave Tower - 5/15/13
16. At 4:13 p.m., there was a yellow extension cord plugged into a surge protector that was plugged into another surge protector in the Respiratory Therapy Room. Multiple devices were plugged into the surge protectors.


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Medical Building at 251 Cohasset Suites 110, 120, 130, 150, and 300, Suite 110 - 5/13/13
17. At 2:17 p.m., there was a surge protector suspended above the floor in the office across from Room 3. A refrigerator was plugged into it.

18. At 2:19 p.m., there was a coffee pot, plugged into an extension cord, connected to a surge protector in the Staff Break Room.

Suite 150
19. At 2:55 p.m., there was a bread machine, a toaster, and a refrigerator plugged into a surge protector, suspended above the floor in Break Room 1.

20. At 2:57 p.m., there was an extension cord in use in Staff Break Room 2.

Enloe Rehabilitation Center 340 W East Ave - 5/14/13
21. At 2:12 p.m., there was a surge protector plugged into another surge protector in the Staff Office (Room 830).

22. At 2:19 p.m., there was a surge protector suspended above the floor in the Therapy Room.

23. At 2:45 p.m., there was an extension cord in use in the Physician's Office.

24. At 3:16 p.m., there was a gas barbecue with a propane tank stored against the facility's main transformer. The label warning on the outside of the transformer read, "requires three feet of clearance from the sides."

Enloe Medical Center-Cohasset - 5/15/13
25. At 9:12 a.m., there was an extension cord in the First Sleep Bay of the Ambulance Quarters.

EOC Buildings A, B and, C at 888 Lakeside Commons - 5/16/13
26. At 8:09 a.m., there was a toaster plugged into a surge protector in the Building C Break room.

27. At 8:12 a.m., there was a microwave oven plugged into a surge protector in Housekeeping Storage.

28. At 8:20 a.m., there was an oxygen concentrator plugged into a surge protector in the Rehabilitation Exercise Room.

29. At 8:22, there was an extension cord supplying power to a fan in the Exercise Room.

Neurology at Neurodiagnostic Clinic at 1421 Magnolia Ave - 5/16/13
30. At 10:55 a.m.,there was a surge protector plugged into another surge protector, under a desk in the office.