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Based on observations, the facility failed to maintain the protective fire retardant coating applied to the facility's structural steel construction to maintain the assigned construction type classification assigned. Failure to properly maintain the construction classification to include the fire proofing the structural elements can lead to early failure and collapse of the structure, endangering the patients, staff, or other building occupants.

The findings include:

1. On November 18, 2014 at 8:55 AM while on tour with facility staff at the Heliport, it was observed that one of the covered main support columns had become damaged and was cracked open. Visible water damage to the structural steel was observed due to the column now being exposed to the weather and no longer protected by the fire resistance rated construction to maintain the building's construction classification, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 19.7.6.

2. On November 18, 2014 from 9:08 AM to 9:25 AM while on tour with facility staff in the Mechanical Room 50-307, it was observed that multiple areas of the structural steel members showed signs of rubbing and wear to the applied fireproofing. These damaged areas allow for the structural steel to be directly exposed to fire impingement and would result in the early failure of the structural elements, which can lead to an early collapse. Structural Steel and support members shall be maintained for the assigned construction type for the facility, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 19.7.6.

These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director of Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain corridor doors with regard to being a minimum 1 3/4 inch solid bonded wood core door that shall resist the passage of smoke and a means for keeping the door tightly closed in the frame, which can allow for the transfer of fire and smoke gasses, endangering the patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 10:45 AM while on tour with facility staff, on the 4th Floor Patient Room Door 4508, it was observed multiple holes in the door which had not been filled or closed to maintain the smoke tightness of the assembly, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 19.3.6.3, 19.7.6.

2. On November 19, 2014 at 9:53 AM while on tour with facility staff, in Sterile Processing ECS Room 10-019, it was observed that the door failed to tightly latch in the 'closed' position to maintain the smoke tightness of the compartment, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 19.3.6.3, 19.7.6.


These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain proper latching means for the vertical opening to the enclosed and protected egress stairwell, which can allow for the entrance of fire and smoke gases, rendering the egress unusable, endangering patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 10:17 AM while on tour with facility staff at Stairwell 26, it was observed that special door unlocking means were being utilized for delayed egress. Upon verification of the operation of the devices, it was found that the latching hardware had been removed, which when the delayed egress function or fire alarm release function were engaged, the magnetic door holding device releases, allowing for the 1 ½ hour fire resistance rated door to freely open, not maintaining the required fire rated enclosure of the stairwell, in accordance with NFPA 80 (1999) 15-1, 15-1.2, 15-2.1, 15-2.1.1, 15-2.5.3, NFPA 101 (2000) 4.5.7, 4.6.12.1, 7.2.1.5.4, 7.2.1.8, 8.2.5.6, 8.4.1.3, 19.2.2.2.1, 19.3.1.1, 19.7.6.

2. On November 18, 2014 at 10:24 AM while on tour with facility staff at Stairwell Door 40-408, it was observed that special door unlocking means were being utilized for delayed egress. Upon verification of the operation of the devices, it was found that the latching hardware had been removed, which when the delayed egress function or fire alarm release function were engaged, the magnetic door holding device releases, allowing for the 1 ½ hour fire resistance rated door to freely open, not maintaining the required fire rated enclosure of the stairwell, in accordance with NFPA 80 (1999) 15-1, 15-1.2, 15-2.1, 15-2.1.1, 15-2.5.3, NFPA 101 (2000) 4.5.7, 4.6.12.1, 7.2.1.5.4, 7.2.1.8, 8.2.5.6, 8.4.1.3, 19.2.2.2.1, 19.3.1.1, 19.7.6.

3. On November 18, 2014 at 10:41 AM while on tour with facility staff at Stairwell 9, it was observed that special door unlocking means were being utilized for delayed egress. Upon verification of the operation of the devices, it was found that the latching hardware had been removed, which when the delayed, egress function or fire alarm release function were engaged, the magnetic door holding device releases, allowing for the 1 ½ hour fire resistance rated door to freely open, not maintaining the required fire rated enclosure of the stairwell, in accordance with NFPA 80 (1999) 15-1, 15-1.2, 15-2.1, 15-2.1.1, 15-2.5.3, NFPA 101 (2000) 4.5.7, 4.6.12.1, 7.2.1.5.4, 7.2.1.8, 8.2.5.6, 8.4.1.3, 19.2.2.2.1, 19.3.1.1, 19.7.6.


These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain the fire door separations per the manufacture installation of latching devices in the facility which could allow for the transfer of fire and smoke from one compartment to another endangering patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 11:35 AM while on tour with facility staff, in the Corridor of Three West, it was observed that corridor door 3409 was installed with latching means which had an upper and lower receiving device. The lower latching receiver device was not present and no documentation could be provided showing that the manufacture listing allowed for the installation of this type of assembly to maintain the required fire resistance rating of the fire resistance rated door assembly. Door latching means that are part of an manufacturer listed assembly shall be installed and maintained in accordance with the listing per NFPA 80 (1999) 15-2.1, 15-2.1.1, 15-2.4.1, 15-2.4.2, 15-2.5.3, NFPA 101 (2000) 4.6.12.1, 7.2.1.5.4, 19.2.2.2.1, 19.3.6.3.2, 19.7.6.

2. On November 18, 2014 at 3:37 PM while on tour with facility staff, on the Second floor it was observed double fire doors with Asset number 15194 in an two hour fire resistance rated wall assembly and rated for 1 ½ hour fire resistance rating installed with an upper and lower receiving latching device. The lower latching receiver device was not present and no documentation could be provided showing that the manufacture listing allowed for the installation of this type of assembly to maintain the required fire resistance rating of the assembly. Door latching means that are part of an manufacturer listed assembly shall be installed and maintained in accordance with the listing per NFPA 80 (1999) 15-2.1, 15-2.1.1, 15-2.4.1, 15-2.4.2, 15-2.5.3, NFPA 101 (2000) 4.6.12.1, 7.2.1.5.4, 19.2.2.2.1, 19.3.6.3.2, 19.7.6.

These findings were reconfirmed with the Risk Manager, Systems Director Risk Manager, Chief Nursing Officer, System Director Safety & Security, System Vice President of Support Services, Director of EVS, Safety Specialist, Facilities Operations Manager, Facility Maintenance, Director of Facility Operations, Assistant Manager of Clinical Engineering, System COO/Hospital President, Performance Improvement, Accreditation Lead, and Director of Nursing Operations & Practice at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain required fire/smoke barriers to resist the passage of smoke and flames, which could endanger the patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 9:16 AM while on tour with facility staff, in the Mechanical Penthouse Room 50-303, in the pit mid-east wall, it was observed a rigid electrical conduit protruding from a smoke barrier wall, which has been pulled and caused the drywall to separate, creating a hole which no longer maintains the smoke tightness of the space, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 8.3.6, 19.3.7.1, 19.3.7.2, 19.3.7.3, 19.3.7.5, 19.7.6.

2. On November 18, 2014 at 9:41 AM while on tour with facility staff in the IT Closet Room 7501, it was observed visible signs of water damaged to the smoke compartment walls, which fail to maintain the smoke tightness of the space from other areas, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 8.2.3.2.3.1, 8.2.3.2.4.2, 8.2.4.1, 8.2.4.2, 8.2.4.4.1, 8.3.1, 8.3.2, 8.3.3, 8.3.6.1, 19.3.7.1, 19.7.6.

3. On November 18, 2014 at 3:05 PM while on tour with facility staff in the Main Kitchen Cooler area, it was observed just outside the cooler, a damaged ceiling tile. Ceiling tiles shall be maintained to keep the smoke tightness of the compartment, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

4. On November 18, 2014 at 3:50 PM while on tour with facility staff in the IT Room 2626C, it was observed the suspended dropped ceiling grid in an automatic fire sprinkler system protected space had been removed and not been properly replaced, to maintain the smoke tightness of the ceiling system, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

5. On November 18, 2014 at 4:05 PM while on tour with facility staff in the Storage Room across from Labs 6 and 7, it was observed the suspended dropped ceiling grid in an automatic fire sprinkler system protected space had been removed and not been properly replaced to maintain the smoke tightness of the ceiling system, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

6. On November 19, 2014 at 10:25 AM while on tour with facility staff in the Receiving Bay by the automatic fire sprinkler riser, it was observed a strike hole in the wall, leaving an opening into the interior of the separation wall which no longer maintains the smoke tightness of the space, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

7. On November 19, 2014 at 11:16 AM while on tour with facility staff in the Paint Room, it was observed the suspended dropped ceiling grid in an automatic fire sprinkler system protected space had been damaged, and many tiles were missing and not been properly replaced to maintain the smoke tightness of the ceiling system, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

8. On November 19, 2014 at 11:18 AM while on tour with facility staff in the Plant Exit by the Miller Electric Office, it was observed the suspended dropped ceiling grid in an automatic fire sprinkler system protected space had been damaged and many tiles were missing and not been properly replaced to maintain the smoke tightness of the ceiling system, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security, System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on record reviews and staff interviews, the facility failed to maintain their fire alarm system, in accordance with NFPA 72, maintaining the integrity of the system to alarm in the event of a fire to allow for the emergency egress and relocation of patients, staff, or other building occupants, which could result in injury or loss.

The findings include:

On November 17, 2014 from 10:00 AM to 4:30 PM during record review with facility staff, documentation provided for the inspection, testing, and maintenance of the facility's
fire alarm system on 6/30/2014, it was noted that out of the 47 battery supplies for emergency power, 12 of the devices failed. It was also noted that 2 manual pullstations also had failed to properly operate during testing. In interview with the Facility Maintenance Technician during record review, it was acknowledged that there was no documentation to show that the deficiencies identified during the fire alarm inspection were available. Documentation of any and all repairs shall be noted to show corrective action of deficiencies in accordance with NFPA 72 (1999) 7-1, 7-1.1.2, 7-1.2, 7-3.2.1, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.6.1.4, 9.6.1.7, 19.3.4.1, 19.7.6.


These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain the operation of the battery operated smoke alarms for the Resident Staff On-call sleeping rooms. Failure to maintain the smoke alarms can allow for the extended development of fire producing smoke gases and failure to alert the person sleeping in the compartment and allowing the fire to spread, endangering the patients, staff, and other building occupants.

The findings include:

On November 18, 2014 at 11:19 AM while on tour with facility staff in Resident Staff On Call Sleeping Room 4609, it was observed that the smoke alarm for protection of the room, when checked, had the battery removed from the unit rendering the device inoperable. Sleeping rooms shall be covered by a smoke alarm and shall be properly maintained in working order, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.6.1.3, 19.7.6.


These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations, Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to properly maintain portable fire extinguishers in a properly charged condition, stored utilizing proper securing hangers, and properly identify the locations of recessed slim profile storage cabinets to annotate the location of fire extinguishers, which can fail to operate or be immediately located for use in the event of a fire emergency, thereby allowing for the fire to spread, endangering the patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 8:53 AM while on tour with facility staff on the Helipad, it was observed that one of the wheeled fire extinguisher unit's gauges was showing a slight drop and was not in the fully charged range. Facility maintenance staff contacted the facility's fire extinguisher contractor to respond immediately to recharge the unit to proper level in accordance with NFPA 10 (1998) 1-6.2, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.7.4.1, 19.3.5.6, 19.7.6.

2. On November 18, 2014 at 9:03 AM while on tour with facility staff in Mechanical Room 50-307, just inside the door on the floor, it was observed that a fire extinguisher was sitting, due to the wall mounting bracket having come out of the drywall. Fire Extinguishers shall be properly and securely mounted with the bottom of the fire extinguisher a minimum 4 inches above the floor, in accordance with NFPA 10 (1998) 1-6.7, 1-6.8, 1-6.9, 1-6.10, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.7.4.1, 19.3.5.6, 19.7.6.

3. On November 18-19, 2014 during tour with facility staff throughout the Main Hospital, it was observed that the fire extinguisher cabinets in use were of the slim profile and flush into the walls of the building; they can be easily obstructed or unknown as to location due to other carts or equipment when looking down corridors. These locations were not conspicuously designated with signage to show the immediate location of the fire extinguishers, which can delay in the locating of the closest unit in the event of a fire, which is not in accordance with NFPA 10 (1998) 1-6.3, 1-6.6, 1-6.12, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.7.4.1, 19.3.5.6, 19.7.6.

These findings were confirmed with the Risk Manager, Systems Director Risk Manager, Chief Nursing Officer, System Director Safety & Security, System Vice President of Support Services, Director of EVS, Safety Specialist, Facilities Operations Manager, Facility Maintenance, Director of Facility Operations, Assistant Manager of Clinical Engineering, System COO/Hospital President, Performance Improvement, Accreditation Lead, and Director of Nursing Operations & Practice at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain commercial cooking equipment, which could result in a fire endangering the patients, staff, and other building occupants.

The findings include:

On November 18, 2014 at 2:43 PM while on tour with facility staff in the Main Kitchen, it was observed that the fire suppression system spray nozzles protecting the cooking equipment have been moved along with the cooking equipment, and were not properly aligned to maintain the protection of the cooking equipment in the event of a fire. Nozzles shall be permanently placed so as not to be freely moving, and equipment maintained in the proper position for coverage by the fire suppression system, in accordance with NFPA 96 (1998) 9-1.2, 9-1.2.1, 9-1.2.2, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.2.3, 18.3.2.6, 18.7.6.

These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice at the exit conference November 19, 2014 at 2:45 PM.

Based on observations and records reviews, the facility failed to maintain documentation and tags on cubicle curtains utilized to show that the curtains are of a flame retardant construction. Failure to maintain proper flame retardant protected curtains can allow for a rapid fire spread, endangering the patients, staff, and other building occupants.

The findings include:

On November 18-19, 2014 during tour with facility staff throughout the entire facility, it was noted that the cubicle curtains in use did not have any identifying tags reflecting the devices were of flame resistant construction. Documentation provided for the curtains did not provide enough information to identify the multiple styles in use were in fact of the manufacturer and style per the manufacturer to verify that the curtains were flame retardant. Draperies to include cubical curtains, shall be of a flame retardant material and be provided with proper tagging and identification from the manufacturer in accordance with NFPA 101 (2000) 10.3.1, 19.7.5.1.

These findings were confirmed with the Risk Manager, Systems Director Risk Manager, Chief Nursing Officer, System Director Safety & Security, System Vice President of Support Services, Director of EVS, Safety Specialist, Facilities Operations Manager Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain storage of compressed gases in accordance with NFPA 99, Standard for Health Care Facilities, which could result in injury or loss of patients, staff, or other building occupants.

The findings include:

On November 19, 2014 at 10:08 AM while on tour with facility staff in Central Storage, it was observed the storage of pressurized medical gas cylinders were stored in excess of 300 cubic feet and under 3,000 cubic feet with combustible storage within 5 feet of the storage area and electrical service under 5 feet from the finished floor with no signage indicating storage of oxygen within the space. Storage of medical gas cylinders shall be properly noted by signage outside the room stating, "Caution Oxidizing Gases Stored Within ~ No Smoking," and shall have no electrical devices within 5 feet of the floor to include no combustible storage within 5 feet, in accordance with NFPA 99 (1999) 4.3.1.1.2(a)(4), NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.3.2.4, 19.5.1, 19.7.6.

These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain electrical equipment and wiring, in accordance with the National Electric Code (N.E.C.), NFPA 70, which could endanger the patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 9:13 AM while on tour with facility staff in Room 50-303 along the east wall, it was observed an electrical receptacle which had a charring arch mark on the upper outlet. Damaged electrical devices shall be secured from use and repaired to maintain the integrity of the electrical power system, in accordance with NFPA 70 (1999) 110-12(c), NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

2. On November 18, 2014 at 1:30 PM while on tour with facility staff in the Surgical Suites, it was observed in use relocatable power tap devices powering patient care equipment, in lieu of properly provided electrical power. Patient care equipment shall be properly provided with hard-wired electrical power and not utilize temporary relocatable power tap cords, in accordance with NFPA 70 (1999) Article 400-7(b), NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

3. On November 18, 2014 at 2:01 PM while on tour with facility staff in the Toxicology Lab, it was observed that electrical panel SB-3EQL2 circuits 19, 21, 22, 23, 24, 32, and 34 were all labeled as SPARES, but were in the energized position. Electrical panel circuits shall be properly labeled as the intended controls, in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

4. On November 18, 2014 at 2:02 PM while on tour with facility staff in the Toxicology Lab, it was observed that electrical panel SB-3UPS1 circuit 32 was labeled as SPARE, but was in the energized position. Electrical panel circuits shall be properly labeled as the intended controls, in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

5. On November 18, 2014 at 2:35 PM while on tour with facility staff in the Endoscopy Surgical Suite, it was observed in use, relocatable power tap devices powering patient care equipment in lieu of properly provided electrical power. Patient care equipment shall be properly provided with hardwire electrical power and not utilize temporary relocatable power tap cords, in accordance with NFPA 70 (1999) Article 400-7(b), NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

6. On November 19, 2014 at 10:19 AM while on tour with facility staff in the Trash and Bailer Room, it was observed an electrical light switch device which has been damaged due to an strike from an object, allowing the switch to hang freely by the electrical powering wires, and due to the strike has dislodged the protective conduit, exposing the electrical wiring. Damaged electrical equipment shall be repaired and maintained for the integrity of the electrical power supply system, in accordance with NFPA 70 (1999) 110-12(c), NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

7. On November 19, 2014 at 10:42 AM while on tour with facility staff in the Bed Repair Old Laundry Room, it was observed multiple pieces of combustibles and storage items which were obstructing the accessibility to the main electrical panels not maintaining a minimum 3 feet clearance, in accordance with NFPA 70 (1999) Article 110.26, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1, 19.7.6.

These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain the protective fire retardant coating applied to the facility's structural steel construction to maintain the assigned construction type classification assigned. Failure to properly maintain the construction classification to include the fire proofing the structural elements can lead to early failure and collapse of the structure, endangering the patients, staff, or other building occupants.

The findings include:

1. On November 18, 2014 at 8:55 AM while on tour with facility staff at the Heliport, it was observed that one of the covered main support columns had become damaged and was cracked open. Visible water damage to the structural steel was observed due to the column now being exposed to the weather and no longer protected by the fire resistance rated construction to maintain the building's construction classification, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 19.7.6.

2. On November 18, 2014 from 9:08 AM to 9:25 AM while on tour with facility staff in the Mechanical Room 50-307, it was observed that multiple areas of the structural steel members showed signs of rubbing and wear to the applied fireproofing. These damaged areas allow for the structural steel to be directly exposed to fire impingement and would result in the early failure of the structural elements, which can lead to an early collapse. Structural Steel and support members shall be maintained for the assigned construction type for the facility, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 19.7.6.

These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director of Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain corridor doors with regard to being a minimum 1 3/4 inch solid bonded wood core door that shall resist the passage of smoke and a means for keeping the door tightly closed in the frame, which can allow for the transfer of fire and smoke gasses, endangering the patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 10:45 AM while on tour with facility staff, on the 4th Floor Patient Room Door 4508, it was observed multiple holes in the door which had not been filled or closed to maintain the smoke tightness of the assembly, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 19.3.6.3, 19.7.6.

2. On November 19, 2014 at 9:53 AM while on tour with facility staff, in Sterile Processing ECS Room 10-019, it was observed that the door failed to tightly latch in the 'closed' position to maintain the smoke tightness of the compartment, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 19.3.6.3, 19.7.6.


These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain proper latching means for the vertical opening to the enclosed and protected egress stairwell, which can allow for the entrance of fire and smoke gases, rendering the egress unusable, endangering patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 10:17 AM while on tour with facility staff at Stairwell 26, it was observed that special door unlocking means were being utilized for delayed egress. Upon verification of the operation of the devices, it was found that the latching hardware had been removed, which when the delayed egress function or fire alarm release function were engaged, the magnetic door holding device releases, allowing for the 1 ½ hour fire resistance rated door to freely open, not maintaining the required fire rated enclosure of the stairwell, in accordance with NFPA 80 (1999) 15-1, 15-1.2, 15-2.1, 15-2.1.1, 15-2.5.3, NFPA 101 (2000) 4.5.7, 4.6.12.1, 7.2.1.5.4, 7.2.1.8, 8.2.5.6, 8.4.1.3, 19.2.2.2.1, 19.3.1.1, 19.7.6.

2. On November 18, 2014 at 10:24 AM while on tour with facility staff at Stairwell Door 40-408, it was observed that special door unlocking means were being utilized for delayed egress. Upon verification of the operation of the devices, it was found that the latching hardware had been removed, which when the delayed egress function or fire alarm release function were engaged, the magnetic door holding device releases, allowing for the 1 ½ hour fire resistance rated door to freely open, not maintaining the required fire rated enclosure of the stairwell, in accordance with NFPA 80 (1999) 15-1, 15-1.2, 15-2.1, 15-2.1.1, 15-2.5.3, NFPA 101 (2000) 4.5.7, 4.6.12.1, 7.2.1.5.4, 7.2.1.8, 8.2.5.6, 8.4.1.3, 19.2.2.2.1, 19.3.1.1, 19.7.6.

3. On November 18, 2014 at 10:41 AM while on tour with facility staff at Stairwell 9, it was observed that special door unlocking means were being utilized for delayed egress. Upon verification of the operation of the devices, it was found that the latching hardware had been removed, which when the delayed, egress function or fire alarm release function were engaged, the magnetic door holding device releases, allowing for the 1 ½ hour fire resistance rated door to freely open, not maintaining the required fire rated enclosure of the stairwell, in accordance with NFPA 80 (1999) 15-1, 15-1.2, 15-2.1, 15-2.1.1, 15-2.5.3, NFPA 101 (2000) 4.5.7, 4.6.12.1, 7.2.1.5.4, 7.2.1.8, 8.2.5.6, 8.4.1.3, 19.2.2.2.1, 19.3.1.1, 19.7.6.


These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain the fire door separations per the manufacture installation of latching devices in the facility which could allow for the transfer of fire and smoke from one compartment to another endangering patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 11:35 AM while on tour with facility staff, in the Corridor of Three West, it was observed that corridor door 3409 was installed with latching means which had an upper and lower receiving device. The lower latching receiver device was not present and no documentation could be provided showing that the manufacture listing allowed for the installation of this type of assembly to maintain the required fire resistance rating of the fire resistance rated door assembly. Door latching means that are part of an manufacturer listed assembly shall be installed and maintained in accordance with the listing per NFPA 80 (1999) 15-2.1, 15-2.1.1, 15-2.4.1, 15-2.4.2, 15-2.5.3, NFPA 101 (2000) 4.6.12.1, 7.2.1.5.4, 19.2.2.2.1, 19.3.6.3.2, 19.7.6.

2. On November 18, 2014 at 3:37 PM while on tour with facility staff, on the Second floor it was observed double fire doors with Asset number 15194 in an two hour fire resistance rated wall assembly and rated for 1 ½ hour fire resistance rating installed with an upper and lower receiving latching device. The lower latching receiver device was not present and no documentation could be provided showing that the manufacture listing allowed for the installation of this type of assembly to maintain the required fire resistance rating of the assembly. Door latching means that are part of an manufacturer listed assembly shall be installed and maintained in accordance with the listing per NFPA 80 (1999) 15-2.1, 15-2.1.1, 15-2.4.1, 15-2.4.2, 15-2.5.3, NFPA 101 (2000) 4.6.12.1, 7.2.1.5.4, 19.2.2.2.1, 19.3.6.3.2, 19.7.6.

These findings were reconfirmed with the Risk Manager, Systems Director Risk Manager, Chief Nursing Officer, System Director Safety & Security, System Vice President of Support Services, Director of EVS, Safety Specialist, Facilities Operations Manager, Facility Maintenance, Director of Facility Operations, Assistant Manager of Clinical Engineering, System COO/Hospital President, Performance Improvement, Accreditation Lead, and Director of Nursing Operations & Practice at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain required fire/smoke barriers to resist the passage of smoke and flames, which could endanger the patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 9:16 AM while on tour with facility staff, in the Mechanical Penthouse Room 50-303, in the pit mid-east wall, it was observed a rigid electrical conduit protruding from a smoke barrier wall, which has been pulled and caused the drywall to separate, creating a hole which no longer maintains the smoke tightness of the space, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 8.3.6, 19.3.7.1, 19.3.7.2, 19.3.7.3, 19.3.7.5, 19.7.6.

2. On November 18, 2014 at 9:41 AM while on tour with facility staff in the IT Closet Room 7501, it was observed visible signs of water damaged to the smoke compartment walls, which fail to maintain the smoke tightness of the space from other areas, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 8.2.3.2.3.1, 8.2.3.2.4.2, 8.2.4.1, 8.2.4.2, 8.2.4.4.1, 8.3.1, 8.3.2, 8.3.3, 8.3.6.1, 19.3.7.1, 19.7.6.

3. On November 18, 2014 at 3:05 PM while on tour with facility staff in the Main Kitchen Cooler area, it was observed just outside the cooler, a damaged ceiling tile. Ceiling tiles shall be maintained to keep the smoke tightness of the compartment, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

4. On November 18, 2014 at 3:50 PM while on tour with facility staff in the IT Room 2626C, it was observed the suspended dropped ceiling grid in an automatic fire sprinkler system protected space had been removed and not been properly replaced, to maintain the smoke tightness of the ceiling system, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

5. On November 18, 2014 at 4:05 PM while on tour with facility staff in the Storage Room across from Labs 6 and 7, it was observed the suspended dropped ceiling grid in an automatic fire sprinkler system protected space had been removed and not been properly replaced to maintain the smoke tightness of the ceiling system, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

6. On November 19, 2014 at 10:25 AM while on tour with facility staff in the Receiving Bay by the automatic fire sprinkler riser, it was observed a strike hole in the wall, leaving an opening into the interior of the separation wall which no longer maintains the smoke tightness of the space, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

7. On November 19, 2014 at 11:16 AM while on tour with facility staff in the Paint Room, it was observed the suspended dropped ceiling grid in an automatic fire sprinkler system protected space had been damaged, and many tiles were missing and not been properly replaced to maintain the smoke tightness of the ceiling system, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

8. On November 19, 2014 at 11:18 AM while on tour with facility staff in the Plant Exit by the Miller Electric Office, it was observed the suspended dropped ceiling grid in an automatic fire sprinkler system protected space had been damaged and many tiles were missing and not been properly replaced to maintain the smoke tightness of the ceiling system, in accordance with NFPA 101 (2000) 4.6.12.1, 8.3.2, 19.3.7.1, 19.3.7.2, 19.7.6.

These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security, System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on record reviews and staff interviews, the facility failed to maintain their fire alarm system, in accordance with NFPA 72, maintaining the integrity of the system to alarm in the event of a fire to allow for the emergency egress and relocation of patients, staff, or other building occupants, which could result in injury or loss.

The findings include:

On November 17, 2014 from 10:00 AM to 4:30 PM during record review with facility staff, documentation provided for the inspection, testing, and maintenance of the facility's
fire alarm system on 6/30/2014, it was noted that out of the 47 battery supplies for emergency power, 12 of the devices failed. It was also noted that 2 manual pullstations also had failed to properly operate during testing. In interview with the Facility Maintenance Technician during record review, it was acknowledged that there was no documentation to show that the deficiencies identified during the fire alarm inspection were available. Documentation of any and all repairs shall be noted to show corrective action of deficiencies in accordance with NFPA 72 (1999) 7-1, 7-1.1.2, 7-1.2, 7-3.2.1, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.6.1.4, 9.6.1.7, 19.3.4.1, 19.7.6.


These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain the operation of the battery operated smoke alarms for the Resident Staff On-call sleeping rooms. Failure to maintain the smoke alarms can allow for the extended development of fire producing smoke gases and failure to alert the person sleeping in the compartment and allowing the fire to spread, endangering the patients, staff, and other building occupants.

The findings include:

On November 18, 2014 at 11:19 AM while on tour with facility staff in Resident Staff On Call Sleeping Room 4609, it was observed that the smoke alarm for protection of the room, when checked, had the battery removed from the unit rendering the device inoperable. Sleeping rooms shall be covered by a smoke alarm and shall be properly maintained in working order, in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.6.1.3, 19.7.6.


These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations, Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to properly maintain portable fire extinguishers in a properly charged condition, stored utilizing proper securing hangers, and properly identify the locations of recessed slim profile storage cabinets to annotate the location of fire extinguishers, which can fail to operate or be immediately located for use in the event of a fire emergency, thereby allowing for the fire to spread, endangering the patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 8:53 AM while on tour with facility staff on the Helipad, it was observed that one of the wheeled fire extinguisher unit's gauges was showing a slight drop and was not in the fully charged range. Facility maintenance staff contacted the facility's fire extinguisher contractor to respond immediately to recharge the unit to proper level in accordance with NFPA 10 (1998) 1-6.2, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.7.4.1, 19.3.5.6, 19.7.6.

2. On November 18, 2014 at 9:03 AM while on tour with facility staff in Mechanical Room 50-307, just inside the door on the floor, it was observed that a fire extinguisher was sitting, due to the wall mounting bracket having come out of the drywall. Fire Extinguishers shall be properly and securely mounted with the bottom of the fire extinguisher a minimum 4 inches above the floor, in accordance with NFPA 10 (1998) 1-6.7, 1-6.8, 1-6.9, 1-6.10, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.7.4.1, 19.3.5.6, 19.7.6.

3. On November 18-19, 2014 during tour with facility staff throughout the Main Hospital, it was observed that the fire extinguisher cabinets in use were of the slim profile and flush into the walls of the building; they can be easily obstructed or unknown as to location due to other carts or equipment when looking down corridors. These locations were not conspicuously designated with signage to show the immediate location of the fire extinguishers, which can delay in the locating of the closest unit in the event of a fire, which is not in accordance with NFPA 10 (1998) 1-6.3, 1-6.6, 1-6.12, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.7.4.1, 19.3.5.6, 19.7.6.

These findings were confirmed with the Risk Manager, Systems Director Risk Manager, Chief Nursing Officer, System Director Safety & Security, System Vice President of Support Services, Director of EVS, Safety Specialist, Facilities Operations Manager, Facility Maintenance, Director of Facility Operations, Assistant Manager of Clinical Engineering, System COO/Hospital President, Performance Improvement, Accreditation Lead, and Director of Nursing Operations & Practice at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain commercial cooking equipment, which could result in a fire endangering the patients, staff, and other building occupants.

The findings include:

On November 18, 2014 at 2:43 PM while on tour with facility staff in the Main Kitchen, it was observed that the fire suppression system spray nozzles protecting the cooking equipment have been moved along with the cooking equipment, and were not properly aligned to maintain the protection of the cooking equipment in the event of a fire. Nozzles shall be permanently placed so as not to be freely moving, and equipment maintained in the proper position for coverage by the fire suppression system, in accordance with NFPA 96 (1998) 9-1.2, 9-1.2.1, 9-1.2.2, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.2.3, 18.3.2.6, 18.7.6.

These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice at the exit conference November 19, 2014 at 2:45 PM.

Based on observations and records reviews, the facility failed to maintain documentation and tags on cubicle curtains utilized to show that the curtains are of a flame retardant construction. Failure to maintain proper flame retardant protected curtains can allow for a rapid fire spread, endangering the patients, staff, and other building occupants.

The findings include:

On November 18-19, 2014 during tour with facility staff throughout the entire facility, it was noted that the cubicle curtains in use did not have any identifying tags reflecting the devices were of flame resistant construction. Documentation provided for the curtains did not provide enough information to identify the multiple styles in use were in fact of the manufacturer and style per the manufacturer to verify that the curtains were flame retardant. Draperies to include cubical curtains, shall be of a flame retardant material and be provided with proper tagging and identification from the manufacturer in accordance with NFPA 101 (2000) 10.3.1, 19.7.5.1.

These findings were confirmed with the Risk Manager, Systems Director Risk Manager, Chief Nursing Officer, System Director Safety & Security, System Vice President of Support Services, Director of EVS, Safety Specialist, Facilities Operations Manager Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain storage of compressed gases in accordance with NFPA 99, Standard for Health Care Facilities, which could result in injury or loss of patients, staff, or other building occupants.

The findings include:

On November 19, 2014 at 10:08 AM while on tour with facility staff in Central Storage, it was observed the storage of pressurized medical gas cylinders were stored in excess of 300 cubic feet and under 3,000 cubic feet with combustible storage within 5 feet of the storage area and electrical service under 5 feet from the finished floor with no signage indicating storage of oxygen within the space. Storage of medical gas cylinders shall be properly noted by signage outside the room stating, "Caution Oxidizing Gases Stored Within ~ No Smoking," and shall have no electrical devices within 5 feet of the floor to include no combustible storage within 5 feet, in accordance with NFPA 99 (1999) 4.3.1.1.2(a)(4), NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.3.2.4, 19.5.1, 19.7.6.

These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.

Based on observations, the facility failed to maintain electrical equipment and wiring, in accordance with the National Electric Code (N.E.C.), NFPA 70, which could endanger the patients, staff, and other building occupants.

The findings include:

1. On November 18, 2014 at 9:13 AM while on tour with facility staff in Room 50-303 along the east wall, it was observed an electrical receptacle which had a charring arch mark on the upper outlet. Damaged electrical devices shall be secured from use and repaired to maintain the integrity of the electrical power system, in accordance with NFPA 70 (1999) 110-12(c), NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

2. On November 18, 2014 at 1:30 PM while on tour with facility staff in the Surgical Suites, it was observed in use relocatable power tap devices powering patient care equipment, in lieu of properly provided electrical power. Patient care equipment shall be properly provided with hard-wired electrical power and not utilize temporary relocatable power tap cords, in accordance with NFPA 70 (1999) Article 400-7(b), NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

3. On November 18, 2014 at 2:01 PM while on tour with facility staff in the Toxicology Lab, it was observed that electrical panel SB-3EQL2 circuits 19, 21, 22, 23, 24, 32, and 34 were all labeled as SPARES, but were in the energized position. Electrical panel circuits shall be properly labeled as the intended controls, in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

4. On November 18, 2014 at 2:02 PM while on tour with facility staff in the Toxicology Lab, it was observed that electrical panel SB-3UPS1 circuit 32 was labeled as SPARE, but was in the energized position. Electrical panel circuits shall be properly labeled as the intended controls, in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

5. On November 18, 2014 at 2:35 PM while on tour with facility staff in the Endoscopy Surgical Suite, it was observed in use, relocatable power tap devices powering patient care equipment in lieu of properly provided electrical power. Patient care equipment shall be properly provided with hardwire electrical power and not utilize temporary relocatable power tap cords, in accordance with NFPA 70 (1999) Article 400-7(b), NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

6. On November 19, 2014 at 10:19 AM while on tour with facility staff in the Trash and Bailer Room, it was observed an electrical light switch device which has been damaged due to an strike from an object, allowing the switch to hang freely by the electrical powering wires, and due to the strike has dislodged the protective conduit, exposing the electrical wiring. Damaged electrical equipment shall be repaired and maintained for the integrity of the electrical power supply system, in accordance with NFPA 70 (1999) 110-12(c), NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.

7. On November 19, 2014 at 10:42 AM while on tour with facility staff in the Bed Repair Old Laundry Room, it was observed multiple pieces of combustibles and storage items which were obstructing the accessibility to the main electrical panels not maintaining a minimum 3 feet clearance, in accordance with NFPA 70 (1999) Article 110.26, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1, 19.7.6.

These findings were confirmed with the Risk Manager; Systems Director Risk Manager; Chief Nursing Officer; System Director Safety & Security; System Vice President of Support Services; Director of EVS; Safety Specialist; Facilities Operations Manager; Facility Maintenance; Director of Facility Operations; Assistant Manager of Clinical Engineering; System COO/Hospital President; Performance Improvement; Accreditation Lead; and Director of Nursing Operations & Practice, at the exit conference November 19, 2014 at 2:45 PM.