HospitalInspections.org

The facility failed to provide the construction type required by code. Findings include:

During the survey, on the Second Floor - O.R. Nurses' Lounge was observed having a Construction Type of II (000).

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following was observed:

1. Doors failed to close tight as to resist the passage of smoke on the Electrical Room Four West, this surveyor was able to see into room.

2. Door failed to positive latch Patient Room #492 North.

3. Door failed to close tight as to resist the passage of smoke, Procedure Room Vascular Two, this surveyor was able to see into room.

4. Door failed to close tight as to resist the passage of smoke, Electrical Room by C06, CICU, this surveyor was able to see into the room.

5. Doors failed to close tight as to resist the passage of smoke, CICU Waiting Room, Third Floor, this surveyor was able to see into the room.

6. Door failed to positive latch Imaging Room Five First Floor.


NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.



27382


The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following was observed:
A. The following corridor double doors did not have an astragal:
Sixth Floor
1. Linen Supply Closet
Fourth Floor
2. 4 East Telephone Closet (TC EW 411)
Third Floor
3. West Telephone Closet
4. West Electrical Closet across from the Nurses' Station (EC WW 335)
5. "B" Hall Electrical Closet next to room #3115
Second Floor
6. Telephone Closet (TC EW 208) at SICU
7. Electrical Closet in SICU
8. Electrical Closet at One Day Surgery Waiting
First Floor
9. Telephone Closet by the Main Electrical Room

B. The following corridor doors did not have positive latching hardware:
1. Endoscopy Holding/Recovery Room
2. G.I. Endoscopy Lab.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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The facility failed to provide enclosed or protected vertical openings and shafts. Openings shall be protected as appropriate for the fire resistance rating of the barrier. Findings include:

During the survey, two holes the size of a half dollar were observed in the wall of the Elevator Equipment Room.

2000 NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

2000 NFPA 101, 8.2.2. Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following was observed:

1. Unsealed penetrations around a section of sheet rock that had been used to seal the opeings in the Smoke Barrier by Nursing Station C Hall, Five West.

2. Unsealed penetrations at the end of a sleeve in the Smoke Barrier by Charge Nurse Office Four West.

3. Unsealed penetrations at the end of a sleeve, and around wiring in the Smoke Barrier by Patient Room #4131 West Hall.

4. Unsealed penetrations at the end of a sleeve in the Smoke Barrier by Patient Room #486 North.

5. Unsealed penetrations at the end of a sleeve in the Smoke Barrier by Patient Room #474 North.

6. Unsealed penetrations at the end of a sleeve in the Smoke Barrier by CICU West Elevator Lobby.

7. Unsealed penetrations around a water line in the Smoke Barrier above the doors at CICU.

8. Unsealed penetrations at the end of a sleeve and around conduit in the Smoke Barrier by Patient Room CPOU 10.

2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

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





27382


The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following was observed:
Sixth Floor
1. Social Services Office corridor door was in a smoke barrier and did not have a self-closing device.

2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.

Fourth Floor
2. The smoke barrier in the Labor and Delivery Sleep Room:
a. Did not meet the roof deck
b. Was not sealed at the corner
3. The smoke barrier in the Endoscopy Breakroom (above the refrigerator) had a hole approximately 18" X 18"

First Floor
4. The smoke barrier at the smoke door by the Radiology Reading Room had a 2" unsealed penetration around a sprinkler line.

2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

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

1. Doors failed to close tight in the Smoke Barrier in Central Supply Second Floor.

2. Doors failed to close tight in the Smoke Barrier by Patient Room #486.


NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.

The facility failed to maintain fire barriers per code. Findings include:

During the survey, the following was observed:
Second floor
1. The two hour fire wall in the Back Hall had a penetration of approximately 4" X 8" for a copper pipe.
2. The O.R. Nurses' Lounge had several unsealed penetrations.
3. The Doctors' Lounge Door going into the O.R. Suite was in a two hour fire wall and did not have a self-closing device.
4. The left leaf of the fire doors, in the back hall at the Women's Center, did not latch under the fire alarm.

2000 NFPA 101, 7.2.4.3.1 Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)
2000 NFPA 101, 7.2.4.3.4 Any opening in such fire barriers shall be protected as provided in 8.2.3.2.3.
2000 NFPA 101, 7.2.4.3.8 All fire doors in horizontal exits shall be self-closing or automatic-closing in accordance with 7.2.1.8. Horizontal exit doors located across a corridor shall be automatic-closing in accordance with 7.2.1.8.
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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, based upon observation, the Exit by Dietary First Floor was not provided with a light at the Exit Discharge.


NFPA 101, 19.2.8 and 7.8.1.2. Illumination of means of egress shall be continuous.

The facility failed to document fire drills per code. Findings include:

During the survey, per documentation and interview, the facility was not requiring all staff onsite to sign during a fire drill.

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following was observed:

1. The audible/strobe was inoperable in MICU.

2. The audible/strobe was inoperable in SICU.

3. The audible/strobe was inoperable in CICU.

4. Audible/strobes were not provided in the O.R. corridors.

5. The strobe lights were constantly illuminated/were not pulsing while the fire alarm was being tested throughout the facility at different locations on each floor.

1999 NFPA 72, 4-4.2.1
A maximum pulse duration shall be 0.2 seconds with a maximum duty cycle of 40 percent. The pulse duration shall be defined as the time interval between initial and final points of 10 percent of maximum signal.
1999 NFPA 72, 4-4.2.2*
The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity).

1999 NFPA 72, 4-4.3.1
Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

1999 NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.


Upon review of the Fire Alarm inspection conducted by Simplex Grinnell on 12/16/2010, the following was noted:

1. Two Ionization Smoke Detectors failed.

2. Four Heat Detectors failed.

3. Eight Photo Smoke Detectors failed.

4. Two pull station-single action failed.

Wesley, from Engineering, advised this surveyor that Simplex Grinnell was on site 12/16/2010, correcting the above items. This surveyor spoke with Simplex Grinnell's Tech and he advised all items should be corrected by 12/21/2010.

NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.











27382


The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following was observed:
Sixth Floor
1. The audible/visible device at the north west stairwell in Geriactric-Psych was obstructed by a light fixture.
Fourth Floor
2. The east end fire alarm strobe lights were constantly illuminated/were not pulsing, when the fire alarm was tested.
Third Floor
3. There were old and new fire alarm strobe lights not flashing in synchronization,within 6" of each other in the corridors at the following stairwells:
a. Central
b. West
Second Floor
4. The north end fire alarm strobe lights were constantly illuminated/were not pulsing, when the fire alarm was tested.

1999 NFPA 72, 4-4.2 Light Pulse Characteristics.
The flash rate shall not exceed two flashes per second (2 Hz) nor be less than one flash every second (1 Hz) throughout the listed voltage range of the appliance.

1999 NFPA 72, 4-4.2.1
A maximum pulse duration shall be 0.2 seconds with a maximum duty cycle of 40 percent. The pulse duration shall be defined as the time interval between initial and final points of 10 percent of maximum signal.
1999 NFPA 72, 4-4.2.2*
The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity).

1999 NFPA 72, 4-4.3.1
Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

1999 NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.

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Sprinkler coverage was observed, during the survey, not adequately provided. Findings include: During the survey, the following was observed:

1. A sprinkler was covered with sheet rock mud in the Electrical Closet Five West.

2. Two sprinklers with lint/dust build up General Chemistry Second Floor.

3. Multiple sprinklers in the Kitchen and in the corridor by the Kitchen had heavy build up of corrosion around the seat.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.


1. The escutcheon plate was missing on a sprinkler Five West Nursing Station.

2. The escutcheon plate was missing on two sprinklers in Respiratory Care Third Floor.

3. The escutcheon plate was missing on a sprinkler in the Day Surgery Waiting Room.


2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

1. Three coolers and three freezers in the Kitchen were not provided with sprinkler coverage. **Kitchen is fully sprinklered.**

2. The Equipment Room Three by Dietary was not provided with sprinkler coverage. **The corridor into which this room opens is sprinklered.**

3. The Men's Restroom in Pathology was not provided with sprinkler coverage. **This area is fully sprinkered.**

NFPA 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.









27382


The facility failed to provide automatic sprinkler protection per code. Findings include:

During the survey, the following hydraulic elevators were observed without sprinkler protection at the bottom of the elevator hoistway:
a. The elevator for One Day Surgery
b. The two elevators for the Loading Dock
1999 NFPA 13, 5-13.6.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following was observed:
1. The following fire extinguishers, per observation and interview, did not have an inspection tag:
a. At the Nurses' Station
b. At room #697
c. At room #687
2. The fire extinguisher, at room #678, last documented monthly inspection was 09/2010.

1998 NFPA 10, 4-3.4.1
Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.

1998 NFPA 10, 4-3.4.2
At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

1998 NFPA 10, 4-3.4.3
Records shall be kept on a tag or label attached to the fire extinguisher on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

1998 NFPA 10, 4-3.1* Frequency.
Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately
30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

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During the survey, this surveyor observed two employees smoking at the Exit Discharge of the Exit by Wet Lab First Floor. When these employees saw this surveyor and Wesley, with Engineering, they quickly moved to the designated smoking area approximatley 30 feet away. This surveyor observed multiple discarded cigarette butts on the ground at the Exit Discharge. *All items below that are required for the designated smoking area were provided based upon observation by this surveyor.*


NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to maintain the heating, ventilating, and air conditioning (HVAC) system per code. Findings include:

During the survey, the following was observed:
Fourth Floor
1. The HVAC duct passing through the smoke barrier in the Labor and Delivery Sleep Room did not have a damper or an access panel.
2. The smoke damper at smoke doors (EGB 42) at room #485 did not close under activation of the fire alarm.
Third Floor
3. Two HVAC ducts, passing through the smoke barrier at the smoke doors at Nurses' Station Three West Nutrition Room, did not have access panels.
Second Floor
4. Five HVAC ducts, passing through the smoke/fire barrier at the smoke/fire doors (EGA 23) in the Back Hall by One Day Surgery at Nurses' Station Three West Nutrition Room, did not have dampers or access panels.
5. Two HVAC ducts, passing through the smoke/fire barrier in the Doctors' Lounge did not have dampers or access panels.
6. Two HVAC ducts, passing through the smoke/fire barrier in the Doctors' Locker Room, did not have dampers or access panels.
7. Four HVAC ducts, passing through the smoke/fire barrier at the smoke/fire doors at the Surgery Storage Room, one did not have a damper and all four did not have access panels.
8. The HVAC duct, passing through the smoke/fire barrier in the corridor to Surgery at the stairwell, did not have a damper or an access panel.
First Floor
9. The HVAC duct, passing through the smoke barrier at the smoke doors by the HVAC Shop, did not have an access panel.
10. The HVAC duct, passing through the smoke barrier in the Women's Bathroom in the Radiology Waiting Room, did not have a damper or an access panel.
11. The HVAC duct, passing through the smoke barrier in the Radiology Waiting Room, did not have a damper or an access panel.
12. HVAC ducts, passing through smoke and smoke/fire barriers throughout the facility, were observed not having dampers and/or access panels.

1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closest to the smoke barrier.
1999 NFPA 90A, 3-3.1.1*
Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.

1999 NFPA 90A, 3-4.5.4 Dampers shall close against the maximum calculated air flow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
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The facility failed to maintain the dietary hood. Findings include: During the survey, the following was observed:

The filters in the dietary hood were not tight fitting or firmly held in place and approximately a quarter inch gap was observed between three filters.


NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.

The facility failed to adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.

NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to prohibit portable space heating devices. Findings include:

During the survey, a portable space heating device was observed in Labor and Delivery's First Sleep Room, used by the physicians (adjacent to the elevators on the back hall on the Fourth Floor). This portable heater was operating unattended, set on HIGH, up against the bedding, and plugged into an extension cord.

2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
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The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the corridor behind Admitting Office, was observed to be blocked by wheel chairs, and a rack used for storage, preventing readily accesssible means of egress.


NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.


27382


The facility failed to maintain the means of egress per code. Findings include:

During the survey, the following was observed:
1. Seven "case carts", two stretchers, three soiled linen hampers, one roll away bed, one IV pole, and one cleaning cart were observed in Labor and Delivery's corridor on the fourth floor. An employee was overheard stating that leaving her cleaning cart there over night was okay as long as everything was on the same side of the corridor.
2. The ER corridor had two computers mounted on the corridor wall that appeared to be used as a work station. The following was observed:
a. The computer keyboards, when folded up, projected 10" from the corridor wall.
b. The handrail was impeded.
c. The CPUs were mounted 16" above the floor.
d. There were two bed tables and two stools located at the computers.

2000 NFPA 101, 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.
S & C-10-18-LSC CMS is revising its previous guidance to now allow for other items to be wall-mounted in corridors as long as they do not project out more than 6 inches from the corridor wall or conflict with other sections of the Life Safety Code. In addition, the projection shall not exceed a length of 36 inches, shall be separated by at least 48 inches from other projections, shall be installed at least 40 inches or greater above the floor, and shall only be installed in corridors that are at least 6 feet in width. These requirements for wall-mounted items should allow for the installation and use of a handrail without impediment.
No chairs, tables, cabinets, carts or other items associated with the wall-mounted items are located in the corridor when not in use where they would reduce the corridor to less than the required width. This includes keyboard trays and equipment doors that project more than 6 inches into the corridor when in use. These items shall be closed or retracted when the equipment is not in use or is unattended for any period of time.
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The facility failed to provide proper secure oxygen cylinders. Findings include: During the survey, six oxygen E cylinders were observed to be unsecured. Based upon interview with Wesley, from Engineering, these cylinders were not supposed to be stored on the dock with the H cylinders.


1999 NFPA 99, 8-3.1.11.2(g) Cylinders shall be secured from mechanical shock.

During the survey, the following was observed:

1. The battery-powered light in O.R. two were inoperable.

2. The battery-powered light in O.R. four were inoperable.

3. The battery-powered light in O.R. six were inoperable.

1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas.
(e.) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
1999 NFPA 70, 700-12. General Requirements
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
1. A rechargeable battery
2. A battery charging means
3. Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
4. A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment
The batteries shall be of suitable rating and capacity to supply and maintain at not less than 87? percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 1? hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 1? hours. Storage batteries, whether of the acid or alkali type, shall be designed and constructed to meet the requirements of emergency service
Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.
Exception: In a separate and uninterrupted area supplied by a minimum of three normal lighting circuits, a separate branch circuit for unit equipment shall be permitted if it originates from the same panelboard as that of the normal lighting circuits and is provided with a lock-on feature.




27382


The facility failed to provide a smoke venting system per code. Findings include:

During the survey, the following was observed:
1. The two windowless C-Section Rooms on the fourth floor (per department head, they do use general anesthesia in these rooms) did not have a smoke venting system, per observation and interview.
2. The sixteen windowless O.R.s on the second floor did not have a smoke venting system, per observation and interview.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
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During the survey, based of observation and interview with Wesley with Engineering, a battery-powered light was not provided for the Generator Set/Control Room located on the First Floor by the Staff Lounge.


1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.


27382


The facility failed to maintain the oxygen cylinders per code. Findings include:

During the survey, two oxygen cylinders were observed unsecured in the Neonatal Storage Room.
1999 NFPA 99, 4-3.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

The facility failed to provide the requirements for the transferring of oxygen in the facility per code. Findings include:

During the survey, per observation and interview, two liquid oxygen transferring tanks were located in the Anesthesia Work Room. The following was observed:
1. This room was not separarted from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction.
2. This area was not mechanically ventilated.
3. This room had V.C.T. flooring.
4. No signs were posted that transferring is occurring, and that smoking in the immediate area is not permitted.


1999 NFPA 99, 8-6.2.5.2 Transferring Liquid Oxygen.
Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and
(b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and
(c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.
Transferring shall be accomplished utilizing equipment designed to comply with the performance requirements and producers of CGA Pamphlet P-2.6, Transfilling of Low-Pressure Liquid Oxygen to be Used for Respiration, and adhering to those procedures.
The use and operation of small portable liquid oxygen systems shall comply with the requirements of CGA Pamphlet P-2.7, Guide for the Safe Storage, Handling and Use of Portable Liquid Oxygen Systems in Health Care Facilities.

.

During the survey, based upon observation and interview with Wesley with Engineering, the three generators the facility have are not provided with Remote Annunciator Panels.


1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
.

The facility failed to provide approved electrical utilities. Findings include: During the survey, the following was observed:

1. Three junction boxes were missing covers over the washer.

2. A junction box was missing the cover above the ceiling at Cardiovascular Lab Third Floor.


1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.


3. Exposed wiring on the electrical cord on the Ice Cream box located in the Kitchen.

NFPA 101, 19.5.1 Utilities shall comply with NFPA 101, 9.1. Electrical utilities shall comply with 1999 NFPA 70, National Electrical Code.


4. A refrigerator was plugged into a surge protector in the Med Room Five North.

5. A refrigerator was plugged into a surge protector in the Clinical Educator Two Office Four West.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords for temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.





27382


The facility failed to maintain the electrical system code. Findings include:

During the survey, the following was observed:

SIXTH FLOOR
1. Microwave plugged into a surge protector in Geriatric Outpatient Room.
2. Refrigerator plugged into a surge protector in the Supply Room across from the Seclusion Room.
3. Refrigerator plugged into a surge protector at the Nurses' Station on "A" Hall.
4. Refrigerator plugged into a surge protector at the Nurses' Station on "B" Hall.
5. Refrigerator plugged into a surge protector at the Nurses' Station on "C" Hall.

FOURTH FLOOR
6. The following was observed in Labor and Delivery's first Sleep Room on the back hall next to the elevators:
a. Six gang multi-outlet plugged into an electrical outlet.
b. An extension cord.
c. Refrigerator, microwave and portable space heating device plugged into a surge protector.

THIRD FLOOR
7. Refrigerator plugged into a surge protector in the Clinical Education Office.
Second Floor
8. Refrigerator and microwave plugged into a surge protector in the O.R. Team Leader Room.
9. Six gang multi-outlet plugged into an electrical outlet in the SICU's Conference Room.

FIRST FLOOR
10. Extension cord (for the walkie-talkies) was plugged into a three gang multi-outlet, that was plugged into an electrical outlet in the Security Supervisor's Office.
11. T.V and DVD Player was plugged into a homemade extension cord in the E.R. Lounge.


1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

The facility failed to provide the construction type required by code. Findings include:

During the survey, on the Second Floor - O.R. Nurses' Lounge was observed having a Construction Type of II (000).

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following was observed:

1. Doors failed to close tight as to resist the passage of smoke on the Electrical Room Four West, this surveyor was able to see into room.

2. Door failed to positive latch Patient Room #492 North.

3. Door failed to close tight as to resist the passage of smoke, Procedure Room Vascular Two, this surveyor was able to see into room.

4. Door failed to close tight as to resist the passage of smoke, Electrical Room by C06, CICU, this surveyor was able to see into the room.

5. Doors failed to close tight as to resist the passage of smoke, CICU Waiting Room, Third Floor, this surveyor was able to see into the room.

6. Door failed to positive latch Imaging Room Five First Floor.


NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.



27382


The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following was observed:
A. The following corridor double doors did not have an astragal:
Sixth Floor
1. Linen Supply Closet
Fourth Floor
2. 4 East Telephone Closet (TC EW 411)
Third Floor
3. West Telephone Closet
4. West Electrical Closet across from the Nurses' Station (EC WW 335)
5. "B" Hall Electrical Closet next to room #3115
Second Floor
6. Telephone Closet (TC EW 208) at SICU
7. Electrical Closet in SICU
8. Electrical Closet at One Day Surgery Waiting
First Floor
9. Telephone Closet by the Main Electrical Room

B. The following corridor doors did not have positive latching hardware:
1. Endoscopy Holding/Recovery Room
2. G.I. Endoscopy Lab.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
.

The facility failed to provide enclosed or protected vertical openings and shafts. Openings shall be protected as appropriate for the fire resistance rating of the barrier. Findings include:

During the survey, two holes the size of a half dollar were observed in the wall of the Elevator Equipment Room.

2000 NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

2000 NFPA 101, 8.2.2. Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following was observed:

1. Unsealed penetrations around a section of sheet rock that had been used to seal the opeings in the Smoke Barrier by Nursing Station C Hall, Five West.

2. Unsealed penetrations at the end of a sleeve in the Smoke Barrier by Charge Nurse Office Four West.

3. Unsealed penetrations at the end of a sleeve, and around wiring in the Smoke Barrier by Patient Room #4131 West Hall.

4. Unsealed penetrations at the end of a sleeve in the Smoke Barrier by Patient Room #486 North.

5. Unsealed penetrations at the end of a sleeve in the Smoke Barrier by Patient Room #474 North.

6. Unsealed penetrations at the end of a sleeve in the Smoke Barrier by CICU West Elevator Lobby.

7. Unsealed penetrations around a water line in the Smoke Barrier above the doors at CICU.

8. Unsealed penetrations at the end of a sleeve and around conduit in the Smoke Barrier by Patient Room CPOU 10.

2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

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





27382


The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following was observed:
Sixth Floor
1. Social Services Office corridor door was in a smoke barrier and did not have a self-closing device.

2000 NFPA 101, 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.

Fourth Floor
2. The smoke barrier in the Labor and Delivery Sleep Room:
a. Did not meet the roof deck
b. Was not sealed at the corner
3. The smoke barrier in the Endoscopy Breakroom (above the refrigerator) had a hole approximately 18" X 18"

First Floor
4. The smoke barrier at the smoke door by the Radiology Reading Room had a 2" unsealed penetration around a sprinkler line.

2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

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

The facility failed to maintain the smoke barrier to restrict the passage of smoke. Findings include: During the survey, the following was observed:

1. Doors failed to close tight in the Smoke Barrier in Central Supply Second Floor.

2. Doors failed to close tight in the Smoke Barrier by Patient Room #486.


NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.

The facility failed to maintain fire barriers per code. Findings include:

During the survey, the following was observed:
Second floor
1. The two hour fire wall in the Back Hall had a penetration of approximately 4" X 8" for a copper pipe.
2. The O.R. Nurses' Lounge had several unsealed penetrations.
3. The Doctors' Lounge Door going into the O.R. Suite was in a two hour fire wall and did not have a self-closing device.
4. The left leaf of the fire doors, in the back hall at the Women's Center, did not latch under the fire alarm.

2000 NFPA 101, 7.2.4.3.1 Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)
2000 NFPA 101, 7.2.4.3.4 Any opening in such fire barriers shall be protected as provided in 8.2.3.2.3.
2000 NFPA 101, 7.2.4.3.8 All fire doors in horizontal exits shall be self-closing or automatic-closing in accordance with 7.2.1.8. Horizontal exit doors located across a corridor shall be automatic-closing in accordance with 7.2.1.8.
.

The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, based upon observation, the Exit by Dietary First Floor was not provided with a light at the Exit Discharge.


NFPA 101, 19.2.8 and 7.8.1.2. Illumination of means of egress shall be continuous.

The facility failed to document fire drills per code. Findings include:

During the survey, per documentation and interview, the facility was not requiring all staff onsite to sign during a fire drill.

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following was observed:

1. The audible/strobe was inoperable in MICU.

2. The audible/strobe was inoperable in SICU.

3. The audible/strobe was inoperable in CICU.

4. Audible/strobes were not provided in the O.R. corridors.

5. The strobe lights were constantly illuminated/were not pulsing while the fire alarm was being tested throughout the facility at different locations on each floor.

1999 NFPA 72, 4-4.2.1
A maximum pulse duration shall be 0.2 seconds with a maximum duty cycle of 40 percent. The pulse duration shall be defined as the time interval between initial and final points of 10 percent of maximum signal.
1999 NFPA 72, 4-4.2.2*
The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity).

1999 NFPA 72, 4-4.3.1
Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

1999 NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.


Upon review of the Fire Alarm inspection conducted by Simplex Grinnell on 12/16/2010, the following was noted:

1. Two Ionization Smoke Detectors failed.

2. Four Heat Detectors failed.

3. Eight Photo Smoke Detectors failed.

4. Two pull station-single action failed.

Wesley, from Engineering, advised this surveyor that Simplex Grinnell was on site 12/16/2010, correcting the above items. This surveyor spoke with Simplex Grinnell's Tech and he advised all items should be corrected by 12/21/2010.

NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.











27382


The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following was observed:
Sixth Floor
1. The audible/visible device at the north west stairwell in Geriactric-Psych was obstructed by a light fixture.
Fourth Floor
2. The east end fire alarm strobe lights were constantly illuminated/were not pulsing, when the fire alarm was tested.
Third Floor
3. There were old and new fire alarm strobe lights not flashing in synchronization,within 6" of each other in the corridors at the following stairwells:
a. Central
b. West
Second Floor
4. The north end fire alarm strobe lights were constantly illuminated/were not pulsing, when the fire alarm was tested.

1999 NFPA 72, 4-4.2 Light Pulse Characteristics.
The flash rate shall not exceed two flashes per second (2 Hz) nor be less than one flash every second (1 Hz) throughout the listed voltage range of the appliance.

1999 NFPA 72, 4-4.2.1
A maximum pulse duration shall be 0.2 seconds with a maximum duty cycle of 40 percent. The pulse duration shall be defined as the time interval between initial and final points of 10 percent of maximum signal.
1999 NFPA 72, 4-4.2.2*
The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity).

1999 NFPA 72, 4-4.3.1
Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

1999 NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.

.

Sprinkler coverage was observed, during the survey, not adequately provided. Findings include: During the survey, the following was observed:

1. A sprinkler was covered with sheet rock mud in the Electrical Closet Five West.

2. Two sprinklers with lint/dust build up General Chemistry Second Floor.

3. Multiple sprinklers in the Kitchen and in the corridor by the Kitchen had heavy build up of corrosion around the seat.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.


1. The escutcheon plate was missing on a sprinkler Five West Nursing Station.

2. The escutcheon plate was missing on two sprinklers in Respiratory Care Third Floor.

3. The escutcheon plate was missing on a sprinkler in the Day Surgery Waiting Room.


2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

1. Three coolers and three freezers in the Kitchen were not provided with sprinkler coverage. **Kitchen is fully sprinklered.**

2. The Equipment Room Three by Dietary was not provided with sprinkler coverage. **The corridor into which this room opens is sprinklered.**

3. The Men's Restroom in Pathology was not provided with sprinkler coverage. **This area is fully sprinkered.**

NFPA 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.









27382


The facility failed to provide automatic sprinkler protection per code. Findings include:

During the survey, the following hydraulic elevators were observed without sprinkler protection at the bottom of the elevator hoistway:
a. The elevator for One Day Surgery
b. The two elevators for the Loading Dock
1999 NFPA 13, 5-13.6.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.
.

The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following was observed:
1. The following fire extinguishers, per observation and interview, did not have an inspection tag:
a. At the Nurses' Station
b. At room #697
c. At room #687
2. The fire extinguisher, at room #678, last documented monthly inspection was 09/2010.

1998 NFPA 10, 4-3.4.1
Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.

1998 NFPA 10, 4-3.4.2
At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

1998 NFPA 10, 4-3.4.3
Records shall be kept on a tag or label attached to the fire extinguisher on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

1998 NFPA 10, 4-3.1* Frequency.
Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately
30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

.

During the survey, this surveyor observed two employees smoking at the Exit Discharge of the Exit by Wet Lab First Floor. When these employees saw this surveyor and Wesley, with Engineering, they quickly moved to the designated smoking area approximatley 30 feet away. This surveyor observed multiple discarded cigarette butts on the ground at the Exit Discharge. *All items below that are required for the designated smoking area were provided based upon observation by this surveyor.*


NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

The facility failed to maintain the heating, ventilating, and air conditioning (HVAC) system per code. Findings include:

During the survey, the following was observed:
Fourth Floor
1. The HVAC duct passing through the smoke barrier in the Labor and Delivery Sleep Room did not have a damper or an access panel.
2. The smoke damper at smoke doors (EGB 42) at room #485 did not close under activation of the fire alarm.
Third Floor
3. Two HVAC ducts, passing through the smoke barrier at the smoke doors at Nurses' Station Three West Nutrition Room, did not have access panels.
Second Floor
4. Five HVAC ducts, passing through the smoke/fire barrier at the smoke/fire doors (EGA 23) in the Back Hall by One Day Surgery at Nurses' Station Three West Nutrition Room, did not have dampers or access panels.
5. Two HVAC ducts, passing through the smoke/fire barrier in the Doctors' Lounge did not have dampers or access panels.
6. Two HVAC ducts, passing through the smoke/fire barrier in the Doctors' Locker Room, did not have dampers or access panels.
7. Four HVAC ducts, passing through the smoke/fire barrier at the smoke/fire doors at the Surgery Storage Room, one did not have a damper and all four did not have access panels.
8. The HVAC duct, passing through the smoke/fire barrier in the corridor to Surgery at the stairwell, did not have a damper or an access panel.
First Floor
9. The HVAC duct, passing through the smoke barrier at the smoke doors by the HVAC Shop, did not have an access panel.
10. The HVAC duct, passing through the smoke barrier in the Women's Bathroom in the Radiology Waiting Room, did not have a damper or an access panel.
11. The HVAC duct, passing through the smoke barrier in the Radiology Waiting Room, did not have a damper or an access panel.
12. HVAC ducts, passing through smoke and smoke/fire barriers throughout the facility, were observed not having dampers and/or access panels.

1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closest to the smoke barrier.
1999 NFPA 90A, 3-3.1.1*
Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.

1999 NFPA 90A, 3-4.5.4 Dampers shall close against the maximum calculated air flow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
.

The facility failed to maintain the dietary hood. Findings include: During the survey, the following was observed:

The filters in the dietary hood were not tight fitting or firmly held in place and approximately a quarter inch gap was observed between three filters.


NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.

The facility failed to adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.

NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to prohibit portable space heating devices. Findings include:

During the survey, a portable space heating device was observed in Labor and Delivery's First Sleep Room, used by the physicians (adjacent to the elevators on the back hall on the Fourth Floor). This portable heater was operating unattended, set on HIGH, up against the bedding, and plugged into an extension cord.

2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
.

The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the corridor behind Admitting Office, was observed to be blocked by wheel chairs, and a rack used for storage, preventing readily accesssible means of egress.


NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.


27382


The facility failed to maintain the means of egress per code. Findings include:

During the survey, the following was observed:
1. Seven "case carts", two stretchers, three soiled linen hampers, one roll away bed, one IV pole, and one cleaning cart were observed in Labor and Delivery's corridor on the fourth floor. An employee was overheard stating that leaving her cleaning cart there over night was okay as long as everything was on the same side of the corridor.
2. The ER corridor had two computers mounted on the corridor wall that appeared to be used as a work station. The following was observed:
a. The computer keyboards, when folded up, projected 10" from the corridor wall.
b. The handrail was impeded.
c. The CPUs were mounted 16" above the floor.
d. There were two bed tables and two stools located at the computers.

2000 NFPA 101, 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.
S & C-10-18-LSC CMS is revising its previous guidance to now allow for other items to be wall-mounted in corridors as long as they do not project out more than 6 inches from the corridor wall or conflict with other sections of the Life Safety Code. In addition, the projection shall not exceed a length of 36 inches, shall be separated by at least 48 inches from other projections, shall be installed at least 40 inches or greater above the floor, and shall only be installed in corridors that are at least 6 feet in width. These requirements for wall-mounted items should allow for the installation and use of a handrail without impediment.
No chairs, tables, cabinets, carts or other items associated with the wall-mounted items are located in the corridor when not in use where they would reduce the corridor to less than the required width. This includes keyboard trays and equipment doors that project more than 6 inches into the corridor when in use. These items shall be closed or retracted when the equipment is not in use or is unattended for any period of time.
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The facility failed to provide proper secure oxygen cylinders. Findings include: During the survey, six oxygen E cylinders were observed to be unsecured. Based upon interview with Wesley, from Engineering, these cylinders were not supposed to be stored on the dock with the H cylinders.


1999 NFPA 99, 8-3.1.11.2(g) Cylinders shall be secured from mechanical shock.

During the survey, the following was observed:

1. The battery-powered light in O.R. two were inoperable.

2. The battery-powered light in O.R. four were inoperable.

3. The battery-powered light in O.R. six were inoperable.

1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas.
(e.) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
1999 NFPA 70, 700-12. General Requirements
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
1. A rechargeable battery
2. A battery charging means
3. Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
4. A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment
The batteries shall be of suitable rating and capacity to supply and maintain at not less than 87? percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 1? hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 1? hours. Storage batteries, whether of the acid or alkali type, shall be designed and constructed to meet the requirements of emergency service
Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.
Exception: In a separate and uninterrupted area supplied by a minimum of three normal lighting circuits, a separate branch circuit for unit equipment shall be permitted if it originates from the same panelboard as that of the normal lighting circuits and is provided with a lock-on feature.




27382


The facility failed to provide a smoke venting system per code. Findings include:

During the survey, the following was observed:
1. The two windowless C-Section Rooms on the fourth floor (per department head, they do use general anesthesia in these rooms) did not have a smoke venting system, per observation and interview.
2. The sixteen windowless O.R.s on the second floor did not have a smoke venting system, per observation and interview.

1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
1999 NFPA 99, 5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures (see A-5-4.1).
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During the survey, based of observation and interview with Wesley with Engineering, a battery-powered light was not provided for the Generator Set/Control Room located on the First Floor by the Staff Lounge.


1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.


27382


The facility failed to maintain the oxygen cylinders per code. Findings include:

During the survey, two oxygen cylinders were observed unsecured in the Neonatal Storage Room.
1999 NFPA 99, 4-3.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

The facility failed to provide the requirements for the transferring of oxygen in the facility per code. Findings include:

During the survey, per observation and interview, two liquid oxygen transferring tanks were located in the Anesthesia Work Room. The following was observed:
1. This room was not separarted from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction.
2. This area was not mechanically ventilated.
3. This room had V.C.T. flooring.
4. No signs were posted that transferring is occurring, and that smoking in the immediate area is not permitted.


1999 NFPA 99, 8-6.2.5.2 Transferring Liquid Oxygen.
Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and
(b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and
(c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.
Transferring shall be accomplished utilizing equipment designed to comply with the performance requirements and producers of CGA Pamphlet P-2.6, Transfilling of Low-Pressure Liquid Oxygen to be Used for Respiration, and adhering to those procedures.
The use and operation of small portable liquid oxygen systems shall comply with the requirements of CGA Pamphlet P-2.7, Guide for the Safe Storage, Handling and Use of Portable Liquid Oxygen Systems in Health Care Facilities.

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During the survey, based upon observation and interview with Wesley with Engineering, the three generators the facility have are not provided with Remote Annunciator Panels.


1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
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The facility failed to provide approved electrical utilities. Findings include: During the survey, the following was observed:

1. Three junction boxes were missing covers over the washer.

2. A junction box was missing the cover above the ceiling at Cardiovascular Lab Third Floor.


1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.


3. Exposed wiring on the electrical cord on the Ice Cream box located in the Kitchen.

NFPA 101, 19.5.1 Utilities shall comply with NFPA 101, 9.1. Electrical utilities shall comply with 1999 NFPA 70, National Electrical Code.


4. A refrigerator was plugged into a surge protector in the Med Room Five North.

5. A refrigerator was plugged into a surge protector in the Clinical Educator Two Office Four West.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords for temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.





27382


The facility failed to maintain the electrical system code. Findings include:

During the survey, the following was observed:

SIXTH FLOOR
1. Microwave plugged into a surge protector in Geriatric Outpatient Room.
2. Refrigerator plugged into a surge protector in the Supply Room across from the Seclusion Room.
3. Refrigerator plugged into a surge protector at the Nurses' Station on "A" Hall.
4. Refrigerator plugged into a surge protector at the Nurses' Station on "B" Hall.
5. Refrigerator plugged into a surge protector at the Nurses' Station on "C" Hall.

FOURTH FLOOR
6. The following was observed in Labor and Delivery's first Sleep Room on the back hall next to the elevators:
a. Six gang multi-outlet plugged into an electrical outlet.
b. An extension cord.
c. Refrigerator, microwave and portable space heating device plugged into a surge protector.

THIRD FLOOR
7. Refrigerator plugged into a surge protector in the Clinical Education Office.
Second Floor
8. Refrigerator and microwave plugged into a surge protector in the O.R. Team Leader Room.
9. Six gang multi-outlet plugged into an electrical outlet in the SICU's Conference Room.

FIRST FLOOR
10. Extension cord (for the walkie-talkies) was plugged into a three gang multi-outlet, that was plugged into an electrical outlet in the Security Supervisor's Office.
11. T.V and DVD Player was plugged into a homemade extension cord in the E.R. Lounge.


1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.