HospitalInspections.org

Based on observation, the facility failed to maintain their occupancy separation walls. This was evidenced by penetrations in occupancy separation walls at two of three outpatient clinics. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 3/5/12 to 3/8/12, the occupancy separation walls were observed.

3/6/12 - Outpatient Surgery Center- Medical Plaza at St Johns

At 2:55 p.m., there was an approximately 1 1/2 inch x 3 inch cut out around wires, in the front wall of the occupancy separation, between the surgery center lobby and the Medical Office Plaza. There was an approximately 1/2 inch penetration around wires inside of a conduit in the left wall.


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3/7/12 - Physical Therapy Clinic

At 8:25 a.m., the separation wall, between the reception area of the offsite physical therapy clinic and the adjacent doctor's offices, was observed. There was an approximately 5 inch by 3 inch penetration around two conduits near the center of the wall.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in the walls and ceilings. This affected three of five floors in the main hospital and one of three outpatient clinics. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 3/15/12 to 3/18/12, the walls and ceilings were observed at the main hospital and three outpatient clinics.

Garden Level - 3/5/12
1. At 11: 20 a.m., There was an approximately 1/4 inch round penetration in the back wall, between refrigerators, in the Education Area storage room. There were three approximately 1/4 - 1/2 inch penetrations and an approximately 1/8 inch penetration in the left side of the back wall above the top shelf. There were two approximately 1/4 - 1/2 inch penetrations and an approximately 1/8 inch penetration in the back wall above the second shelf.

2. At 1:41 p.m., there was an approximately 1/8 inch penetration on one side of a sprinkler near the Central Supply store room door.

Mall Level - 3/6/12

3. At 8:25 a.m., there was an approximately 1/4 - 1/2 inch penetration around two side by side pipes, in the housekeeping closet ceiling, across from the radiology reception area. There was an approximately 1/2 - 1 inch penetration around a copper pipe, and an approximately 1/8 inch penetration around another pipe in the same area.

4. At 8:33 a.m., there were two approximately 1/2 inch round penetrations in a ceiling tile in the Emergency Room (ER) Nurses' Station.

5. At 9 a.m., there was an approximately 1/2 x 4 inch penetration on the edge of a broken ceiling tile, in the bathroom across from Trauma Room 5.

6. At 10:24 a.m., there was an approximately 1/8 x 1 inch gap at the top of the buzzer cover plate, in the corridor outside the OR (operating room) Staff Lounge.


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Main Hospital Level 3 - 3/5/12
7. At 2:07 p.m., the storage room near the 3 North department was observed. There was an approximately 1 foot by 3/4 foot ceiling tile missing next to the left wall.

Outpatient Physical Therapy - 3/7/12
8. At 8:32 a.m., on 3/7/12, there were two approximately 1/2 inch penetrations, around two copper pipes, in the back wall of the water heater closet at the outpatient physical therapy center.

Based on observation, the facility failed to maintain their corridor doors, as evidenced by doors that were obstructed from closing, and by doors that failed to latch. This affected four of five floors in the main hospital and one of three offsite clinics. This could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with staff, from 3/5/12 to 3/8/12, the doors were observed in the main hospital and three offsite facilities.

Main Hospital Level 4 - 3/5/12
1. At 11:07 a.m., the door to Room 4220 was obstructed from closing by a soiled linen bin.

2. At 11:30 a.m., the door to Room 4103, was obstructed from closing by a soiled linen bin.

3. At 11:42 a.m., the door to Room 4125, was obstructed from closing by a biohazard bucket.

Main Hospital Level 3
4. At 2:05 a.m., the door to the communication closet, in 3 North, was equipped with a self-closing device. The door closed but failed to latch.

Main Hospital Level 2
5. At 3:17 p.m., the door to Room 2277, was obstructed from closing by a soiled linen receptacle.

3/6/12
6. At 8:21 a.m., the door to Room 2103, was obstructed from closing by crutches and an oxygen concentrator.

7. At 8:29 a.m., the door to Room 2111, was obstructed from closing by a soiled linen receptacle.

Mall Level - 3/6/12
8. At 10:34 a.m., the door to the cardiac rehabilitation room, was equipped with a self-closing device. The door was held open by a wedge.

Physical Therapy - 3/7/12
9. At 8:22 a.m., the door to the outpatient physical therapy director's office failed to positive latch.

10. At 8:31 a.m., the door to the outpatient physical therapy employee lounge was equipped with a self-closing device. The door closed but failed to latch.

Based on observation, the facility failed to maintain the integrity of their smoke barrier walls. This was evidenced by penetrations in the smoke barrier walls on three of five floors in the main hospital and one of three offsite clinics. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 3/5/12 to 3/8/12, the smoke barrier walls were observed at the main hospital and in three offsite clinics.

Garden Level - 3/5/12

1. At 11 a.m., there was an approximately 1/4 inch penetration around a blue flex hose, on the left side of the smoke barrier wall at the cafeteria.
There was an approximately 1/4 - 1/2 inch penetration around wires at the bottom of one conduit. The conduit was the bottom one of five conduits in a row. There was an approximately 1/8 inch penetration around a white wire, inside a 1/2 inch conduit.

2. At 11:43 a.m., there was an approximately 1/4 inch penetration around wires, inside a conduit, in the smoke barrier at the elevator lobby, across from medical records. The penetration was above the left smoke barrier door.

Mall Level - 3/6/12
3. At 8:23 a.m., there was an approximately 1/4 inch penetration around wires, inside a 1/2 inch conduit, in the smoke barrier at the ER/GI Lab area, Door 11062B.

4. At 9:08 a.m., there was an approximately 2 1/2 x 2 1/2 penetration, around two white wires, in the smoke barrier near the radiology waiting room.

5. At 10:35 a.m., there was an approximately 1/4 - 1/2 inch triangular penetration around a wire, above the right side door of the smoke barrier wall, at the ER waiting room. There was an approximately 1/2 inch penetration around a wire, inside a conduit in the middle area above the doors.

Outpatient Surgery Center - 3/6/12
6. At 3 p.m., there was an approximately 1/2 inch penetration around the top conduit, in the smoke barrier at the entrance to the patient area. There was an approximately 2 1/2 x 2 inch cut out around a wire, and an approximately 1/2 inch penetration around a 1 inch conduit in the same barrier.

7. At 3:07 p.m., there was an approximately 1/4 - 1/2 inch round penetration above the door from the OR area into recovery. There was an approximately 1/4 - 1/2 inch penetration around a pull wire in the wall to the left of the door.

8. At 3:10 p.m., there was an approximately 1/2 inch penetration around wires inside a flex conduit, at the smoke barrier, above the middle doors, into the OR area. There was an approximately 1/4 inch penetration around a conduit at the wall.

9. At 3:20 p.m., there was an approximately 1/4 - 1/2 inch penetration around blue wires, inside a conduit, above the far smoke barrier doors into the OR. The door frame was labeled Smoke Compartment. There was an approximately 1 inch penetration in the wall and an approximately 1/4 - 1/2 inch penetration around a conduit and a flex conduit on the lower right side of the wall.


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10. At 3:10 p.m., the smoke barrier wall inside the surgery suite was observed. There was an approximately 1/2 inch unsealed conduit near the center of the wall.

Based on observation, the facility failed to ensure that smoke barrier doors are capable to resist the passage of smoke, and that doors are self-closing. This was evidenced by 1 door that failed to close completely and latch. This affected one of five floors in the main hospital, and could result in the spread of smoke in the event of a fire.

Findings:

During the facility tour with facility staff, from 3/5/12 - 3/8/12, the smoke barrier doors were observed.

On 3/5/12, at 11:21 a.m., the smoke barrier doors at IT failed to close and latch during 4 of 5 attempts. The doors were help open to their fullest extent and released. The air flow obstructed the door from closing completely.

Based on observation and interview, the facility failed to ensure that hazardous areas are protected by smoke resistant partitions and self-closing doors. This was evidenced by hazardous areas with no walls or self-closing doors, and by self-closing doors that failed to latch. This affected two of five floors of the main hospital and one of three offsite clinics. This could result in the spread of smoke and fire from hazardous areas to other areas of the facility.

Findings:

During the facility tour with staff from 3/5/12 to 3/8/12, the hazardous areas were observed. Rooms greater than 50 square feet with combustible storage are considered hazardous areas.

Garden Level - 3/5/12
Laboratory
1. At 11:59 a.m., there were six cases of paper records, shelving units with more than 17 cardboard boxes, stacks of papers and other supplies, and equipment in the lab storage closet near the care coordinator's office. The door was not equipped with a self closing device. The door was obstructed from closing by equipment placed in front of the door.

2. At 12:02 p.m., there were three cardboard boxes of paper and records, two trash bins greater than 20 gallons, two 18 gallon biohazard bins, and three case size boxes of other papers, in the alcove near the care coordinator's office. There was no door for the alcove. The area was greater than 50 square feet in size.

3. At 2:25 p.m., the door to the morgue was equipped with a self-closing device. The door closed but failed to latch.

Mall Level - 3/6/12
4. At 9:24 a.m., the endoscopy storage room contained four shelves with binders and other papers, a four drawer filing cabinet, cardboard boxes of supplies, 21 plastic bins of supplies in paper and plastic packages, a four shelf metal rack of supplies including sanitizers and endoscopy equipment, and two ERCP carts. The door was not equipped with a self-closing device. The room was greater than 50 square feet in size.

OR Suite - 3/6/12 and 3/7/12
5. At 9:27 a.m., a cubicle area was used for supply storage in the Pre-Op area. The area was greater than 80 square feet in size and contained a 5 x 5 foot clean linen cart filled with towels, blankets, gowns, paper lined plastic pads, and other linens. There was a wheeled shelving unit with paper and plastic wrapped supplies, blanket warmer gowns, and plastic bins of supplies. A crib and a wheelchair were located next to the clean linen cart and the shelving unit. There were plastic bins and supplies stacked on the counter. The area was not protected with smoke resisting partitions or a self-closing door.

During an interview at 9:30 a.m., Engineering Staff 2 confirmed the use of the cubicle for storage.

On 3/7/12 at 11:09 a.m., most of the above items remained stored in the Pre-Op storage cubicle.

6. At 9:50 a.m., there were large quantities of supplies stored the length of the hallway adjacent to OR 8. The area contained carts and shelves of linens, blankets, paper and plastic wrapped supplies, cloth wrapped surgery kits, cases of plastic bottles of sterile water, instruments on shelves, plastic shelving and cabinets of supplies, and case carts of clean instruments. Patient and surgical equipment were stored in the area. There were spare batteries, video equipment and other electrical equipment in the area. There were surgical supplies on five wire shelving units, clean instruments wrapped in green bundles approximately 10 x 18 inches in size, and shelves with patient gowns. There was a rack with approximately 15 lead aprons hanging from it and a clean linen cart. The area was greater than 50 square feet in size and was not protected with smoke resisting partitions or a self-closing door.

On 3/7/12 at 11:12 a.m., most of the above items remained stored in the hallway outside of OR 8. During an interview on 3/7/12, at 11:13 a.m., LN10 and the Compliance/Privacy Officer stated that this area was used for "overflow storage."

7. At 10:01 a.m., there were quantities of combustible supplies stored outside of OR 3. The area contained a row of five wire shelving units with paper and plastic wrapped supplies, instruments, and surgical supplies on shelves. There were case carts of clean instruments, and patient and surgical equipment were stored in the area. There were surgical supplies and clean instruments wrapped in blue bundles approximately 10 x 18 inches in size on wire shelving units covering most of the wall area. There was a rack with approximately 20 lead aprons hanging from it. The area was greater than 50 square feet in size and was not protected with smoke resisting partitions or a self-closing door.

On 3/7/12 at 11:14 a.m., most of the above items remained stored in the hallway and area outside of OR 3.

On 3/8/12, photos were taken to document the quantity of items stored in the OR suite.

Mall Level 3/6/12
8. At 11 a.m., the door to the gift shop storage area was held open with kick type hardware. The room contained quantities of combustible storage and was greater than 50 square feet in size. The door was equipped with a self-closing device. When the hardware was removed the door closed but failed to latch in three of three tries. The Director of Facilities Management removed three wreath hangers from the top of the door to allow the door to close and latch.


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Outpatient Industrial Therapy - 3/7/12
9. At 9:09 a.m., the file storage room in the outpatient industrial therapy center was observed. The room was approximately 80 square feet and contained more than 20 boxes of papers and files. The door to the file storage room was not equipped with a self-closing device.

Based on observation the facility failed to ensure exits are accessible at all times, as evidenced by two exits that were blocked during the survey. This failure could result in the inability of patients and staff to exit, in the event of a fire or other emergency. This affected one of four levels in the main hospital.

Findings:

During the facility tour with facility staff, on 3/6/12, the exits on the Mall Level were observed.

At 8:38 a.m., the left side door in the Emergency Room inner hallway was obstructed. A housekeeping cart obstructed the door from opening

At 10:47 a.m., there was an exit sign posted above the right door exiting from the admitting office area. The door was locked and could not be opened to exit from the office.

Based on observation and interview, the facility failed to maintain their emergency lighting in accordance with NFPA 101. This was evidenced by no testing records for testing one battery-powered emergency light fixture. This affected one of three outpatient clinics and could result in the failure of the emergency light, in the event of a power-outage.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a facility tour with staff from 3/5/12 to 3/8/12, the battery-powered emergency lights were observed.

Outpatient Physical Therapy - 3/7/12
At 8:27 a.m., there was a battery-powered emergency light fixture in the hallway of the outpatient physical therapy clinic.

During an interview at 8:28 a.m., Engineering Staff 1 stated that the battery-powered light is not tested monthly or annually.

Based on record review, the facility failed to ensure that fire drills are conducted in accordance with NFPA 101. This was evidenced by one missing NOC shift fire drill, by no transmission of alarms during drills conducted between 6 AM and 9 PM, and by incomplete information on the fire drill reports. This affected five of five floors in the main hospital and three of three offsite clinics. This could result in a delay in staff response in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
21.7.1.2 Fire drills in ambulatory health care facilities 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.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During record review on 3/7/12, the fire drill records were requested for the main hospital and three offsite clinics.

1. At 1:30 p.m., the fire drill records for the main hospital and offsite surgery center were provided. There was no documentation for a NOC shift fire drill conducted at the main hospital during October, November, or December of 2011.

2. At 1:32 p.m., documentation indicated a fire drill was conducted in the surgery department at the main hospital, on 10/24/11 at 2:35 p.m. The document indicated that no alarm was activated during the drill.

3. At 1:34 p.m., documentation indicated a fire drill was conducted in the outpatient surgery center, on 10/5/11 at 1:35 p.m. The document indicated that no alarm was activated during the drill.

4. At 4:29 p.m., documentation for fire drills conducted at the offsite physical therapy center and the offsite industrial therapy center were provided. The documents indicated that coded announcements were used, instead of the transmission of alarms, during the fire drills. There were no descriptions of emergency scenarios, evaluations of staff response, and no indication of which staff members participated in the drills.

Based on observation and interview, the facility failed to maintain their fire alarm system in accordance with NFPA 72. This was evidenced by an obstructed pull station, by one pull station that failed, by alarm notification devices that failed, and by no dates on the sealed-lead acid batteries in the panels. This affected four of five floors and the penthouse in the main hospital and two of three outpatient clinics. This could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Table 7-3.2
6. Batteries d. Sealed-Lead Acid Type 1. Charger Test (Replace battery every 4 years.)

Findings:

During the facility tour with staff, from 3/5/12 to 3/8/12, the fire alarm system was observed and tested.

1. At 2:40 p.m., on 3/6/12, the pull station, in the lobby of the outpatient surgery center, was obstructed by a table and a plant.

Alarm Testing - 3/7/12
2. At 1:54 p.m., a smoke detector in the 3 North department on Level 3 was activated. The strobe of the alarm notification device, in the 3 South public restroom, failed to illuminate.

3. At 2:01 p.m., on a pull station in the 3 South department on Level 3 was activated. The alarm notification device next to Room 3103 failed to chime.

4. At 2:10 p.m., the waterflow alarm on Level 4 was activated. The alarm notification device, in the corridor right outside 4 North, failed to chime.

5. At 2:20 p.m., on 3/8/12, the pull station next to the door in Mechanical Room 413, in the penthouse, was tested. No alarm devices were activated when Engineering Staff 1 pulled the alarm. Engineering Staff 1 adjusted the pull box and tested it again at 2:23 p.m. Alarm devices were activated during the second attempt. Engineering Staff 2 tested the pull box for a third time at 2:24 p.m. It took approximately 47 seconds, and adjustment of the pull box by Engineering Staff 1, until the alarm notification devices activated.

During an interview at 2:26 p.m., Engineering Staff 1 stated that the pull box needed repair.

Outpatient Therapy - 3/8/12
5. At 8:35 a.m., the dialer for the smoke detection system was observed in the outpatient industrial therapy center. The dialer activates a call to the monitoring company when a fire alarm device is activated. There was no date of installation indicated on the sealed-lead acid battery in the dialer.





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Garden Level - 3/5/12
6. At 3:12 p.m., the batteries in the fire alarm control panel were dated 8/21/07. The batteries should have been replaced in August of 2011.

7. On 3/7/12, at 7:10 a.m., there was no date on the batteries in the fire alarm control panel in the surgery center. There was no indication of when the batteries should be replaced.

Alarm Testing - 3/7/12
8. At 11:35 a.m., a smoke detector was activated on One South. There was no audible chime for the chime strobe device located at Patient Room 1120.

9. At 1:52 p.m., an alarm device was activated on Level 2. There was no audible chime for the chime strobe device located at Patient Room 2108.

10. At 2:04 p.m., a pull station was activated on Level 3, at the Nurses' Station. There was no audible chime for the chime strobe device located outside of the Nurses' Station, across from Patient Room 3230.

11. At 2:09 p.m., a smoke detector was activated on Level 4, at the elevator lobby. There was no audible chime for the chime strobe device located at the soiled utility room at the main corridor.

12. From 2:13 p.m. through 2:19 p.m., fire alarm devices were activated on Level 4. There was no audible chime for the chime strobe device at the occupational and physical therapy doors. There was no audible chime for the chime strobe device at Room 4218. There was no audible chime for the chime strobe device at the dining room.

13. At 2:48 p.m., there was no audible trouble alarm at the fire alarm control panel when the tamper alarm was tested, at the O S & Y valves.

Based on observation, record review, and interview, the facility failed to ensure that smoke detectors are maintained in accordance with NFPA 72. This was evidenced by no records for testing smoke detectors and no records for sensitivity testing for the detectors, in one of three outpatient clinics. This could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Findings:

During the facility tour with staff from 3/7/12 to 3/8/12, the smoke detection system was observed in the outpatient industrial therapy center.

At 9:26 a.m., on 3/7/12, four hard-wired smoke detectors and two single station smoke detectors were observed in the facility. Records for testing the detectors were requested.

During an interview at 9:27 a.m., the director of the outpatient clinic stated that he was unsure if the detectors had been tested.
During an interview at 1:15 p.m., Engineering Staff 1 stated that no testing documents were available.

At 8:45 a.m., on 3/8/12, manufacturing testing instructions for the single station smoke detectors were engraved around the test buttons. The manufacturer recommends weekly testing of the smoke detectors. No documents were provided for weekly testing of the single station smoke detectors or for sensitivity testing for the hard-wired detectors.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by escutcheon rings that were not flush to the ceiling, by storage that was less than 18 inches away from a sprinkler deflector, by no trouble signal during testing of the tamper alarm, by missing spare sprinkler heads, and by no documentation for quarterly inspections at one of three offsite clinics. This affected five of five floors at the main hospital and one of three offsite clinics. This could result in a delay in extinguishing a fire, in the event of a fire.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition.
3-2.9.3 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:
(1) For systems having less than 300 sprinklers, not fewer than six sprinklers
(2) For systems with 300 to 1000 sprinklers, not fewer than 12 sprinklers
(3) For systems with over 1000 sprinklers, not fewer than 24 sprinklers

5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. At minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or temperature exceeding 100?F (38?C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

4.3.1 Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request.

9-5.1 Inspection and Testing of Sprinkler Pressure Reducing Control Valves. Sprinkler pressure reducing control valves shall be inspected and tested as described in 9-5.1.1 and 9-5.1.2.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

Findings:

During the facility tour with staff from 3/5/12 to 3/8/12, the automatic sprinkler system was observed and maintenance documents were requested.

Garden Level - 3/5/12
At 10:47 a.m., the escutcheon ring was missing above the Pepsi machine in the cafeteria.
At 1:55 p.m., the sprinkler and escutcheon ring were corroded in the housekeeping closet near Conference Room 4. The sprinkler had turned blue/green.
At 3:05 p.m., the box of spare sprinklers was observed in the fire pump room. There were two upright sprinkler heads, six pendant sprinkler heads and two side wall type sprinkler heads in the box with a wrench.

During an interview at 3:07 p.m., Maintenance Staff 1 reported there were no other sprinklers on site.

During an interview on 3/6/12, at 2:30 p.m., Maintenance Staff 1 reported that they had consulted with the vendor for the sprinkler system. He determined that the facility should have 24 spare sprinklers available.

3/5/12
At 3:40 p.m., the escutcheon ring was missing in the Cath Lab staff area.

At 3:47 p.m., the escutcheon ring was missing in the bathroom in the Cath Lab sleep room.

Mall Level - 3/6/12
At 10:30 a.m., the sprinkler cap was missing in the main lobby, near the smoke barrier doors to the ER/Outpatient corridor.

During fire alarm testing on 3/7/12, the valves were closed at the O S & Y(outside screw and yolk) located behind the hospital. Closing a valve shuts off the water to the sprinkler system and should activate a tamper alarm.

At 2:48 p.m., there was no audible trouble alarm at the fire alarm control panel when the tamper alarm was tested, at the O S & Y valves. Closing one of two valves failed to activate the tamper alarm.


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Level 4 - 3/5/12
At 11:19 a.m., there was a leather case stored approximately 11 inches from the sprinkler deflector in the storage closet next to speech therapy.

At 11:44 a.m., the sprinkler head, near the bathroom in Room 4123, had no escutcheon ring, revealing an approximately 2 inch penetration around the sprinkler pipe.

Level 3 - 3/5/12
At 1:52 p.m., there was an approximately 1/2 inch gap between the escutcheon ring and the ceiling, in the bathroom of Room 3119.

At 1:56 p.m., there was an approximately 1 inch gap between the escutcheon ring and the ceiling, in the bathroom of Room 3122.

Level 1 - 3/6/12
At 10:54 a.m., the escutcheon ring was missing, in the corridor near Room 1116, revealing an approximately 1 inch penetration around the sprinkler pipe.

Outpatient Physical Therapy - 3/7/12
At 8:35 a.m., there was an approximately 1 inch gap between the escutcheon ring and the ceiling, in the IT Closet at the outpatient physical therapy clinic.

At 8:40 a.m., there were no spare sprinkler heads or wrench observed at the outpatient physical therapy clinic.

During an interview at 8:42 a.m., Engineering Staff 1 was unsure if there were spare sprinkler heads at the facility or where they were stored.

At 8:45 a.m., the sprinkler system at the outpatient physical therapy clinic could not be tested. Staff did not know where the test valves were located.

During record review, at 4:42 p.m., the facility provided records for testing the sprinkler system at the outpatient physical therapy clinic. The document indicated that a 5 year inspection of the sprinkler system was conducted by a vendor on 3/7/12, the day of the survey. No documents for the previous 5 year inspection or quarterly testing of the sprinkler system were provided.

During an interview at 7:59 a.m., on 3/8/12, Engineering Staff 1 stated that no other documents for testing the sprinkler system at the outpatient physical therapy clinic were available.

Based on observation, the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This was evidenced by fire extinguishers that were not secured, by fire extinguishers that were obstructed, and by fire extinguishers that were missing monthly checks. This affected two of five floors of the main hospital and two of three outpatient facilities. This could result in a delay in extinguishing a fire.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location.

1.6.10 Fire extinguishers having a gross weight not exceeding 40 lbs (18.4 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight of more than 40 lb (18.4 kg) (except wheel type) shall be so installed that the top of the fire extinguisher is not more than 3.5 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in (10.2 cm).

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.
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.

Findings:

During the facility tour with staff from 3/5/12 to 3/8/12, the fire extinguishers were observed at the main hospital and in three offsite clinics.

Garden Level - 3/5/12
At 3:06 p.m., there were 22 fire extinguishers located in the fire pump room. The extinguishers were unsecured and sitting on the floor. The tags on the extinguishers indicated they were certified in 8/2011. There were no monthly checks noted for any of the extinguishers.

During an interview at 3:07 p.m., Staff 1 reported that the spare extinguishers are stored in the fire pump room. He stated that they do not check them monthly when they are not in use.


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Level 2 - 3/6/12
At 8:26 a.m., the fire extinguisher, in the 2 North supply room, was obstructed by two tall trash receptacles.

Surgery Center - 3/6/12
At 3:00 p.m., the fire extinguisher was obstructed by a chair, in Operating Room 3 at the offsite surgery center.

Offsite Physical Therapy - 3/7/12
At 8:29 a.m., the tag on the hallway fire extinguisher, indicated that it was annually serviced in August of 2011. There were two monthly checks recorded on the tag dated 1/24/12 and 2/24/12. The tag indicated that no monthly checks were conducted in September, October, November, and December of 2011.

Based on observation and interview, the facility failed to ensure the means of egress were free of all obstructions, as evidenced by obstructions in one exit corridor. This affected one of five floors in the main hospital and could result in delayed evacuation, in the event of a fire.

Findings:

During a facility tour with staff from 3/5/12 to 3/8/12, the exit corridors were observed.

Garden Level
At 4:50 p.m., on 3/5/12, there were five dietary carts parked in the exit corridor across from the kitchen.

At 8:15 a.m., on 3/6/12, there were six dietary carts parked in the exit corridor across from the kitchen.
At 12 p.m., there were 3 food carts parked in the exit corridor across from the kitchen.

During an interview at 8:17 a.m., the dietary manager stated that carts are cleaned out around 9 p.m. and used the following morning. He stated that carts are stored in the corridor when they are not in use.

Based on observation, the facility failed to ensure that the capacity of soiled linen, stored within a 64 square foot area, does not exceed 32 gallons in rooms not protected as hazardous areas. This was evidenced by full and partially full soiled linen bins stored side by side in rooms or areas not protected as hazardous areas. This affected three of five floors of the main hospital and two of four suites on the mall level. This could result in an increased risk of a fire.

Findings:

During a facility tour with staff from 3/5/12 to 3/8/12, soiled linen bins were observed at the main hospital and three of three outpatient clinics.

Level 4 - 3/5/12
At 11:39 a.m., there was a full 32-gallon soiled linen bin stored in Room 4129. The soiled linen bin was approximately 1 foot away from approximately 16 gallons of soiled isolation gowns. The door to the room was not equipped with a self-closing device.






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Lab area - 3/5/12
At 12:02 p.m., there were two trash bins, greater than 20 gallons, and two 18 gallon biohazard bins, in the alcove adjacent to the care coordinator's office. Other combustible storage was located in the alcove. The area was not protected with a door.

Mall Level - 3/6/12
At 8:55 a.m., there was a 55 gallon trash can placed in the emergency room (ER) inner hallway. The trash can was adjacent to a housekeeping cart with trash and cleaning supplies. There was no staff in the immediate area. ER staff tried to locate a housekeeping staff. No housekeeping staff were present in the ER.

At 9:03 a.m., there were two approximately 30 gallon soiled linen bins placed side by side in the west ER cubical area. There were two approximately 20 gallon trash receptacles within 8 feet of the soiled linen bins.

At 9:15 a.m., there were three soiled linen bins, side by side, against the interior wall of the endoscopy area. There was a dirty pillow receptacle within approximately 2 inches of the soiled linen bins.

At 9:35 a.m., there were two approximately 30 gallon soiled linen bins in front of the PACU Nurses' Station. An approximately 23 gallon trash can was placed between the soiled linen bins. All three were within a 64 square foot area.

At 9:57 a.m., there were two bins, greater than 85 gallons, in the sub corridor exiting from Operating Rooms 4 and 5, to the main corridor. During an interview at 9:58 a.m., OR staff reported the bins were for soiled linen and trash. In the same area there were two 64 gallon recycle receptacles and two 32 gallon biohazard receptacles.

The exterior corridor door is self-closing. The interior doors are convenience doors. They do not self-close or latch.

Based on observation and interview, the facility failed to maintain their electrical wiring in accordance with NFPA 70. This was evidenced by appliances plugged into multi-plug adaptors, by multi-plug adaptors plugged into other multi-plug adaptors, by extension cords used as permanent wiring, by obstructions in front of electrical panels, and by no cover plates on electrical boxes. This affected four of five floors in the main hospital and could result in an increased risk of an electrical fire.

NFPA 70, National Electric Code, 1999 Edition.
110-26
(a)Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

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

400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.


Findings:

During the facility tour with staff from 3/5/12 to 3/8/12, the electrical wiring and equipment was observed at the main hospital and three offsite facilities.

Level 3 - 3/5/12
At 2:26 p.m., there was a microwave plugged into a six-plug surge protector in Room 3201 on Level 3.

Level 2
At 3:15 p.m., there was no cover plate on an electrical box with a cable, in the satellite pharmacy room, on 2 South

At 3:25 p.m., there was a six-plug surge protector plugged into a 4-plug surge protector in the clinical education office.

At 3:35 p.m., there was a 6-plug surge protector plugged into a 6-plug surge protector in the cogent healthcare office.

At 9:06 a.m., on 3/6/12, there was no cover plate on an electrical box in the telephone room across from the ICU waiting room.

During an interview on 3/6/12, at 9:07 a.m., Engineering Staff 1 confirmed that wires in the electrical box were exposed. He stated that the electrical box was connected to a telephone that was removed approximately one year ago.










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Garden Level - 3/5/12
At 10:45 a.m., computer equipment was connected to a surge protector plugged into a surge protector, in the Credit Union office area.

At 11:24 a.m., the electrical panel (GEC3D), in the IT Computer Room, was missing two blanks. Two panels, GEC3D and GNC, were obstructed by a table holding plastic cases. The table was approximately 5 inches from the table and plastic cases. The door could not be opened without knocking over the plastic cases.

At 2 p.m., there was a surge protector plugged into a surge protector in the Transformational Care Office.

At 2:50 p.m., a refrigerator was plugged into a surge protector in the Materials Management area.

At 3 p.m., there was an extension cord attached to the wall, above the doors, in the plumber's room. There was a yellow, heavy duty splicer connecting a surge protector to the extension cord. The extension cord connected devices on one side of the room to the wall outlet on the opposite side of the room.

Mall Level - 3/6/12
At 10:45 a.m., a refrigerator was connected to a surge protector in the clinical education office.

At 11:07 a.m., a surge protector was plugged into an extension cord, in the back wall cubical area, in Human Resources.

At 11:11 a.m., a surge protector was connected to a surge protector in the computer kiosk area, in Human Resources.

Based on observation and interview, the facility failed to ensure that ABHR dispensers are not installed over ignition sources. This was evidenced by ABHR dispensers that were installed over light switches and electrical outlets. This affected two of five floors in the main hospital and three of three outpatient clinics. This could result in the increased risk of a fire.

Findings:

During the facility tour with staff from 3/5/12 to 3/8/12, the ABHR dispensers were observed at the main hospital and three offsite facilities.

At 10:51 a.m., on 3/5/12, the ABHR dispenser in the 4 South private treatment room was observed. It was installed approximately 1/2 inch above and approximately 1 inch to the right of a light switch.
During an interview at 10:52 a.m., Engineering Staff 1 confirmed the evidence of alcohol hand rub splatter on the light switch cover plate.

At 2:09 p.m., on 3/5/12, the ABHR dispenser in the second floor Palliative Care break room was observed. It was installed approximately 6 inches above and approximately 1 inch to the right of a light switch.
During an interview at 2:10 p.m., Engineering Staff 1 confirmed the evidence of alcohol hand rub splatter on the light switch cover plate.

At 2:58 p.m., on 3/6/12, the ABHR dispenser in Operating Room 2 of the offsite surgery center was observed. It was installed approximately 2 1/2 feet directly over a red emergency receptacle outlet.

At 8:21 a.m., on 3/7/12, the ABHR dispenser in the offsite physical therapy director's office was observed. It was installed approximately 5 inches directly above a light switch.

At 9:18 a.m., on 3/7/12, the ABHR dispenser in the hand rehab room at the offsite industrial therapy center was observed. It was installed directly adjacent to a light switch such that the nozzle was approximately 1/2 inch above the flip switch.

Based on observation, the facility failed to maintain their occupancy separation walls. This was evidenced by penetrations in occupancy separation walls at two of three outpatient clinics. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 3/5/12 to 3/8/12, the occupancy separation walls were observed.

3/6/12 - Outpatient Surgery Center- Medical Plaza at St Johns

At 2:55 p.m., there was an approximately 1 1/2 inch x 3 inch cut out around wires, in the front wall of the occupancy separation, between the surgery center lobby and the Medical Office Plaza. There was an approximately 1/2 inch penetration around wires inside of a conduit in the left wall.


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3/7/12 - Physical Therapy Clinic

At 8:25 a.m., the separation wall, between the reception area of the offsite physical therapy clinic and the adjacent doctor's offices, was observed. There was an approximately 5 inch by 3 inch penetration around two conduits near the center of the wall.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in the walls and ceilings. This affected three of five floors in the main hospital and one of three outpatient clinics. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 3/15/12 to 3/18/12, the walls and ceilings were observed at the main hospital and three outpatient clinics.

Garden Level - 3/5/12
1. At 11: 20 a.m., There was an approximately 1/4 inch round penetration in the back wall, between refrigerators, in the Education Area storage room. There were three approximately 1/4 - 1/2 inch penetrations and an approximately 1/8 inch penetration in the left side of the back wall above the top shelf. There were two approximately 1/4 - 1/2 inch penetrations and an approximately 1/8 inch penetration in the back wall above the second shelf.

2. At 1:41 p.m., there was an approximately 1/8 inch penetration on one side of a sprinkler near the Central Supply store room door.

Mall Level - 3/6/12

3. At 8:25 a.m., there was an approximately 1/4 - 1/2 inch penetration around two side by side pipes, in the housekeeping closet ceiling, across from the radiology reception area. There was an approximately 1/2 - 1 inch penetration around a copper pipe, and an approximately 1/8 inch penetration around another pipe in the same area.

4. At 8:33 a.m., there were two approximately 1/2 inch round penetrations in a ceiling tile in the Emergency Room (ER) Nurses' Station.

5. At 9 a.m., there was an approximately 1/2 x 4 inch penetration on the edge of a broken ceiling tile, in the bathroom across from Trauma Room 5.

6. At 10:24 a.m., there was an approximately 1/8 x 1 inch gap at the top of the buzzer cover plate, in the corridor outside the OR (operating room) Staff Lounge.


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Main Hospital Level 3 - 3/5/12
7. At 2:07 p.m., the storage room near the 3 North department was observed. There was an approximately 1 foot by 3/4 foot ceiling tile missing next to the left wall.

Outpatient Physical Therapy - 3/7/12
8. At 8:32 a.m., on 3/7/12, there were two approximately 1/2 inch penetrations, around two copper pipes, in the back wall of the water heater closet at the outpatient physical therapy center.

Based on observation, the facility failed to maintain their corridor doors, as evidenced by doors that were obstructed from closing, and by doors that failed to latch. This affected four of five floors in the main hospital and one of three offsite clinics. This could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with staff, from 3/5/12 to 3/8/12, the doors were observed in the main hospital and three offsite facilities.

Main Hospital Level 4 - 3/5/12
1. At 11:07 a.m., the door to Room 4220 was obstructed from closing by a soiled linen bin.

2. At 11:30 a.m., the door to Room 4103, was obstructed from closing by a soiled linen bin.

3. At 11:42 a.m., the door to Room 4125, was obstructed from closing by a biohazard bucket.

Main Hospital Level 3
4. At 2:05 a.m., the door to the communication closet, in 3 North, was equipped with a self-closing device. The door closed but failed to latch.

Main Hospital Level 2
5. At 3:17 p.m., the door to Room 2277, was obstructed from closing by a soiled linen receptacle.

3/6/12
6. At 8:21 a.m., the door to Room 2103, was obstructed from closing by crutches and an oxygen concentrator.

7. At 8:29 a.m., the door to Room 2111, was obstructed from closing by a soiled linen receptacle.

Mall Level - 3/6/12
8. At 10:34 a.m., the door to the cardiac rehabilitation room, was equipped with a self-closing device. The door was held open by a wedge.

Physical Therapy - 3/7/12
9. At 8:22 a.m., the door to the outpatient physical therapy director's office failed to positive latch.

10. At 8:31 a.m., the door to the outpatient physical therapy employee lounge was equipped with a self-closing device. The door closed but failed to latch.

Based on observation, the facility failed to maintain the integrity of their smoke barrier walls. This was evidenced by penetrations in the smoke barrier walls on three of five floors in the main hospital and one of three offsite clinics. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 3/5/12 to 3/8/12, the smoke barrier walls were observed at the main hospital and in three offsite clinics.

Garden Level - 3/5/12

1. At 11 a.m., there was an approximately 1/4 inch penetration around a blue flex hose, on the left side of the smoke barrier wall at the cafeteria.
There was an approximately 1/4 - 1/2 inch penetration around wires at the bottom of one conduit. The conduit was the bottom one of five conduits in a row. There was an approximately 1/8 inch penetration around a white wire, inside a 1/2 inch conduit.

2. At 11:43 a.m., there was an approximately 1/4 inch penetration around wires, inside a conduit, in the smoke barrier at the elevator lobby, across from medical records. The penetration was above the left smoke barrier door.

Mall Level - 3/6/12
3. At 8:23 a.m., there was an approximately 1/4 inch penetration around wires, inside a 1/2 inch conduit, in the smoke barrier at the ER/GI Lab area, Door 11062B.

4. At 9:08 a.m., there was an approximately 2 1/2 x 2 1/2 penetration, around two white wires, in the smoke barrier near the radiology waiting room.

5. At 10:35 a.m., there was an approximately 1/4 - 1/2 inch triangular penetration around a wire, above the right side door of the smoke barrier wall, at the ER waiting room. There was an approximately 1/2 inch penetration around a wire, inside a conduit in the middle area above the doors.

Outpatient Surgery Center - 3/6/12
6. At 3 p.m., there was an approximately 1/2 inch penetration around the top conduit, in the smoke barrier at the entrance to the patient area. There was an approximately 2 1/2 x 2 inch cut out around a wire, and an approximately 1/2 inch penetration around a 1 inch conduit in the same barrier.

7. At 3:07 p.m., there was an approximately 1/4 - 1/2 inch round penetration above the door from the OR area into recovery. There was an approximately 1/4 - 1/2 inch penetration around a pull wire in the wall to the left of the door.

8. At 3:10 p.m., there was an approximately 1/2 inch penetration around wires inside a flex conduit, at the smoke barrier, above the middle doors, into the OR area. There was an approximately 1/4 inch penetration around a conduit at the wall.

9. At 3:20 p.m., there was an approximately 1/4 - 1/2 inch penetration around blue wires, inside a conduit, above the far smoke barrier doors into the OR. The door frame was labeled Smoke Compartment. There was an approximately 1 inch penetration in the wall and an approximately 1/4 - 1/2 inch penetration around a conduit and a flex conduit on the lower right side of the wall.


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10. At 3:10 p.m., the smoke barrier wall inside the surgery suite was observed. There was an approximately 1/2 inch unsealed conduit near the center of the wall.

Based on observation, the facility failed to ensure that smoke barrier doors are capable to resist the passage of smoke, and that doors are self-closing. This was evidenced by 1 door that failed to close completely and latch. This affected one of five floors in the main hospital, and could result in the spread of smoke in the event of a fire.

Findings:

During the facility tour with facility staff, from 3/5/12 - 3/8/12, the smoke barrier doors were observed.

On 3/5/12, at 11:21 a.m., the smoke barrier doors at IT failed to close and latch during 4 of 5 attempts. The doors were help open to their fullest extent and released. The air flow obstructed the door from closing completely.

Based on observation and interview, the facility failed to ensure that hazardous areas are protected by smoke resistant partitions and self-closing doors. This was evidenced by hazardous areas with no walls or self-closing doors, and by self-closing doors that failed to latch. This affected two of five floors of the main hospital and one of three offsite clinics. This could result in the spread of smoke and fire from hazardous areas to other areas of the facility.

Findings:

During the facility tour with staff from 3/5/12 to 3/8/12, the hazardous areas were observed. Rooms greater than 50 square feet with combustible storage are considered hazardous areas.

Garden Level - 3/5/12
Laboratory
1. At 11:59 a.m., there were six cases of paper records, shelving units with more than 17 cardboard boxes, stacks of papers and other supplies, and equipment in the lab storage closet near the care coordinator's office. The door was not equipped with a self closing device. The door was obstructed from closing by equipment placed in front of the door.

2. At 12:02 p.m., there were three cardboard boxes of paper and records, two trash bins greater than 20 gallons, two 18 gallon biohazard bins, and three case size boxes of other papers, in the alcove near the care coordinator's office. There was no door for the alcove. The area was greater than 50 square feet in size.

3. At 2:25 p.m., the door to the morgue was equipped with a self-closing device. The door closed but failed to latch.

Mall Level - 3/6/12
4. At 9:24 a.m., the endoscopy storage room contained four shelves with binders and other papers, a four drawer filing cabinet, cardboard boxes of supplies, 21 plastic bins of supplies in paper and plastic packages, a four shelf metal rack of supplies including sanitizers and endoscopy equipment, and two ERCP carts. The door was not equipped with a self-closing device. The room was greater than 50 square feet in size.

OR Suite - 3/6/12 and 3/7/12
5. At 9:27 a.m., a cubicle area was used for supply storage in the Pre-Op area. The area was greater than 80 square feet in size and contained a 5 x 5 foot clean linen cart filled with towels, blankets, gowns, paper lined plastic pads, and other linens. There was a wheeled shelving unit with paper and plastic wrapped supplies, blanket warmer gowns, and plastic bins of supplies. A crib and a wheelchair were located next to the clean linen cart and the shelving unit. There were plastic bins and supplies stacked on the counter. The area was not protected with smoke resisting partitions or a self-closing door.

During an interview at 9:30 a.m., Engineering Staff 2 confirmed the use of the cubicle for storage.

On 3/7/12 at 11:09 a.m., most of the above items remained stored in the Pre-Op storage cubicle.

6. At 9:50 a.m., there were large quantities of supplies stored the length of the hallway adjacent to OR 8. The area contained carts and shelves of linens, blankets, paper and plastic wrapped supplies, cloth wrapped surgery kits, cases of plastic bottles of sterile water, instruments on shelves, plastic shelving and cabinets of supplies, and case carts of clean instruments. Patient and surgical equipment were stored in the area. There were spare batteries, video equipment and other electrical equipment in the area. There were surgical supplies on five wire shelving units, clean instruments wrapped in green bundles approximately 10 x 18 inches in size, and shelves with patient gowns. There was a rack with approximately 15 lead aprons hanging from it and a clean linen cart. The area was greater than 50 square feet in size and was not protected with smoke resisting partitions or a self-closing door.

On 3/7/12 at 11:12 a.m., most of the above items remained stored in the hallway outside of OR 8. During an interview on 3/7/12, at 11:13 a.m., LN10 and the Compliance/Privacy Officer stated that this area was used for "overflow storage."

7. At 10:01 a.m., there were quantities of combustible supplies stored outside of OR 3. The area contained a row of five wire shelving units with paper and plastic wrapped supplies, instruments, and surgical supplies on shelves. There were case carts of clean instruments, and patient and surgical equipment were stored in the area. There were surgical supplies and clean instruments wrapped in blue bundles approximately 10 x 18 inches in size on wire shelving units covering most of the wall area. There was a rack with approximately 20 lead aprons hanging from it. The area was greater than 50 square feet in size and was not protected with smoke resisting partitions or a self-closing door.

On 3/7/12 at 11:14 a.m., most of the above items remained stored in the hallway and area outside of OR 3.

On 3/8/12, photos were taken to document the quantity of items stored in the OR suite.

Mall Level 3/6/12
8. At 11 a.m., the door to the gift shop storage area was held open with kick type hardware. The room contained quantities of combustible storage and was greater than 50 square feet in size. The door was equipped with a self-closing device. When the hardware was removed the door closed but failed to latch in three of three tries. The Director of Facilities Management removed three wreath hangers from the top of the door to allow the door to close and latch.


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Outpatient Industrial Therapy - 3/7/12
9. At 9:09 a.m., the file storage room in the outpatient industrial therapy center was observed. The room was approximately 80 square feet and contained more than 20 boxes of papers and files. The door to the file storage room was not equipped with a self-closing device.

Based on observation the facility failed to ensure exits are accessible at all times, as evidenced by two exits that were blocked during the survey. This failure could result in the inability of patients and staff to exit, in the event of a fire or other emergency. This affected one of four levels in the main hospital.

Findings:

During the facility tour with facility staff, on 3/6/12, the exits on the Mall Level were observed.

At 8:38 a.m., the left side door in the Emergency Room inner hallway was obstructed. A housekeeping cart obstructed the door from opening

At 10:47 a.m., there was an exit sign posted above the right door exiting from the admitting office area. The door was locked and could not be opened to exit from the office.

Based on observation and interview, the facility failed to maintain their emergency lighting in accordance with NFPA 101. This was evidenced by no testing records for testing one battery-powered emergency light fixture. This affected one of three outpatient clinics and could result in the failure of the emergency light, in the event of a power-outage.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a facility tour with staff from 3/5/12 to 3/8/12, the battery-powered emergency lights were observed.

Outpatient Physical Therapy - 3/7/12
At 8:27 a.m., there was a battery-powered emergency light fixture in the hallway of the outpatient physical therapy clinic.

During an interview at 8:28 a.m., Engineering Staff 1 stated that the battery-powered light is not tested monthly or annually.

Based on record review, the facility failed to ensure that fire drills are conducted in accordance with NFPA 101. This was evidenced by one missing NOC shift fire drill, by no transmission of alarms during drills conducted between 6 AM and 9 PM, and by incomplete information on the fire drill reports. This affected five of five floors in the main hospital and three of three offsite clinics. This could result in a delay in staff response in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
21.7.1.2 Fire drills in ambulatory health care facilities 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.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During record review on 3/7/12, the fire drill records were requested for the main hospital and three offsite clinics.

1. At 1:30 p.m., the fire drill records for the main hospital and offsite surgery center were provided. There was no documentation for a NOC shift fire drill conducted at the main hospital during October, November, or December of 2011.

2. At 1:32 p.m., documentation indicated a fire drill was conducted in the surgery department at the main hospital, on 10/24/11 at 2:35 p.m. The document indicated that no alarm was activated during the drill.

3. At 1:34 p.m., documentation indicated a fire drill was conducted in the outpatient surgery center, on 10/5/11 at 1:35 p.m. The document indicated that no alarm was activated during the drill.

4. At 4:29 p.m., documentation for fire drills conducted at the offsite physical therapy center and the offsite industrial therapy center were provided. The documents indicated that coded announcements were used, instead of the transmission of alarms, during the fire drills. There were no descriptions of emergency scenarios, evaluations of staff response, and no indication of which staff members participated in the drills.

Based on observation and interview, the facility failed to maintain their fire alarm system in accordance with NFPA 72. This was evidenced by an obstructed pull station, by one pull station that failed, by alarm notification devices that failed, and by no dates on the sealed-lead acid batteries in the panels. This affected four of five floors and the penthouse in the main hospital and two of three outpatient clinics. This could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Table 7-3.2
6. Batteries d. Sealed-Lead Acid Type 1. Charger Test (Replace battery every 4 years.)

Findings:

During the facility tour with staff, from 3/5/12 to 3/8/12, the fire alarm system was observed and tested.

1. At 2:40 p.m., on 3/6/12, the pull station, in the lobby of the outpatient surgery center, was obstructed by a table and a plant.

Alarm Testing - 3/7/12
2. At 1:54 p.m., a smoke detector in the 3 North department on Level 3 was activated. The strobe of the alarm notification device, in the 3 South public restroom, failed to illuminate.

3. At 2:01 p.m., on a pull station in the 3 South department on Level 3 was activated. The alarm notification device next to Room 3103 failed to chime.

4. At 2:10 p.m., the waterflow alarm on Level 4 was activated. The alarm notification device, in the corridor right outside 4 North, failed to chime.

5. At 2:20 p.m., on 3/8/12, the pull station next to the door in Mechanical Room 413, in the penthouse, was tested. No alarm devices were activated when Engineering Staff 1 pulled the alarm. Engineering Staff 1 adjusted the pull box and tested it again at 2:23 p.m. Alarm devices were activated during the second attempt. Engineering Staff 2 tested the pull box for a third time at 2:24 p.m. It took approximately 47 seconds, and adjustment of the pull box by Engineering Staff 1, until the alarm notification devices activated.

During an interview at 2:26 p.m., Engineering Staff 1 stated that the pull box needed repair.

Outpatient Therapy - 3/8/12
5. At 8:35 a.m., the dialer for the smoke detection system was observed in the outpatient industrial therapy center. The dialer activates a call to the monitoring company when a fire alarm device is activated. There was no date of installation indicated on the sealed-lead acid battery in the dialer.





21026

Garden Level - 3/5/12
6. At 3:12 p.m., the batteries in the fire alarm control panel were dated 8/21/07. The batteries should have been replaced in August of 2011.

7. On 3/7/12, at 7:10 a.m., there was no date on the batteries in the fire alarm control panel in the surgery center. There was no indication of when the batteries should be replaced.

Alarm Testing - 3/7/12
8. At 11:35 a.m., a smoke detector was activated on One South. There was no audible chime for the chime strobe device located at Patient Room 1120.

9. At 1:52 p.m., an alarm device was activated on Level 2. There was no audible chime for the chime strobe device located at Patient Room 2108.

10. At 2:04 p.m., a pull station was activated on Level 3, at the Nurses' Station. There was no audible chime for the chime strobe device located outside of the Nurses' Station, across from Patient Room 3230.

11. At 2:09 p.m., a smoke detector was activated on Level 4, at the elevator lobby. There was no audible chime for the chime strobe device located at the soiled utility room at the main corridor.

12. From 2:13 p.m. through 2:19 p.m., fire alarm devices were activated on Level 4. There was no audible chime for the chime strobe device at the occupational and physical therapy doors. There was no audible chime for the chime strobe device at Room 4218. There was no audible chime for the chime strobe device at the dining room.

13. At 2:48 p.m., there was no audible trouble alarm at the fire alarm control panel when the tamper alarm was tested, at the O S & Y valves.

Based on observation, record review, and interview, the facility failed to ensure that smoke detectors are maintained in accordance with NFPA 72. This was evidenced by no records for testing smoke detectors and no records for sensitivity testing for the detectors, in one of three outpatient clinics. This could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Findings:

During the facility tour with staff from 3/7/12 to 3/8/12, the smoke detection system was observed in the outpatient industrial therapy center.

At 9:26 a.m., on 3/7/12, four hard-wired smoke detectors and two single station smoke detectors were observed in the facility. Records for testing the detectors were requested.

During an interview at 9:27 a.m., the director of the outpatient clinic stated that he was unsure if the detectors had been tested.
During an interview at 1:15 p.m., Engineering Staff 1 stated that no testing documents were available.

At 8:45 a.m., on 3/8/12, manufacturing testing instructions for the single station smoke detectors were engraved around the test buttons. The manufacturer recommends weekly testing of the smoke detectors. No documents were provided for weekly testing of the single station smoke detectors or for sensitivity testing for the hard-wired detectors.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by escutcheon rings that were not flush to the ceiling, by storage that was less than 18 inches away from a sprinkler deflector, by no trouble signal during testing of the tamper alarm, by missing spare sprinkler heads, and by no documentation for quarterly inspections at one of three offsite clinics. This affected five of five floors at the main hospital and one of three offsite clinics. This could result in a delay in extinguishing a fire, in the event of a fire.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition.
3-2.9.3 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:
(1) For systems having less than 300 sprinklers, not fewer than six sprinklers
(2) For systems with 300 to 1000 sprinklers, not fewer than 12 sprinklers
(3) For systems with over 1000 sprinklers, not fewer than 24 sprinklers

5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. At minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or temperature exceeding 100?F (38?C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

4.3.1 Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request.

9-5.1 Inspection and Testing of Sprinkler Pressure Reducing Control Valves. Sprinkler pressure reducing control valves shall be inspected and tested as described in 9-5.1.1 and 9-5.1.2.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

Findings:

During the facility tour with staff from 3/5/12 to 3/8/12, the automatic sprinkler system was observed and maintenance documents were requested.

Garden Level - 3/5/12
At 10:47 a.m., the escutcheon ring was missing above the Pepsi machine in the cafeteria.
At 1:55 p.m., the sprinkler and escutcheon ring were corroded in the housekeeping closet near Conference Room 4. The sprinkler had turned blue/green.
At 3:05 p.m., the box of spare sprinklers was observed in the fire pump room. There were two upright sprinkler heads, six pendant sprinkler heads and two side wall type sprinkler heads in the box with a wrench.

During an interview at 3:07 p.m., Maintenance Staff 1 reported there were no other sprinklers on site.

During an interview on 3/6/12, at 2:30 p.m., Maintenance Staff 1 reported that they had consulted with the vendor for the sprinkler system. He determined that the facility should have 24 spare sprinklers available.

3/5/12
At 3:40 p.m., the escutcheon ring was missing in the Cath Lab staff area.

At 3:47 p.m., the escutcheon ring was missing in the bathroom in the Cath Lab sleep room.

Mall Level - 3/6/12
At 10:30 a.m., the sprinkler cap was missing in the main lobby, near the smoke barrier doors to the ER/Outpatient corridor.

During fire alarm testing on 3/7/12, the valves were closed at the O S & Y(outside screw and yolk) located behind the hospital. Closing a valve shuts off the water to the sprinkler system and should activate a tamper alarm.

At 2:48 p.m., there was no audible trouble alarm at the fire alarm control panel when the tamper alarm was tested, at the O S & Y valves. Closing one of two valves failed to activate the tamper alarm.


29665

Level 4 - 3/5/12
At 11:19 a.m., there was a leather case stored approximately 11 inches from the sprinkler deflector in the storage closet next to speech therapy.

At 11:44 a.m., the sprinkler head, near the bathroom in Room 4123, had no escutcheon ring, revealing an approximately 2 inch penetration around the sprinkler pipe.

Level 3 - 3/5/12
At 1:52 p.m., there was an approximately 1/2 inch gap between the escutcheon ring and the ceiling, in the bathroom of Room 3119.

At 1:56 p.m., there was an approximately 1 inch gap between the escutcheon ring and the ceiling, in the bathroom of Room 3122.

Level 1 - 3/6/12
At 10:54 a.m., the escutcheon ring was missing, in the corridor near Room 1116, revealing an approximately 1 inch penetration around the sprinkler pipe.

Outpatient Physical Therapy - 3/7/12
At 8:35 a.m., there was an approximately 1 inch gap between the escutcheon ring and the ceiling, in the IT Closet at the outpatient physical therapy clinic.

At 8:40 a.m., there were no spare sprinkler heads or wrench observed at the outpatient physical therapy clinic.

During an interview at 8:42 a.m., Engineering Staff 1 was unsure if there were spare sprinkler heads at the facility or where they were stored.

At 8:45 a.m., the sprinkler system at the outpatient physical therapy clinic could not be tested. Staff did not know where the test valves were located.

During record review, at 4:42 p.m., the facility provided records for testing the sprinkler system at the outpatient physical therapy clinic. The document indicated that a 5 year inspection of the sprinkler system was conducted by a vendor on 3/7/12, the day of the survey. No documents for the previous 5 year inspection or quarterly testing of the sprinkler system were provided.

During an interview at 7:59 a.m., on 3/8/12, Engineering Staff 1 stated that no other documents for testing the sprinkler system at the outpatient physical therapy clinic were available.

Based on observation, the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This was evidenced by fire extinguishers that were not secured, by fire extinguishers that were obstructed, and by fire extinguishers that were missing monthly checks. This affected two of five floors of the main hospital and two of three outpatient facilities. This could result in a delay in extinguishing a fire.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location.

1.6.10 Fire extinguishers having a gross weight not exceeding 40 lbs (18.4 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight of more than 40 lb (18.4 kg) (except wheel type) shall be so installed that the top of the fire extinguisher is not more than 3.5 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in (10.2 cm).

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.
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.

Findings:

During the facility tour with staff from 3/5/12 to 3/8/12, the fire extinguishers were observed at the main hospital and in three offsite clinics.

Garden Level - 3/5/12
At 3:06 p.m., there were 22 fire extinguishers located in the fire pump room. The extinguishers were unsecured and sitting on the floor. The tags on the extinguishers indicated they were certified in 8/2011. There were no monthly checks noted for any of the extinguishers.

During an interview at 3:07 p.m., Staff 1 reported that the spare extinguishers are stored in the fire pump room. He stated that they do not check them monthly when they are not in use.


29665

Level 2 - 3/6/12
At 8:26 a.m., the fire extinguisher, in the 2 North supply room, was obstructed by two tall trash receptacles.

Surgery Center - 3/6/12
At 3:00 p.m., the fire extinguisher was obstructed by a chair, in Operating Room 3 at the offsite surgery center.

Offsite Physical Therapy - 3/7/12
At 8:29 a.m., the tag on the hallway fire extinguisher, indicated that it was annually serviced in August of 2011. There were two monthly checks recorded on the tag dated 1/24/12 and 2/24/12. The tag indicated that no monthly checks were conducted in September, October, November, and December of 2011.

Based on observation and interview, the facility failed to ensure the means of egress were free of all obstructions, as evidenced by obstructions in one exit corridor. This affected one of five floors in the main hospital and could result in delayed evacuation, in the event of a fire.

Findings:

During a facility tour with staff from 3/5/12 to 3/8/12, the exit corridors were observed.

Garden Level
At 4:50 p.m., on 3/5/12, there were five dietary carts parked in the exit corridor across from the kitchen.

At 8:15 a.m., on 3/6/12, there were six dietary carts parked in the exit corridor across from the kitchen.
At 12 p.m., there were 3 food carts parked in the exit corridor across from the kitchen.

During an interview at 8:17 a.m., the dietary manager stated that carts are cleaned out around 9 p.m. and used the following morning. He stated that carts are stored in the corridor when they are not in use.

Based on observation, the facility failed to ensure that the capacity of soiled linen, stored within a 64 square foot area, does not exceed 32 gallons in rooms not protected as hazardous areas. This was evidenced by full and partially full soiled linen bins stored side by side in rooms or areas not protected as hazardous areas. This affected three of five floors of the main hospital and two of four suites on the mall level. This could result in an increased risk of a fire.

Findings:

During a facility tour with staff from 3/5/12 to 3/8/12, soiled linen bins were observed at the main hospital and three of three outpatient clinics.

Level 4 - 3/5/12
At 11:39 a.m., there was a full 32-gallon soiled linen bin stored in Room 4129. The soiled linen bin was approximately 1 foot away from approximately 16 gallons of soiled isolation gowns. The door to the room was not equipped with a self-closing device.






21026

Lab area - 3/5/12
At 12:02 p.m., there were two trash bins, greater than 20 gallons, and two 18 gallon biohazard bins, in the alcove adjacent to the care coordinator's office. Other combustible storage was located in the alcove. The area was not protected with a door.

Mall Level - 3/6/12
At 8:55 a.m., there was a 55 gallon trash can placed in the emergency room (ER) inner hallway. The trash can was adjacent to a housekeeping cart with trash and cleaning supplies. There was no staff in the immediate area. ER staff tried to locate a housekeeping staff. No housekeeping staff were present in the ER.

At 9:03 a.m., there were two approximately 30 gallon soiled linen bins placed side by side in the west ER cubical area. There were two approximately 20 gallon trash receptacles within 8 feet of the soiled linen bins.

At 9:15 a.m., there were three soiled linen bins, side by side, against the interior wall of the endoscopy area. There was a dirty pillow receptacle within approximately 2 inches of the soiled linen bins.

At 9:35 a.m., there were two approximately 30 gallon soiled linen bins in front of the PACU Nurses' Station. An approximately 23 gallon trash can was placed between the soiled linen bins. All three were within a 64 square foot area.

At 9:57 a.m., there were two bins, greater than 85 gallons, in the sub corridor exiting from Operating Rooms 4 and 5, to the main corridor. During an interview at 9:58 a.m., OR staff reported the bins were for soiled linen and trash. In the same area there were two 64 gallon recycle receptacles and two 32 gallon biohazard receptacles.

The exterior corridor door is self-closing. The interior doors are convenience doors. They do not self-close or latch.

Based on observation and interview, the facility failed to maintain their electrical wiring in accordance with NFPA 70. This was evidenced by appliances plugged into multi-plug adaptors, by multi-plug adaptors plugged into other multi-plug adaptors, by extension cords used as permanent wiring, by obstructions in front of electrical panels, and by no cover plates on electrical boxes. This affected four of five floors in the main hospital and could result in an increased risk of an electrical fire.

NFPA 70, National Electric Code, 1999 Edition.
110-26
(a)Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

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

400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.


Findings:

During the facility tour with staff from 3/5/12 to 3/8/12, the electrical wiring and equipment was observed at the main hospital and three offsite facilities.

Level 3 - 3/5/12
At 2:26 p.m., there was a microwave plugged into a six-plug surge protector in Room 3201 on Level 3.

Level 2
At 3:15 p.m., there was no cover plate on an electrical box with a cable, in the satellite pharmacy room, on 2 South

At 3:25 p.m., there was a six-plug surge protector plugged into a 4-plug surge protector in the clinical education office.

At 3:35 p.m., there was a 6-plug surge protector plugged into a 6-plug surge protector in the cogent healthcare office.

At 9:06 a.m., on 3/6/12, there was no cover plate on an electrical box in the telephone room across from the ICU waiting room.

During an interview on 3/6/12, at 9:07 a.m., Engineering Staff 1 confirmed that wires in the electrical box were exposed. He stated that the electrical box was connected to a telephone that was removed approximately one year ago.










21026

Garden Level - 3/5/12
At 10:45 a.m., computer equipment was connected to a surge protector plugged into a surge protector, in the Credit Union office area.

At 11:24 a.m., the electrical panel (GEC3D), in the IT Computer Room, was missing two blanks. Two panels, GEC3D and GNC, were obstructed by a table holding plastic cases. The table was approximately 5 inches from the table and plastic cases. The door could not be opened without knocking over the plastic cases.

At 2 p.m., there was a surge protector plugged into a surge protector in the Transformational Care Office.

At 2:50 p.m., a refrigerator was plugged into a surge protector in the Materials Management area.

At 3 p.m., there was an extension cord attached to the wall, above the doors, in the plumber's room. There was a yellow, heavy duty splicer connecting a surge protector to the extension cord. The extension cord connected devices on one side of the room to the wall outlet on the opposite side of the room.

Mall Level - 3/6/12
At 10:45 a.m., a refrigerator was connected to a surge protector in the clinical education office.

At 11:07 a.m., a surge protector was plugged into an extension cord, in the back wall cubical area, in Human Resources.

At 11:11 a.m., a surge protector was connected to a surge protector in the computer kiosk area, in Human Resources.