HospitalInspections.org

Based on observation and interview, the facility failed to maintain their occupancy separation. This was evidenced by the failure of the fire-rated occupancy separation door to close upon activation of the fire alarm system on the B Side. This was also evidenced by the failure of the occupancy separation door to fully close once released from its hold-open device. This affected one of seven smoke compartments on the I Side and one of seven smoke compartments on the B Side. This could result in the faster spread of smoke and fire between the occupancies.

NFPA 101, Life Safety Code, 2012 Edition.
19.1.3.3 Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
(3) For other than previously approved occupancy separation arrangements, the entire building is protected throughout
by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

8.4.3 Opening Protectives.
8.4.3.1 Doors in smoke partitions shall comply with 8.4.3.2 through 8.4.3.5.
8.4.3.2 Doors shall comply with the provisions of 7.2.1.
8.4.3.3 Doors shall not include louvers.
8.4.3.4 Door clearances shall be in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
8.4.3.5 Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.

7.2.1.8.1 A door leaf 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, unless otherwise permitted by 7.2.1.8.3.

7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the
authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria
are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair.

Findings:

During fire alarm testing with Maint1, Maint2, Maint4, and SV1 on 2/9/17, the fire doors were observed. The I Side of the facility contained the Emergency Department, Medical Surgical Unit, Critical Care Unit, Labor and Delivery, and the Surgical Suite. The B Side of the facility contained the main lobby, admissions, gift shop, laboratory, Radiology Department, Physical Therapy, cafe, and kitchen. Both sides were protected by the same fire alarm system. The system was installed such that activation of initiation devices on the B Side did not activate the notification devices on the I Side and vice versa. The fire doors and smoke barrier doors of the facility were held open by electronic devices connected to the fire alarm system.

1. At 7:39 a.m., on 2/9/17, SV1 tested the B West Inspector's Test Valve (ITV) and the fire alarm system was activated on the B Side. The fire door between the I Side and B Side, near the hospital's main entrance, failed to release from its electronic hold open device. The door was labeled as being part of the 2-hour occupancy separation between both sides of the facility.

At 8:02 a.m., on 2/9/17, Maint1 tested a fire pull station in the main lobby, located in the B Side, but the fire door in the occupancy separation failed to release from its electronic hold open device.

Activation of fire alarm devices on the B Side failed to close the occupancy separation door and could result in the faster spread of smoke and fire from the B Side to the I Side.

2. At 7:56 a.m., on 2/9/17, Maint1 tested a fire pull station in the I Side waiting area, near the occupancy separation fire door, and the door released from its electronic hold open device. The door failed to fully close and remained approximately 2 inches ajar.

During an interview at 7:57 a.m., Maint1 stated that this may be due to an air balance issue.

Based on record review and interview, the facility failed to maintain their laboratory. This was evidenced by no records of fire prevention procedures specific for the laboratory, by the failure to correct deficiencies noted during an inspection of the pathology fume hood, and by the failure to inspect the nuclear medicine fume hood since 2014. This affected two of seven smoke compartments on the B Side. This could result in the increased risk of a hazardous condition and a delay in extinguishing a fire in the laboratory.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.2.2 Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.

NFPA 99, Health Care Facilities Code, 2012 Edition.
15.4 Laboratories. Laboratories using chemicals shall comply with NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, unless otherwise modified by other provisions of this code.

NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, 2011 Edition.
6.6.1 Fire Prevention Procedures.
6.6.1.1 Fire prevention procedures shall be established.
6.6.1.2 Certain critical areas shall require special consideration, including, but not limited to, the following:
(1) Handling and storage of chemicals, flammable and combustible liquids, and gases
(2) Open flame and spark-producing equipment work permit system
(3) Arrangements and use of portable electrical cords
(4) Smoking area controls

6.6.2 Maintenance Procedures. Maintenance procedures shall be established.

6.6.3 Emergency Plans.
6.6.3.1 Plans for laboratory emergencies shall be developed, which shall include the following:
(1) Alarm activation
(2) Evacuation and building re-entry procedures
(3) Shutdown procedures or applicable emergency operations for equipment, processes, ventilation devices, and
enclosures
(4) Fire-fighting operations
(5) Non-fire hazards
(6) Information as required by the AHJ to allow the emergency responders to develop response tactics.

6.6.3.2 Procedures for extinguishing clothing fires shall be established.

8.2.5 Exhaust and supply systems shall be designed to prevent a pressure differential that would impede egress or ingress when either system fails or during a fire or emergency scenario. This design includes reduced operational modes or shutdown of either the supply or the exhaust ventilation system.

8.3.2 The location and configuration of fresh air intakes shall be chosen so as to avoid drawing in chemicals or products of combustion coming either from the laboratory building itself or from other structures and devices.

8.4.6 Chemical fume hood face velocities and exhaust volumes shall be sufficient to contain contaminants generated within the hood and exhaust them outside of the laboratory building.

8.4.7 The hood shall provide containment of the possible hazards and protection for personnel at all times when chemicals are present in the hood.

8.13 Inspection, Testing, and Maintenance.
8.13.1 When installed or modified and at least annually thereafter, chemical fume hoods, chemical fume hood exhaust systems, and laboratory special exhaust systems shall be inspected and tested as applicable, as follows:
(1) Visual inspection of the physical condition of the hood interior, sash, and ductwork (see 7.5.3)
(2) Measuring device for hood airflow
(3) Low airflow and loss-of-airflow alarms at each alarm location
(4) Face velocity
(5) Verification of inward airflow over the entire hood face
(6) Changes in work area conditions that might affect hood performance.

8.13.2 Deficiencies in hood performance shall be corrected, or one of the following shall apply:
(1) The activity within the hood shall be restricted to the capability of the hood.
(2) The hood shall not be used.

8.13.3 Chemical fume hood face velocity profile or hood exhaust air quantity shall be checked after any adjustment to the ventilation system balance.

8.13.4 Detectors and Alarms.
8.13.4.1 Air system flow detectors, if installed, shall be inspected and tested annually.

8.13.4.2 Where potentially corrosive or obstructive conditions exist, the inspection and test frequency shall be increased.

8.13.5 Fans and Motors.
8.13.5.1 Air supply and exhaust fans, motors, and components shall be inspected at least annually.

8.13.5.2 Where airflow detectors are not provided or airflow rate tests are not made, fan belts shall be inspected quarterly; double sheaves and belts shall be permitted to be inspected semiannually.

Findings:

During a facility tour with staff from 2/7/17 to 2/10/17, the laboratory safety protocols and fume hood inspection records were requested.

1. At 7:45 a.m., on 2/7/17, the laboratory safety procedures, including for fire emergencies and hazardous chemical spills, were requested. No lab specific fire response or emergency protocols were provided during the survey.

During an interview at 3:59 p.m., on 2/9/17, Maint1 stated that the lab director was not at the facility during the survey and the documents were not available.

Staff in the laboratory did not know the fire response procedures. (See K711)

2. At 11:46 a.m., on 2/7/17, the radioisotope fume hood in the nuclear medicine room had a sticker that indicated that it was last inspected in 2014. The hood was running.

During an interview at 11:27 a.m., on 2/7/17, Rd1 stated that they no longer used the hood and only have the negative pressure checked in the room instead of certifying the hood.

During an interview at 12:25 p.m., on 2/8/17, Maint1 confirmed that the nuclear medicine hood was no longer inspected. He said that the radiology staff used to do a certain blood test in that hood that they no longer do. He stated that they keep it on because it is part of the negative pressure of the room.

3. At 1:03 p.m., on 2/8/17, records of an inspection of the pathology hood, dated 12/21/16, were provided. Notes from the hood certifier stated, "Filter alarming intermittently. Recommend replacement. Please let us know if you would like us to order and replace. We recommend that the back panel where the air slots are free and clear of paper." The vendor indicated that the air inlets in the back of the hood were obstructed by paper and that the filter saturation alarms were periodically activated.

During an interview at 1:04 p.m., Maint1 stated he was unaware of the deficiencies noted in the report.

At 1:23 p.m., on 2/9/17, Maint1 provided a proposal from the certifier dated 2/9/17 to replace the filters.

Based on record review and interview, the facility failed to maintain a safe environment in their anesthetizing locations. This was evidenced by the failure to ensure that their policy for maintaining relative humidity (RH) between 20% and 60% was compatible with the safety guidelines of equipment used in the OR. This was also evidenced by the failure to perform corrective actions when RH levels fell below 20% on days with surgeries. This affected four of four ORs and could result in the increased risk of an OR fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.1.1.1.3 General. The provisions of Chapter 4, General, shall apply.

4.5.8 Maintenance. 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 maintained, unless the Code exempts such maintenance.

4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

On 2/20/15, CMS released memorandum S&C: 15-27-Hospital, CAH & ASC titled "Potential Adverse Impact of Lower Relative Humidity (RH) in Operating Rooms (ORs)." The memorandum stated:

"The Centers for Medicare & Medicaid Services (CMS) previously issued a categorical waiver via S&C 13-25-LSC & ASC, which permits hospitals and CAHs with new and existing ventilation systems supplying anesthetizing locations to operate with a RH level of 20 % or greater in accordance with American Society for Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities." It also stated "Subsequently it has come to light that an RH level <30% is not compatible with the instructions for use (IFUs) for some sterile supplies and electro-medical equipment used in operating rooms" and "The CMS expects hospitals, CAHs and ASCs to follow the current IFUs for supplies and equipment used in their ORs. Failure to adhere to the IFUs must be cited, even if the facility has opted to use the categorical waiver of the LSC RH requirements. Citations would fall under §482.41(c)(2) for hospitals, §485.623(b)(1), for CAHs, and §415.44(a)(1) for ASCs."

Findings:

During record review with staff from 2/7/17 to 2/10/17, policies for maintaining the RH in the OR, the OR temperature/humidity logs, and the OR equipment IFUs were requested.

1. At 10:56 a.m., on 2/7/17, Maint3 showed the centralized computer system used by the Facilities Department to monitor temperature and humidity levels in the ORs. According to the system, the set point and ambient temperature for OR 1 was 63 degrees Fahrenheit, 5 degrees below the low point of the 68 to 72 degrees Fahrenheit range allowed per the facility's policy. Ambient temperature in OR 2 was 65 degrees Fahrenheit and was 65.5 degrees Fahrenheit in OR 3. There was a legend on the screen that indicated certain colors can show different conditions of the system like red for "alarm" and orange for "fault." No alarm conditions were exhibited.

During an interview at 10:57 a.m., on 2/7/17, Maint3 confirmed that the temperature was out of range. He stated that the surgeons always complain about the ORs being too hot. He said he was unsure if any alarm set points have been programmed into the system.

During an interview at 3:36 p.m., on 2/7/17, Maint3 stated that he records the temperature and humidity values into a paper log once a day anytime between 7 a.m. to 3:30 p.m. but usually in the mornings. He stated that the HVAC vendor confirmed that the system had a capability to exhibit alarms when the OR conditions were out of range but no alarm set points have been programmed into their system yet.

2. During an interview at 3:41 p.m., on 2/7/17, LN13 stated that maintenance staff were responsible for checking temperature and humidity in the OR but she checks the thermostat for temperature. She did not mention checking the humidistats (which show the ambient RH levels in each OR) and said she was not sure what the required humidity levels in the OR were.

During an interview at 3:42 p.m., on 2/7/17, LN14 confirmed that only maintenance staff were checking the temperature and humidity levels in the ORs.

During an interview at 10:45 a.m., on 2/8/17, LN12 stated that she did not know the required temperature and humidity ranges in the ORs without looking at the policy. She said that maintenance staff were responsible for maintaining the OR temperature and humidity levels.

3. The facility failed to ensure that the OR conditions were monitored in a reliable manner. Per the handwritten humidity and temperature logs created by maintenance, the humidity levels fell below 20% and no corrective actions were recorded:

a. OR 1: the humidity was recorded as 17% on 12/18/16 and no corrective action was recorded.

b. OR 2: the humidity was recorded as 18.6% on 12/18/16 and no corrective action was recorded.

c. OR 3: the humidity was recorded as 18.5% on 12/3/16, the humidity was recorded as 19.2% on 12/17/16, and the humidity was recorded as 12.7% on 12/18/16. No corrective actions were recorded.

d. OR 3: the humidity was recorded as 18.4% on 11/30/16 and a note next to the date stated "notified OR. Check in 24 hours" but no follow up humidity reading or specific corrective action was recorded. It was unclear if the note was regarding the temperature or humidity since both were out of range.

e. OR 3: the humidity was recorded as 17.4% on 10/8/16 and a note next to the date stated "notified OR. Check in 24 hours. Turn temperature up" but no follow up humidity reading was recorded. It was unclear if the note was regarding temperature or humidity levels since they were both out of range.

f. OR 4: the humidity was recorded as 18% on 12/3/16 and as 15.4% on 12/18/16. No corrective actions were recorded for both dates.

4. At 8:37 a.m., on 12/9/17, maintenance staff showed electronic graphs of previous humidity trends in the ORs from their computer system. Cross-referencing the graphs and the surgery schedule showed that the humidity levels fell below 20% during surgeries as listed below:

a. OR 1, 12/20/16: the graph showed that the humidity was 19.63% at 1040 a.m. and dipped to 5.5% by 2:20 p.m. The surgery schedule showed that a procedure was performed in OR 1 that day.

b. OR 1, 11/18/16: the graph showed that the humidity was 19.67% at 8:44 a.m. and dipped to 16.61% by 12:24 p.m. The surgery schedule showed that two procedures were performed in OR 1 that day, one at 7:30 a.m. and a second at 10:00 a.m.

c. OR 2, 12/20/16: the graph showed that the humidity was 18.75% at 6:57 a.m., gradually dipped to 5% by 1:05 p.m., and increased to 19.46% by 3:32 p.m. The humidity was below 20% for approximately 8 hours and the surgery schedule showed that there were two procedures performed in OR 2 that day.

d. OR 2, 12/19/16: the graph showed that the humidity was 16.73% at 7:38 a.m. and went down to 15.43% at 12:32 p.m. The surgery schedule showed that there were three procedures performed in OR 2 that day with start times of 7:30 a.m., 9:00 a.m., and 10:00 a.m.

e. OR 2, 11/18/16: the graph showed that the humidity was 19.81% at 11:41 a.m. and dropped to 14.36% by 2:08 p.m. The surgery schedule showed that there was a procedure performed with the start time of 11:30 a.m. that day.

f. OR 3, 12/19/16: the graph showed that the humidity had gradually decreased from the day before down to 13.72% at 6:34 a.m. and increased to 19.69% by 12:40 p.m. The surgery schedule showed that there were three procedures performed in OR 3 that day starting at 7:00 a.m., 7:15 a.m., and 8:30 a.m.

g. OR 4, 12/19/16, the graph showed that the humidity was 17.32% at 9:00 a.m. and continued to go in an out of range until the next day. The surgery schedule showed that there were seven procedures performed in OR 4 on 12/19/16.

h. OR 4, 11/18/16, the graph showed that the humidity was 19.5% at 9:57 a.m. and decreased to 10.75% by 12:24 p.m. The surgery schedule showed that there was a procedure performed in OR 4 that began at 9:30 a.m.

Surgeries were performed when humidity levels were below 20%.

5. At 11:20 a.m., on 2/8/17, the "Temperature and Humidity in the Perioperative Department" policy dated 9/16 was provided. Under the "Background" heading, the policy stated that generally acceptable relative humidity levels were between 30 to 60 % but that new standards are in process to decrease the relative humidity to 20%. The background information section also included this sentence "older equipment may not be optimal at that level." Under the "Procedure" section, the policy stated that maintenance were to note the humidity levels daily and the acceptable parameters were 20 - 60%. Part C of the "Procedure" section stated that the facility would follow the "manufacturer's instructions for use relating to relative humidity and temperature."

During an interview at 12:39 p.m., on 2/8/17, Maint1 stated that he would need to track down the IFUs for the equipment used in the ORs. He stated that the facility was going by the 20 to 60% humidity range.

At 3:20 p.m., on 2/9/17, the IFU for the lithotripsy laser machine indicated that the operating conditions included an RH level from 30 to 60%.

IFUs for the anesthesia machines and the laser were provided but none were provided for the rest of the equipment.

The facility failed to review all the equipment IFUs, in accordance with CMS guidelines and their policy, before implementing an OR humidity range of 20 to 60%.

6. At 12:00 p.m., on 2/8/17, the temperature and humidity logs kept by maintenance staff were provided for the four ORs. Review of the last three months showed days where the humidity fell below 30% which may not have been compatible with all equipment IFUs:

a. OR 1: the humidity fell below 30% during 4 of 31 days in January 2017, during 8 of 31 days in December 2016, and during 2 of 31 days in October 2016.

b. OR 2: the humidity fell below 30% during 7 of 31 days in January 2017, during 8 of 31 days in December 2016, during 1 of 30 days in November 2016, and during 2 of 31 days in October 2016.

c. OR 3: the humidity fell below 30% during 14 of 31 days in January 2017, during 17 of 31 days in December 2016, during 8 of 30 days in November 2016, and during 5 of 31 days in October 2016.

d. OR 4: the humidity fell below 30% during 8 of 31 days in January 2017 and during 14 of 31 days of December 2016.

The facility failed to ensure that humidity levels less than 30% were compatible with the equipment used in the OR.

Based on observation, record review, and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by grease filters that were not tight fitting and required repair. This affected one of two commercial kitchen hoods on the B Side and could result in the increased risk of a grease fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition.
6.2.3.1 Grease filters shall be listed and constructed of steel or listed equivalent material.

6.2.3.2 Grease filters shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions.

6.2.3.3 Grease filters shall be arranged so that all exhaust air passes through the grease filters.

6.2.3.4 Grease filters shall be easily accessible and removable for cleaning.

6.2.5 Grease Filter Orientation. Grease filters that require a specific orientation to drain grease shall be clearly so designated, or the hood shall be constructed so that filters cannot be installed in the wrong orientation.

11.1.5 Listed exhaust hoods shall be operated in accordance with the terms of their listings and the manufacturer's instructions.

Findings:

During a facility tour with staff from 2/7/17 to 2/10/17, the kitchen and the cafe were observed.

1. At 10:00 a.m., on 2/7/17, two of eight filters in the cafe's commercial kitchen hood were not tight fitting. There was an approximately 1 inch clearance across the width of the top of the filters and the inside of the hood was exposed. The two filters were also missing their handles.

During an interview at 10:02 a.m., DDS stated that the filters could be oriented correctly because they were missing their handles which were attached to a lever that holds them in place. He stated that he placed a work order with the facilities department back in January.

At 10:07 a.m., Maint3 was unable to arrange the filters without the presence of the handles.

At 10:11 a.m., DDS provided a copy of the work order sent to Maint1 and Maint2 dated 1/17/17 at 9:16 a.m. The work order stated "the exhaust hood in Cafe needs two of the removable doors fixed - they keep falling out."

Based on observation, record review, and interview, the facility failed to maintain their fire alarm system. This was evidenced by pull stations that were obstructed or obscured from view, by the failure to test smoke alarms in accordance with manufacturer requirements, by no records of smoke detector sensitivity testing for the I Side, and by no records of repairing a deficiency noted during a fire alarm inspection. This affected the seven of seven smoke compartments in the I Side, the service yard, and the outpatient Sleep Disorder Center. This could result in a delay in notification and staff response, in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 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 and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
10.2 Purpose. The purpose of the fire alarm and signaling systems shall be primarily to provide notification of alarm, supervisory, and trouble conditions; to alert the occupants; to summon aid; and to control emergency control functions.

10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

10.16.3.2 All required annunciation means shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.

10.16.4 Alarm Annunciation Display. Visible annunciators shall be capable of displaying all zones in alarm.

10.16.4.1 If all zones in alarm are not displayed simultaneously, the zone of origin shall be displayed.

10.16.4.2 If all zones in alarm are not displayed simultaneously, there shall be an indication that other zones are in alarm.

14.4.5.3 In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7.

14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with
14.4.5.3.3.

14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its
listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.

14.4.5.3.3.2 In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control
unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

14.4.5.3.6 Smoke detectors or smoke alarms listed as field adjustable shall be permitted to either be adjusted within the listed and marked sensitivity range, cleaned, and recalibrated, or be replaced.

14.4.5.3.7 The detector or smoke alarm sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector or smoke alarm.

17.14.5 Manual fire alarm boxes shall be installed so that they are conspicuous, unobstructed, and accessible.

Findings:

During a facility tour with staff from 2/7/17 to 2/10/17, the fire alarm system was observed and maintenance records were requested.

1. At 8:46 a.m., on 2/7/17, access to the manual pull station, in the boiler room of the service yard, was obstructed by carts and barrels.

2. At 9:36 a.m., on 2/7/17, the manual pull station in the I Side waiting room, close to the main entrance, was obscured from view by a fire door that was held open. The pull station was mounted on a wall directly behind the door leaf.

During an interview at 9:37 a.m., Maint2 stated that the door remains open during the day and closes upon activation of the fire alarm system.

3. At 10:04 a.m., on 2/9/17, the interconnected smoke alarms in the outpatient Sleep Disorder Center had manufacturer's instructions etched onto their shells. The instructions stated "push to test weekly." There were no records of testing the detectors weekly.

During an interview at 10:05 a.m., Maint5 stated that he tested them monthly when he does the fire extinguisher inspections. He said he did not know about the weekly testing requirement.

4. At 11:20 a.m., on 2/9/17, records showed that the fire alarm vendor conducted smoke detector and duct detector sensitivity testing for the B Side in October 2016. There were no records of smoke detector sensitivity testing for the I Side devices.

During an interview at 8:57 a.m., Maint1 confirmed with the vendor that they only did sensitivity testing on the B Side. He stated the smoke detectors were self-calibrating. No records were provided to verify that the smoke detectors were self-calibrating and programmed to send a signal to the panel when they were out of their listed sensitivity range.

5. At 1:06 p.m., on 2/9/17, records showed that the fire alarm vendor functionally tested the initiation devices in the I Side on 4/18/16. The vendor indicated that the smoke detector in Room 231 "failed to notify the nurse call." No corrective action records were provided.

During an interview at 8:55 a.m., on 2/10/17, Maint1 said the vendor clarified to him that when a smoke detector goes off in the patient room, it sends a notification signal to the nurse call light system so staff can identify the origin of the alarm. The fire alarm vendor told him that the call light system vendor has the capability to fix it.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinkler heads that were corroded, by sprinkler heads that were missing their escutcheon rings, by storage that was less than 18 inches from sprinkler deflectors, and by sprinkler control valves that were missing identification signs. This was also evidenced by the failure to conduct an internal inspection of the two check valves during the 5-year inspections. Escutcheon rings are part of the list sprinkler assemblies and their absence could delay activation of the sprinklers. Storage too close to the sprinkler deflector can disrupt the sprinkler spray pattern and delay extinguishment of a fire. This affected seven of seven smoke compartments on the I Side and two of seven smoke compartments on the B Side.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 13, Standard for Installation of Sprinkler Systems, 2010 Edition.
8.5.6.1 Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

8.16.1.1.8 Control Valve Identification. Identification signs shall be provided at each valve to indicate its function and what it controls.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
5.2.1.1 Sprinklers shall be inspected from the floor level annually.

5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) Loading
(6) Painting unless painted by the sprinkler manufacturer

5.2.1.2 The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.

5.2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level.

5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion.

13.4.2 Check Valves.
13.4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate correctly, move freely, and are in good condition.

13.4.2.2 Maintenance. Internal components shall be cleaned, repaired, or replaced as necessary in accordance with the manufacturer's instructions.

Findings:

During a facility tour with staff from 2/7/17 to 2/10/17, the sprinkler system was observed and the maintenance records were requested.

1. At 8:55 a.m., on 2/7/17, the two outside screw & yoke (OS&Y) valves and the post-indicator valve (PIV) outside the service yard were missing their identification signs.

During an interview at 8:56 a.m., Maint1 confirmed that these valves controlled the water supply to four of four risers in the entire hospital.

During an interview at 8:22 a.m., on 2/9/17, SV1 was onsite and confirmed that the valves needed signs.

2. At 9:54 a.m., on 2/7/17, six sprinkler heads in the overhang outside of the cafe showed signs of corrosion. The sprinkler heads had were green and brown in color.

3. At 3:00 p.m., on 2/7/17, four of four quarterly inspection records of the sprinkler system, conducted in 2016, contained a note from the vendor dated 9/22/15 that stated, "unable to perform internal check valve inspection due to electrical boxes obstructing face plate. Was able to confirm check valves hold pressure." The note was first mentioned in the 3/23/16 quarterly inspection record and most recently included in the 12/1/16 inspection.

During an interview at 7:49 a.m., on 2/8/17, Maint1 stated that the 5-year inspection was conducted on 9/22/15 and would need to ask the vendor to explain the note on the check valve.

At 11:25 a.m., on 2/8/17, Maint1 showed the check valves on Risers I-West and I-East. The check valves were obstructed by electrical boxes.

During an interview at 11:26 a.m., Maint1 said that the vendor could not inspect the check valves because the bolts of the check valve were blocked by the tamper switch electrical boxes.

During an interview at 8:10 a.m., on 2/9/17, SV1 was onsite and confirmed that the electrical boxes prevented the internal check valve inspection required during the 5-year certification.

4. At 8:51 a.m., on 2/8/17, there was a cardboard box approximately 10 inches from the deflector of a sprinkler head in the mezzanine of the warehouse. The sprinkler did not have 18 inches of clearance. That sprinkler head was also missing an escutcheon ring.

5. At 8:52 a.m., on 2/8/17, there was a cardboard box approximately 11 inches from the deflector of another sprinkler head in the mezzanine of the warehouse. The sprinkler did not have 18 inches of clearance.

6. At 9:21 a.m., on 2/8/17, the sprinkler head in the Emergency Department medication room was missing an escutcheon ring.

7. At 9:23 a.m., on 2/8/17, one sprinkler head in the Emergency Department overhang was missing an escutcheon ring.

Based on observation and interview, the facility failed to maintain their fire extinguishers. This was evidenced by one fire extinguisher along a normal path of travel that was removed. This affected one of seven smoke compartments on the B Side and could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition.
6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.

6.1.3.2 Fire extinguishers shall be located along normal paths of travel, including exits from areas.

6.2.1.2 Fire extinguishers shall be located so that the maximum travel distances shall not exceed those specified in
Table 6.2.1.1, except as modified by 6.2.1.4. (See Annex E.)

Table 6.2.1.1 Fire Extinguisher Size and Placement for Class A Hazards
Maximum travel distance to extinguisher 75 ft

Table 6.3.1.1 Fire Extinguisher Size and Placement for Class B Hazards

6.4 Installations for Class C Hazards.
6.4.3 Because fire is a Class A or Class B hazard, the fire extinguishers shall be sized and located on the basis of the anticipated Class A or Class B hazard.

Findings:

During a facility tour with staff from 2/7/17 to 2/8/17, the fire extinguishers were observed.

1. At 11:34 a.m., on 2/7/17, the fire extinguisher cabinet in the egress corridor, outside the MRI room, was empty. There was a note on the cabinet saying that there was an MRI safe extinguisher in the control room. The empty fire extinguisher cabinet was approximately 40 feet from the main Radiology exit door. The closest available fire extinguisher in the egress corridor was more than 78 feet away from the main exit door.

During an interview at 11:35 a.m., Rad1 stated that the extinguisher was removed because a MRI-safe extinguisher was placed inside the MRI control room.

Access to the MRI room and control room was limited and the facility failed to provide a fire extinguisher along the normal path of travel within the minimum travel distances required by NFPA 10.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by one door that was obstructed from closing and by doors that failed to latch. This affected two of seven smoke compartments on the I Side and one of seven smoke compartments on the B Side. This could result in the faster spread of smoke and fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.6.3.5 Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic
sprinkler system in accordance with 19.3.5.7.

Findings:

During a facility tour with staff from 2/7/17 to 2/10/17, the corridor doors were observed. The facility had 1-hour fire-rated corridors and fire-rated corridor doors.

1. At 9:38 a.m., on 2/7/17, the 20-minute fire rated door behind the reception desk was obstructed from closing by a rubber wedge.

2. At 3:27 p.m., on 2/7/17, Room I-309 Storage and Receiving in the sterile corridor was self-closing and 1-hour fire-rated. The door failed to latch.

3. At 3:28 p.m., on 2/7/17, Room I-311 Equipment Storage in the sterile corridor was self-closing and 1-hour fire-rated. The door failed to latch.

4. At 9:10 a.m., on 2/8/17, the public restroom door near the Emergency Department entrance was self-closing and 1-hour fire-rated. The door failed to latch.

5. At 10:39 a.m., on 2/8/17, Room 304A Soiled Hold in the Surgery Department was self-closing and 1-hour fire-rated. The door failed to latch.

Based on interviews and observation, the facility failed to ensure that all staff were aware of their duties and responsibilities in the event of a fire emergency. This was evidenced by staff that were unfamiliar with the emergency fire response procedures and by staff that were unfamiliar with fire safety equipment. This affected patients, visitors, and staff on the B Side and could result in a delay in staff response, in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.

19.7.1.2 All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1.

19.7.1.8 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2 Procedure in Case of Fire.
19.7.2.1 Protection of Patients.
19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.

19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

19.7.2.3 Staff Response.
19.7.2.3.1 All health care occupancy personnel shall be instructed in the use of and response to fire alarms.
19.7.2.3.2 All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system 19.7.2.3.3 Personnel hearing the code announced shall first
activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition.
10.5.7 Instruction shall be provided to employees regarding the proper use of portable fire extinguishers and the manual activation of fire-extinguishing equipment.

NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, 2011 Edition
6.6.3 Emergency Plans.
6.6.3.1 Plans for laboratory emergencies shall be developed, which shall include the following:
(1) Alarm activation
(2) Evacuation and building re-entry procedures
(3) Shutdown procedures or applicable emergency operations for equipment, processes, ventilation devices, and enclosures
(4) Fire-fighting operations
(5) Non-fire hazards
(6) Information as required by the AHJ to allow the emergency responders to develop response tactics

Findings:

During a facility tour with staff from 2/7/17 to 2/10/17, staff were interviewed about the emergency fire response procedures and equipment.

1. During an interview at 10:10 a.m., on 2/7/17, DS2 was asked what he would do in the event of a grease fire. DS2 was the staff closest to the hood inside the kitchen during the interview and was overseeing the food being prepared on the stove. DS2 stated that he knew he would have to use the extinguisher for grease and not the red one. When asked what other steps he would take, he stated he was unsure but would get that information. DS2 arrived approximately 2 minutes later and stated that he would use the pull station for the fire suppression system. He stated that he had to ask his manager about what to do.

2. During an interview at 10:27 a.m., on 2/7/17, Lab1 was asked what she would do in the event of a fire. She said she would follow the steps of the acronym RACE. She stated R stood for "run", A for "alarm", C for "close door", and E for "evacuate". When asked how she would activate the fire alarm, she pointed to a communication panel used internally for the facility. The panel had a "Code Gray" button, "EVS" button, "Staff Assist" button, and "Code Blue" button. She did not know where the fire alarm pull stations were located or where the fire extinguishers were located. When she was pointed towards the fire extinguisher, she did not know the steps to use it.

3. During an interview at 10:29 a.m., on 2/7/17, Lab2 was asked what she would do in the event of a fire. She stated that she would use the designated escape route, announce a "Code Red," and call 911. She did not mention activating the fire alarm, confining the fire, or use of the fire extinguisher.

4. During an interview at 10:36 a.m., on 2/7/17, Adm2 was asked what she would do in the event of a fire. Adm2 was in the medical records office where a large amount of combustibles were stored. She stated that she would activate the pull station, close the door, and call the hospital operator to report a "Code Red." She did not readily know the locations of the pull stations and fire extinguishers. After she was guided to the extinguisher, she said she would have to read the instructions on how to use the extinguisher because she did not know the steps.

5. During an interview at 11:37 a.m., on 2/7/17, Rd2 was asked what she would do in the event of a fire in the MRI room. She stated that she would shut down the equipment and use the MRI-safe extinguisher. She said that she would activate the panel used for internal communications in the facility. The panel had a "Code Gray" button, "EVS" button, "Staff Assist" button, and "Code Blue" button. She said that it depends if the situation was "internal or external" she would use either the facility's panel or the fire alarm pull station. She did not elaborate on what fire situation would prompt the use of the internal panel versus the pull station.

Based on observation and interview, the facility failed to ensure that precautionary NO SMOKING signs were posted at hazardous areas. This was evidenced by the absence of NO SMOKING signs at the main shut off for the natural gas lines and at the diesel generator location. This affected the exterior of the building and could increase risk of a fire near egress pathways and the public way.

NFPA 101, Life Safety Code, 2012 Edition.
19.7.4 Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During a facility tour with staff from 2/7/17 to 2/10/17, the hazardous areas were observed.

1. At 8:50 a.m., at 2/7/17, there was no precautionary "No Smoking" sign at the main emergency shut off for the natural gas lines outside the service yard.

2. At 8:51 a.m., at 2/7/17, there was no precautionary "No Smoking" sign on the generator enclosure. The generator enclosure housed both the generator itself and a 5,000-gallon capacity diesel fuel tank.

During an interview at 8:52 a.m., Maint1 stated that there was a sign on the door to the enclosure but it may have detached due to weather.

Based on observation and interview, the facility failed to maintain their means of egress. This was evidenced by one egress pathway in the surgical suite that was obstructed by a construction barrier. This affected one of three exits from the surgical suite. This could result in a delay in evacuation and the increased risk of injury to surgical patients and staff.

NFPA 101, Life Safety Code, 2012 Edition.
19.7.9.1 Construction, repair, and improvement operations shall comply with 4.6.10.

19.7.9.2 The means of egress in any area undergoing construction, repair, or improvements shall be inspected daily for compliance with 7.1.10.1 and shall also comply with NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition Operations.

7.1.10.1 General. 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.

4.6.10.1 Buildings, or portions of buildings, shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place.

Findings:

During a facility tour with staff from 2/7/17 to 2/10/17, the sterile area of the surgical suite was observed.

1. At 3:24 p.m., on 2/7/17, there was a construction barrier along the entire width of the corridor near OR 4 which obstructed the north exit door of the sterile corridor.

During an interview at 3:25 p.m., Maint3 stated that the barrier was put up on Friday (2/3/17) because the floor in OR 4 was being replaced.

During telephone communication at 4:11 p.m., on 2/7/17, the OSHPD CO stated that replacement of the floors required communication with OSHPD. No OSHPD permit was required but the facility was required to maintain a 6 foot clearance for egress. He stated that the construction barrier should not obstruct the entire width of the egress path.

Based on record review and interview, the facility failed to maintain their piped-in medical gas and vacuum systems. This was evidenced by the failure to inspect the medical gas connections in the MRI room. This affected one of seven smoke compartments in the B Side and could result in the increased risk of a hazardous condition to patients receiving MRI services.

NFPA 99, Health Care Facilities Code, 2012 Edition.
Chapter 5 Gas and Vacuum Systems
5.1.14.2.2.2 Inspection Schedules. Scheduled inspections for equipment and procedures shall be established through the
risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations
and other recommendations as required by the authority having jurisdiction.

5.1.14.2.2.3 Inspection Procedures. The facility shall be permitted to use any inspection procedure(s) or testing methods
established through its own risk assessment.

5.1.14.2.2.4 Maintenance Schedules. Scheduled maintenance for equipment and procedures shall be established through
the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations
and other recommendations as required by the authority having jurisdiction.

5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through
5.1.15 shall be inspected or tested as part of the maintenance program as follows:
(11)Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks

Findings:

During record review from 2/7/17 to 2/10/17, the annual piped-in medical gas system inspection record, dated 6/26/16, was provided and reviewed.

1. At 11:09 a.m., on 2/8/17, the vendor indicated, under the discrepancies section, that the medical gas connections in MRI B-039 could not be checked.

During an interview at 1:20 p.m., on 2/9/17, Maint1 stated that the vendor said he could not access the MRI area at the time of inspection in June. He said that the vendor was scheduled to come inspect the room tomorrow on 2/10/17.

Based on record review, the facility failed to determine their risk category classification in accordance with NFPA 99. This was evidenced by inaccurate assessment of the impact of essential electrical system (EES) failure on critical care rooms. This affected all patients in six of six critical care unit (CCU) rooms and four of four ORs. This could result in a prolonged duration of unsafe conditions due to insufficient assessment of critical building systems.

NFPA 99, Health Care Facilities Code, 2012 Edition.
4.1 Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.

4.1.1 Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code.

4.1.2 Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code.

4.2 Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure.

4.3 Application. The Category definitions in Chapter 4 shall apply to Chapters 5 through 11.

6.3.2.2.10 Essential Electrical Systems (EES).
6.3.2.2.10.1 Critical care rooms (Category 1 Room) shall be served only by a Type I EES.

6.3.2.2.10.2 General care rooms (Category 2 Room) shall be served by a Type I or Type II EES.

6.3.2.2.10.3 A Type I EES serving a critical care room (Category 1 Room) shall be permitted to serve general care rooms (Category 2 Room) in the same facility.

6.3.2.2.10.4 Basic care rooms shall not be required to be served by an EES.

Findings:

During record review from 2/7/17 to 2/10/17, a risk assessment corresponding to the building systems was requested.

1. At 12:54 p.m., on 2/7/17, a risk assessment listing categories in accordance with NFPA 99 was provided by Maint1. The risk assessment categorized CCU Rooms 1 to 6 and ORs 1 to 4 as Category 2 rooms (general care rooms) instead of Category 1 rooms (critical care rooms).

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by the misuse of power strips and extension cords and by flexible cables that were run through an attic access door. This affected one of seven smoke compartments on the I Side, two of seven smoke compartments on the B Side, and the offsite Imaging Center. This could result in the increased risk of an electrical fire.

NFPA 99, Health Care Facilities Code, 2012 Edition.
10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cartmounted, provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment assembly.
(2) The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.
(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.
(4) The electrical and mechanical integrity of the assembly is regularly verified and documented.

NFPA 70, National Electrical Code, 2011 Edition.
400.8 Uses Not Permitted. Unless specifically permitted in 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 to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage.

Findings:

During a facility tour with staff from 2/7/17 to 2/10/17, the electrical wiring was observed.

1. At 10:25 a.m., on 2/7/17, there was an extension cord plugged into a multi-outlet power strip under the reception desk in the laboratory waiting room.

2. At 11:30 a.m., on 2/7/17, there were two flexible cables going through an 18 inch by 18 inch attic access door in the MRI equipment room. One cable was connected to an MRI alarm panel and one was coming from an electrical junction in the floor.

3. At 9:15 a.m., on 2/8/17, the tele-robot charger was plugged into a heavy duty extension cord in the physician's reading room in the Emergency Department.

4. At 10:20 a.m., on 2/9/17, there was a power strip plugged into an extension cord in the employee break room.

Based on observation, the facility failed to maintain their medical gas cylinder storage. This was evidenced by medical gas cylinders that were not securely chained and by medical gas cylinders that were stored adjacent to a flammable liquid and combustibles. This was also evidenced by the absence of required precautionary signs at cylinder storage locations. This affected the service yard and one of seven smoke compartments on the I Side. This could result in the increased risk of a fire and increased risk of injury to patients, visitors, and staff.

NFPA 99, Health Care Facilities Code, 2012 Edition.
Chapter 11 Gas Equipment
11.1 Applicability.
11.1.1 This chapter shall apply to the use, at normal atmospheric pressure, of all of the following:
(1) Nonflammable medical gases
(2) Vapors and aerosols
(3) Equipment required for the administration of 11.1.1(1) and (2)

11.1.2 When used in this chapter, the term oxygen shall be intended to mean 100 percent oxygen as well as mixtures of oxygen and air.

11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.

11.3.2.2 Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.

11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1.2 hour

11.3.2.6 Cylinder or container restraints shall comply with 11.6.2.3.

11.3.2.7 Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 6.1 m (20 ft) of outside storage locations.

11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a facility tour with staff from 2/7/17 to 2/10/17, the medical gas storage was observed.

1A. At 11:07 a.m., on 2/7/17, there were medical gases stored in the trash compactor enclosure of the service yard. There were 6 nitrous oxide H-tanks, 1 nitrous oxide E-cylinder, 4 carbon dioxide H-tanks, and 5 nitrogen H-tanks. The words "FULL" were painted on the wall of the enclosure above the cylinders which indicated that this was a storage location for full medical gas cylinders. There was no precautionary signage outside the enclosure to indicate that nitrous oxide, an oxidizing gas, was stored inside.

1B. At 11:08 a.m., on 2/7/17, the 15 H-tanks and 1 E-cylinder were provided with only one chain for support and the nitrous oxide E-cylinder was not secured at all and could be toppled over. The H-tanks could also be tilted more than 30 degrees.

1C. At 11:09 a.m., on 2/7/17, there were two approximately 20-gallon barrels that were labeled "Xylene" (a flammable liquid) directly against the nitrous oxide tanks. The barrels were full. The facility failed to ensure that flammable liquids were not less than 20 feet from the cylinders in the nonsprinklered enclosure.

2. At 10:29 a.m., on 2/8/17, there were 5 full oxygen E-cylinders and 2 empty oxygen E-cylinders in the General Storage Room of the Medical Surgical Unit. There was no precautionary signage outside the room to indicate that medical gas was stored within.

3. At 10:30 a.m., on 2/8/17, the oxygen cylinders in the General Storage Room were directly adjacent to shelves of storage. The shelves contained equipment that was wrapped in plastic. The facility failed to ensure that combustible storage was not less than 5 feet from the medical gas cylinders.