HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity of the walls and ceiling of the building in a condition that would resist the passage of smoke and fire. This was evidenced by observed unsealed penetrations. This affected three of seven floors at the Merrit Building and three of six floors in the Providence Building, and could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

NFPA 101 Life Safety Code, 2000 edition
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following
conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.


Findings:

During a tour of the facility with engineering staff, walls and ceilings were observed.

Merritt Building
1. On 3/5/12, at 11:20 a.m., Room 4303 had an approximately six inch by six inch ceiling tile that was out of place, creating an approximately two inch by six inch unsealed penetration in the ceiling.
When asked, Engineering Staff 1 confirmed that it was a fire-rated ceiling tile.


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Merritt Building
2. On 3/5/12, at 10:51 a.m., in the Merritt Building on the 5th floor South Wing, in the electrical closet, there was a 3" and a 2" pipe conduit that had not been sealed.
3. At 2:32 p.m., in the Merritt Building on the 1st floor North Wing in Radiology 5, there was a large circular hole above the doorway. The hole was approximately 7" in diameter.

Providence Building
4. On 3/6/12, at 9:50 a.m., in the Providence Building on the 5th floor room 5430, the clock junction box had not been sealed and a 4"X4" penetration in the wall was exposed.
5. On 3/6/12, at 10:55 a.m., in the Providence Building on the 3rd floor in room 3407, there was a cut out square in the sheet rock with two 1" penetrations in the middle.


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Providence Building:
6. On 3/6/12 at 11:58 a.m., there was one approximately four foot by two foot unsealed penetration in the hardtop ceiling of Room L454.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. This affected five of seven floors at the Merritt Building and one of six floors at the Providence Building. The failure of the corridor doors to close and latch could result in the spread of smoke and/or fire into other areas of the facility.

Findings:

During a tour of the facility with Engineering Staff 1, between 3/05/12 and 3/08/12, corridor doors were inspected throughout the facility.

Merritt Building
1. On 3/5/12, at 10:55 a.m., the corridor door to Patient Room 4274 could not be closed when tested by pulling the door shut. The metal door edge was damaged near the bottom of the door preventing it from closing.

2. On 3/5/12, at 10:55 a.m., the corridor door to Patient Room 4278 was impeded from closing by a linen hamper that was stored in the swing area of the door.

3. On 3/5/12, at 10:56 a.m., the corridor door to Patient Room 4254 was impeded from closing by a linen hamper that was stored in the swing area of the door.

4. On 3/5/12, at 10:56 a.m., the corridor door to Patient Room 4258 was impeded from closing by a linen hamper that was stored in the swing area of the door.

5. On 3/5/12, at 10:57 a.m., the corridor door to Patient Room 4266 was impeded from closing by a linen hamper that was stored in the swing area of the door.

6. On 3/5/12, at 10:57 a.m., the corridor door to Patient Room 4242 was impeded from closing by a linen hamper that was stored in the swing area of the door.

7. On 3/5/12, at 10:59 a.m., the corridor door to Patient Room 4234 was impeded from closing by a linen hamper that was stored in the swing area of the door.

8. On 3/5/12, at 11:00 a.m., the corridor door to Patient Room 4226 was impeded from closing by a linen hamper that was stored in the swing area of the door.

9. On 3/5/12, at 11:03 a.m., the corridor door to Patient Room 4222 was impeded from closing when tested by releasing the door from an open position. The metal door edge was damaged near the bottom of the door preventing it from closing.

10. On 3/5/12, at 11:05 a.m., the corridor door to Patient Room 4218 had a door hanger that was hooked over the top of the door. This hanger prevented the door from latching when it was tested by releasing the door from an open position.

11. On 3/5/12, at 11:25 a.m., the 1 1/2 hour fire-rated corridor door to Room 4317 did not positive latch when tested by releasing the door from an open position.

12. On 3/5/12, at 11:44 a.m., the door Lounge 4357 did not close when tested by releasing it from an open position.

13. On 3/5/12, at 1:25 p.m., the corridor door to Electric Room 4033 did not positive latch when tested by releasing the door from an open position.

14. On 3/5/12, at 1:26 p.m., the door to Patient Room 4018 was impeded from closing by a door hanger that was attached to the top of the door. This door could not be pulled shut. Engineering Staff 1 stated that the door hanger was attached to the door incorrectly. There was also a linen hamper that was stored in the swing area of the door that also prevented the door from closing.

15. On 3/5/12, at 1:36 p.m., door 4161 to the Intensive Care Unit 1 Lounge did not positive latch when tested by releasing the door from an open position.



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Merritt Building
16. On 3/5/12 at 10:33 a.m., in the Merritt Building on the 5th floor West Wing room 5052, the door was equipped with a self-closing mechanism and when released the door did not positively latch.

17. On 3/5/12 at 10:37 a.m., in the Merritt Building on the 5th floor West Wing room 5046, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

18. On 3/5/12 at 10:18 a.m., in the Merritt Building on the 5th floor South Wing room 5113, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

19. On 3/5/12 at 10:57 a.m., in the Merritt Building on the 5th floor South Wing room 5113, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

20. On 3/5/12 at 11:00 a.m., in the Merritt Building on the 5th floor South Wing room 5116, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

21. On 3/5/12 at 11:03 a.m., in the Merritt Building on the 5th floor South Wing room 5122, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

22. On 3/5/12 at 11:45 a.m., in the Merritt Building on the 2nd floor North Wing room 2386, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

23. On 3/5/12 at 11:47 a.m., in the Merritt Building on the 2nd floor North Wing room 2372, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

24. On 3/5/12 at 11:48 a.m., in the Merritt Building on the 2nd floor North Wing room 2368, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

Providence Building
25. On 3/6/12 at 9:58 a.m., in the Providence Building on the 2nd floor Eastside room 2520, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.
26. On 3/6/12 at 10:10 a.m., in the Providence Building on the 2nd floor Eastside room 2532, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.


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Merritt Building:
27. On 3/5/12 at 11:16 a.m., the corridor door to the Clean Dumbwaiter Room (Room 3135A) was equipped with an automatic closing device. The door was obstructed from closing by a cart located directly in the swing path of the door.

28. On 3/5/12 at 11:27 a.m., the corridor doors to the Cryogenic Freezer Room, located across from Room 3141, were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of two doors failed to latch. The door was obstructed from latching by the door frame.

29. On 3/5/12 at 11:28 a.m., the corridor door to the Housekeeping Closet (Room 3141) was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to a wad of white mesh stuffed inside the striker plate.

30. On 3/5/12 at 11:32 a.m., the corridor door to Staff Office Room 3103 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a door wedge.

31. On 3/5/12 at 1:28 p.m., the corridor door to Storage Room 3215 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The latching barrel had been removed from the latching hardware.

32. On 3/5/12 at 2:13 p.m., the corridor door to the Operator Room G275 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a door wedge.

Based on observation and interview, the facility failed to maintain all vertical openings between floors in accordance with 2000 NFPA 101. This was evidenced by a door in a trash chute that did not positive latch when tested. This affected six of seven floors at the Main Hospital Merritt Campus and could potentially result in the spread of smoke and/or fire from one story to another.

8.2.5 Vertical Openings.
8.2.5.1 Every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation. (See 3.3.182 for definition of Smoke Barrier.)
Exception: This requirement shall not apply where otherwise specified by 8.2.5.5, 8.2.5.6, or Chapters 11 through 42.

8.2.5.2* Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.
Exception No. 1: This requirement shall not apply where otherwise specified by 8.2.5.5, 8.2.5.6, 8.2.5.7, or Chapters 11 through 42.
Exception No. 2: This requirement shall not apply to escalators and moving walks protected in accordance with 8.2.5.11.
Exception No. 3:* This requirement shall not apply to expansion or seismic joints designed to prevent the penetration of fire and shown to have a fire resistance rating of not less than the required fire resistance rating of the floor when tested in accordance with ANSI/UL 2079, Test of Fire Resistance of Building Joint Systems.
Exception No. 4: Enclosure shall not be required for pneumatic tube conveyors protected in accordance with 8.2.3.2.4.2.
Exception No. 5: This requirement shall not apply to existing mail chutes where one of the following conditions is met:
(a) The cross-sectional area does not exceed 16 in.2 (103 cm2).
(b) The building is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.

8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door
Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

Merritt Building
During a tour of the facility with Engineering Staff on 3/5/12, the self-closing door to the Trash Chute in Room 4069 had the latching hardware taped back preventing the door from latching when closed. When asked, Engineering Staff 1 stated that the chute went all the way to the Lower Level.

Based on observation and interview, the facility failed to maintain and mark all exits with readily visible signs where the exit is not apparent in accordance with 2000 NFPA 101. This was evidenced by rooms with no exit signs, exit signs that were not visible from any direction of exit access, an exit sign that was not illuminated, and self-luminous exit sign that was expired. This affected three of seven floors at the Merritt Building and could potentially result delayed evacuation during an emergency.

SECTION 7.10 MARKING OF MEANS OF EGRESS
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations,interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.
7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be the nearest exit is not apparent.

Findings:

Merritt Building
During a tour of the facility with Engineering Staff, exit signs were inspected.

1. On 3/5/12, at 2:12 p.m., the two exit signs located in the Fourth Floor Intensive Care Unit (ICU) 3 and 4 could not be seen from approximately 80 percent of the ICU Unit. Engineering Staff 1 confirmed that the signs were not visible from most of the room.

2. On 3/5/12, at 2:40 p.m., the sterile processing area located in the Lower Level did not have any exit signs in it. This room was approximately 600 square feet in size and had approximately eight doors which could be confused as exit doors. The way to an exit was not obvious from any point in the room.

3. On 3/5/12, at 4:30 p.m., the exit sign at the end of the corridor could not be seen when standing in the corridor between Rooms L195 and L175 on the Lower Level.

4. On 3/8/12 at 10:40 a.m., the exit sign located at ground level Stairwell 9 was not illuminated.


Surveyor: 27893
Providence Building
5. On 3/7/12 at 8:57 a.m., a self-luminous exit sign was mounted to a wall near Room L533. The label on the sign indicated that the exit sign should be replaced by January 2006. The exit sign was approximately six years overdue for replacement.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in three smoke barrier walls. This affected two of six floors in the Providence Building and could result in the spread of smoke or fire to other smoke compartments.

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

Findings:

During a facility tour with staff, the smoke barrier walls in the facility were observed.

Providence Building
1. On 3/7/12 at 9:01 a.m., the two hour fire rated wall above the smoke barrier doors near Room L526 was observed. There were eight metal pipes running through the wall at that location. The diameter of the pipes ranged from a half inch to two and a half inches. There were unsealed penetrations in the two hour fire rated wall surrounding the pipes at that location.

2. On 3/7/12 at 9:39 a.m., the fire barrier wall above the smoke barrier doors near Room G450 was observed. There were two approximately two inch diameter unsealed penetrations in the wall with one cable running though each. There was an approximately two inch diameter metal pipe running through the wall at that location. There was an unsealed penetration in the wall surrounding the pipe at that location.

3. On 3/7/12 at 9:43 a.m., the two hour fire rated wall above the smoke barrier doors near Room G100A was observed. There was one approximately one inch diameter unsealed penetration in the wall at that location. The penetration was located just above a thin metal conduit running through the wall at that location.

Based on observation, the facility failed to maintain its fire doors to continuously serve as a barrier to prevent the spread of smoke and/or fire. This was evidenced by cross-corridor fire doors which were equipped with latching hardware and which failed to latch when tested. This affected four of seven floors at the Merritt Building and could potentially result in the spread of smoke and/or fire from one compartment to another.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

Merritt Building
During a tour of the facility with Engineering Staff, fire/smoke barrier doors were inspected.

1. On 3/5/12 at 11:25 a.m., the 1 1/2 hour fire-rated cross corridor doors separating Rooms 4026 through 4064 from the rest of the Merritt Campus did not positive latch when tested by releasing the doors from an open position.

2. On 3/5/12 at 1:36 p.m., the 1 1/2 hour fire-rated cross corridor doors separating fourth floor Ehmann from the South Tower did not close completely and latch when tested by releasing the doors from an open position.

3. On 3/6/12 at 1:44 p.m., the right leaf facing south of the 1 1/2 hour fire-rated cross corridor doors near Room 4193 did not positive latch when tested by activation of the fire alarm system.



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Merritt Building
4. On 3/5/12 at 1:42 p.m., in the Merritt Building 4th floor North Wing in the EKG Department by room 4371, the right hand fire door released upon activation of the fire alarm system and fully closed, but failed to positively latch.

5. On 3/5/12 at 2:03 p.m., in the Merritt Building on the 3rd floor in the Ehman Corridor by room 3301, the right hand fire door released upon activation of the fire alarm system and fully closed, but failed to positively latch.

6. On 3/5/12 at 2:17 p.m., in the Merritt Building on the 2nd floor in the Ehman Corridor by room 2340, the left hand fire door released upon activation of the fire alarm system and fully closed, but failed to positively latch.


27893

Providence Building
7. On 3/6/12 at 11:12 a.m., the smoke barrier door leading from Room L580D to L580C was equipped with a self-closing device. The door was located in a two hour fire rated wall. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

8. On 3/7/12 at 1:59 p.m., the smoke barrier doors near Room 2436 were equipped with self-closing devices and magnetic hold-open devices. The fire alarm system was tested in that area. The magnetic hold-open devices released the smoke barrier doors when the fire alarm system was activated. One of two smoke barrier doors failed to latch. The door was obstructed from latching by the astragal attachment on the opposing door leaf.

9. On 3/7/12 at 2:26 p.m., the smoke barrier doors near Room L600 were equipped with self-closing devices and magnetic hold-open devices. The fire alarm system was tested in that area. The magnetic hold-open devices released the smoke barrier doors when the fire alarm system was activated. One of two smoke barrier doors failed to latch. The door was obstructed from latching due to air pressure differences.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by one hazardous area door that was not equipped with a self-closing device. This affected one of seven floors in the Merrit Building and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff, the hazardous areas in the facility were observed.

Merritt Building
1. On 3/6/12 at 9:13 a.m., the door to the Soiled Utility Room 4119 across from Room 4120 was not equipped with a self-closing or automatic-closing device. The door was held open to the fullest extent and allowed to close. The door failed to close and remained in the open position.

Based on observation, the facility failed to maintain a fire rated exit passage way. This was evidenced by a two hour fire rated exit passageway that had unsealed penetrations. This affected one of seven floors in the Merritt Building and could result in the spread of smoke or fire into the exit passageway.

NFPA 101, 2000 edition
7.1.3.2 Exits.
7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) *The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) *The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
Exception No. 1: In existing non-high-rise buildings, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 2: In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 3: One-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.
Exception No. 1: Openings in exit passageways in covered mall buildings as provided in Chapters 36 and 37 shall be permitted.
Exception No. 2: In buildings of Type I or Type II construction, existing fire-protection rated doors shall be permitted to interstitial spaces provided that such space meets the following criteria:
(a) The space is used solely for distribution of pipes, ducts, and conduits.
(b) The space contains no storage.
(c) The space is separated from the exit enclosure in accordance with 8.2.3.
(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.
(f) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures.
7.1.3.2.2 An exit enclosure shall provide a continuous protected path of travel to an exit discharge.
7.1.3.2.3 An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a facility tour with staff, the exit passageways in the facility were observed.

Merritt Building
1. On 3/6/12 at 10:26 a.m., the two hour fire-rated wall above the cross-corridor doors near Room L145A was observed. The wall terminated at the ceiling and did not extend to the deck above. The two hour fire-rated wall was part of an exit discharge passageway from Stairway 3.

2. On 3/6/12 at 10:28 a.m., the two hour fire-rated wall near Room L110 was observed. The portion of the wall above the ceiling was observed. There were five metal pipes running through the wall at that location. The pipe diameters ranged from two to three inches. There were unsealed penetrations in the two hour fire-rated wall surrounding the pipes at that location. The two hour fire-rated wall was part of an exit discharge passageway from Stairway 3.

Based on observation, record review, and interview, the facility failed to maintain their emergency lighting units. This was evidenced by three emergency lighting units that failed to operate and the facility's failure to perform annual ninety minute tests on all their emergency lighting units equipped with battery back-up. This affected all patients in the Merritt Building and Providence Building and could result in a loss of visibility during a power failure in conjunction with a generator delay or malfunction.

NFPA 101, 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 1.5 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 record review and a facility tour with staff, the emergency lighting units in the facility were observed.

Merritt Building
1. On 3/5/12 at 10:53 a.m., the emergency lighting unit in Operating Room 4 was observed. The lighting unit failed to illuminate when tested. The word "BAD" was written on the side of the lighting unit in permanent black marker. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 did not know how long the lighting unit had been non-functional.

2. On 3/7/12 at 11:44 a.m., the facility was observed to have emergency lighting units equipped with battery back-up. The emergency lighting units were located throughout the facility but most notably in the Operating Rooms. The test records for the emergency lighting units were reviewed. The test records indicated that the emergency lighting units are tested monthly for function. There were no records that indicate that the emergency lighting units had been tested for a duration of ninety continuous minutes during the past twelve months. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 confirmed that the emergency lighting units are not tested annually for ninety minutes. The facility had twelve Operating Rooms. All twelve Operating Rooms were equipped with emergency lighting units.

Providence Building
3. On 3/7/12 at 11:44 a.m., the facility was observed to have emergency lighting units equipped with battery back-up. The emergency lighting units were located throughout the facility but most notably in the Operating Rooms. The test records for the emergency lighting units were reviewed. The test records indicated that the emergency lighting units are tested monthly for function. There were no records that indicated the emergency lighting units had been tested for a duration of ninety continuous minutes during the past twelve months. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 confirmed that the emergency lighting units are not tested annually for ninety minutes. The facility had seven Operating Rooms. All seven Operating Rooms were equipped with an emergency lighting unit.



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Merritt Building
4. On 3/5/12, at 2:33 p.m., the battery back-up egress/task light in the Sterile Supply Office did not function when tested.

5. On 3/5/12 at 2:40 p.m., the battery back-up egress/task light in the Sterile Supply near Room L170 did not function when tested.

Based on observation, the facility failed to maintain their fire alarm system. This was evidenced by one fire alarm chime that was muffled. This affected one of seven floors in the Merritt Building and could result in a delayed notification of a fire.

Findings:

During a facility tour with staff, the fire alarm system and components were observed.

Merritt Building
1. On 3/5/12 at 11:45 a.m., the fire alarm chime/strobe in Quality and Outcomes Room 3180 was observed. The chime speaker on the device had a paper wad taped over it.

Based on observation, interview, and document review, the facility fail to maintain its automatic sprinkler system in accordance with 1998 NFPA 25 and 1999 NFPA 13. This was evidenced by the failure to maintain a current five year certification for their automatic sprinkler system, missing quarterly sprinkler inspection and testing, and failing to provide sprinkler system Inspector's Test Valve identification signs. This affected two of five Buildings and could potentially result in the automatic sprinkler system failing extinguish a fire in the event that it does not function as designed.

NFPA 13
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.


27254

Findings:

During document review with facility staff on 3/06/12, the documents for the sprinkler system were observed.

Providence Building
1. At 11:00 a.m., the documents for the quarterly flow test were reviewed. The facility failed to provide documents for the 2nd quarter of 2011. During a staff interview, staff stated that in July 2011 the facility started testing the flow tests quarterly. Until then the flow tests were being conducted semi-annually.

2. At 11:30 a.m., the documents for the 5 year certification were reviewed. The 5 year certification was performed on 6/28/11. The previous five year sprinkler certification was performed on 3/31/2006.

The facility is currently working on completion of repairs of all deficiencies found during that inspection but has not completed the 5 year certification process. Documentation provided by the vendor stated that the repairs were approximately 30 percent completed.


27893

During a facility tour with staff, the facility's automatic fire sprinkler system was observed.

Merritt Building
3. On 3/6/12 at 2:12 p.m., the 2nd Floor East Inspector's Test Valve was observed. The valve was not equipped with an identification sign.

Providence Building
4. On 3/7/12 at 1:42 p.m., the 5th Floor Inspector's Test Valve was observed. The valve was not equipped with an identification sign.

Based on observation and interview, the facility failed to maintain all fire extinguishers in accordance with 1998 NFPA 10 Standard for Portable Fire Extinguishers. This was evidenced by fire extinguishers that had not been serviced in the past twelve months, extinguishers that had noted deficiencies from their annual inspection, and items that were stored in front of extinguishers which impeded access to the extinguisher. This affected four of seven floors at the Merritt Building and could potentially result in fire extinguishers failing to function properly in the event of a fire and/or a delay in access to the extinguisher when access to extinguishers are impeded.

1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

4-3 A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer 's service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 4-4.

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

4-4.4 Maintenance Record keeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Findings:

During a tour of the facility with Engineering Staff, fire extinguishers were inspected throughout the facility.

Merritt Building
1. On 3/5/12, at 2:55 p.m., the Halon fire extinguisher located in the Computer Information Technology Cold Room did not have a current annual inspection tag attached to it. The last two inspection tags were dated November 2009 and December 2010. Engineering Staff 1 confirmed the inspection dates on the extinguisher tank.
Documentation provided after the Exit Conference titled Suppression System Inspection Report dated 11/29/11, indicated that the Halon suppression system had been inspected annually, but that there were deficiencies noted.
In the comments section of the suppression system annual report the following was noted:
Note 3: stated that the tank pounds per square inch (PSI) pressure were low and that they should have been 360 PSI. The report noted that the tank pressure was 300 PSI.
Note 4: "This system releases Halon on manual pull station alarms only. Smoke detectors did not fire Halon release circuit. This is enough to fail the system".
Note 5: "One manual pull station operates intermittently".
Note 6: "Abort Station does not signal suppression panel".
When asked, Engineering Staff 1 stated that the Halon suppression system was going to be upgraded and was under an OSHPD permit.

2. On 3/6/12, at 2:54 p.m., the fire extinguisher/fire hose cabinet had pallets and boxes stored in front of it. Engineering Staff moved the boxes at that time.


27254

Merritt Building
3. On 3/5/12, at 10:50 a.m., on the 2nd floor South Wing, in the Medical Staff Office, the fire extinguisher was blocked by a rolling cart that was placed in front of the fire extinguisher.
4. On 3/5/2012, at 11:26 a.m., on the 2nd floor East Wing, the fire extinguisher across from shower room 2255 was blocked by a gurney.
5. On 3/5/12. at 11:30 a.m., on the 2nd floor East Wing, the fire extinguisher by room 2230 was blocked by a gurney.


27893


Merritt Building
6. On 3/5/12 at 11:19 a.m., a portable fire extinguisher was mounted to a wall near Room 3185B. The service tag on the fire extinguisher indicated that it had last been serviced on 2/10/11. The fire extinguisher was approximately one month overdue for an annual service and inspection.

7. On 3/5/12 at 11:19 a.m., a portable fire extinguisher was mounted to a wall in the Surgical Pathology Laboratory (Room 3113). The service tag on the fire extinguisher indicated that it had last been serviced on 2/3/11. The fire extinguisher was approximately one month overdue for an annual service and inspection.

Based on record review and interview, the facility failed to maintain its heating, ventilation, and air conditioning system, in accordance with NFPA 90A. This was evidenced by documentation indicating that dampers had not been inspected due to a lack of access to the dampers and dampers that did not function properly when tested. This finding affected three of three building surveyed and could potentially result in the spread of smoke and/or fire.

9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

2-1.1 Equipment shall be arranged to afford access for inspection, maintenance, and repair.

2-3.4 Air Duct Access and Inspection.
2-3.4.1* A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

2-3.4.5 Openings in walls or ceilings shall be provided so that service openings in air ducts are accessible for maintenance and inspection needs.

NFPA 90A 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review with Engineering Staff on 3/7/12, at 9:50 a.m., documentation for damper inspections was reviewed. Documentation indicated that dampers were inspected by Vendor 1 on 8/24/11 at the Merritt, Providence, and Peralta Buildings with the following deficiencies noted:

Merritt Building
1. Of the 915 dampers, 50 did not have access to the damper to be tested and 33 of the damper actuators did not function properly.

Providence
2. Of the approximately 571 dampers, 45 had dampers that either did not have access to or had problems with the actuator.

Peralta
3. Of the approximately 75 dampers, seven dampers were not accessible.

When asked, Engineering Staff 1 stated that the work and funding had been authorized, but there were no dates scheduled for the repairs to begin.

Based on record review, interview, and observation, the facility failed to protect its cooking facilities in accordance with 1998 NFPA 96. This was evidenced by the kitchen hood fire suppression system not being a UL-300 compliant system. This affected one of seven floors at the Merritt Building and could potentially result in the spread of smoke and/or fire.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations

7-2.2* Automatic fire-extinguishing systems shall comply with standard UL 300, Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with their listing.

Exception: Automatic fire-extinguishing equipment provided as part of listed recirculating systems complying with standard UL 197, Standard for Safety-Commercial Electric Cooking Appliances.

8-2* Inspection. An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Findings:

Merritt Building
During record review on 3/6/12 at 9:00 a.m., documentation provided for the last two semi-annual Kitchen hood fire suppression system inspections were reviewed. Documentation from Vendor 2 titled "Kitchen Fire System Service Reports" dated 4/23/11 and 10/24/11 indicated that the Cafe Kitchen Hood was not a UL-300 compliant fire suppression system, and that "a red tag was affixed to pull station to attest to this". Documentation for each inspection also indicated that the system was being maintained, but not certified.

Documentation provided from Vendor 2 dated 7/22/11 titled "Merritt Cafe UL-300 Upgrade Project Scope of Work" described work to be done to upgrade the R 102 system to a UL-300 compliant system. During an interview with Engineering Staff 1, Staff 1 stated that the work was approved to be done, but no date had been scheduled.
Observation on 3/8/12 at 10:45 a.m. of the red tag on the pull station showed a tag date of 10/20/11.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices in accordance with 2000 NFPA 101, 1999 NFPA 99, and 1999 NFPA 70. This was evidenced by unapproved portable heaters in non-sleeping staff areas of the facility that did not have proper clearance from combustible materials in accordance with the manufacturer's labeled instructions and portable space heaters that were not verified to not exceed 212 degrees Fahrenheit. This affected two of seven floors in the Merritt Building and could result in the ignition of fire.

NFPA 99, 1999 edition
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator 's, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

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

Findings:

During a facility tour with staff, electrical equipment was inspected throughout the facility.

Merritt Building
1. On 3/5/12 at 11:49 a.m., a portable space heater was observed in Staff Room 3069. The portable space heater was located within three feet of furnishings and combustibles.

2. On 3/5/12 at 1:33 p.m., a portable space heater was observed in Pre-Op Testing Room 3205. The portable space heater was within three feet of combustibles. The portable space heater had a coil heating element. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 could not confirm that the portable space heater would not exceed 212 degrees Fahrenheit.

3. On 3/5/12 at 3:01 p.m., a portable space heater was observed in Admitting Room 7 (Room G117). The portable space heater was within three feet of combustibles. The portable space heater had a coil heating element. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 could not confirm that the portable space heater would not exceed 212 degrees Fahrenheit.

4. On 3/5/12 at 3:04 p.m., a portable space heater was observed in Admissions/Bed Control Room G114. The portable space heater was within three feet of combustibles. The portable space heater had a coil heating element. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 could not confirm that the portable space heater would not exceed 212 degrees Fahrenheit. The portable space heater was plugged into a surge protected multi-outlet extension cord and not directly to an electrical wall receptacle.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items stored in an exit corridor that could impede egress during an evacuation. This affected one of seven floors at the Main Hospital Merritt Campus and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

During a tour of the facility with Engineering Staff on 3/5/12, exit corridors were inspected.

Merritt Building
1. At 4:45 p.m., the exit corridor located on the Lower Level near Stairwell 2 near Room L195 had two stacks of steel stored in the corridor against the southwest wall. One stack was pipe that was approximately eight feet long three feet wide and 18 inches high and the other one was approximately the same dimension, but was composed of square tubing. Engineering Staff 1 stated that the steel was from the new construction that was taking place.

Based on observation and interview, the facility failed to maintain safe storage of soiled linen receptacles. This was evidenced by four large soiled linen receptacles stored in a corridor and not inside a room protected as a hazardous area. This affected one of seven floors in the Merritt Building and could result in a fire to build and spread at that location.

Findings:

During a facility tour with staff, the trash and soiled linen receptacles were observed.

Merritt Building
1. On 3/5/12 at 11:23 a.m., four large soiled linen roller carts were located in the corridor near Room 3144. Each of the four soiled linen carts had a capacity greater than thirty-two gallons. Surgery Staff 1 was interviewed at that time. Surgery Staff 1 indicated that the soiled linen carts are kept at this location. Surgery Staff 1 indicated that the soiled linen carts are picked up approximately every four hours on a busy day. The soiled linen carts were not located inside a room protected as a hazardous area.

Based on observation, the facility failed to maintain safe storage of medical gas cylinders. This was evidenced by medical gas cylinders that were stored in a corridor alcove and not in a room protected as a hazardous area, light switches that were lower than five feet high from floor level, and medical gas cylinders that were free standing and unsecured. This affected three of seven floors in the Merritt Building and one of six floors in the Providence Building. This could result in a ruptured compressed gas cylinder or another medical gas cylinder initiated emergency.

NFPA 101, 2000 edition
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies
and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

NFPA 99, 1999 edition
4-3.1.1.2(a)2 Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
4-3.1.1.2(a) 3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
8-3.1.11.2(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Findings:

During a facility tour with staff, the medical gas cylinder storage locations were observed.

Merritt Building
1. On 3/5/12 at 11:03 a.m., medical gas cylinders were observed stored in a corridor alcove near Room 3125. 15 oxygen E cylinders, 12 carbon dioxide E cylinders, 4 compressed air E cylinders, 4 nitrous oxide E cylinders, 2 carbon dioxide H tanks, and 1 nitrogen H tank were located in that alcove. The medical gas cylinders were not stored inside a room protected as a hazardous area.

2. On 3/5/12 at 3:38 p.m., the Medical Gas Manifold/Storage Room L090A was observed. Two light switches in that room were mounted on the wall approximately four feet high from floor level.

3. On 3/5/12 at 3:46 p.m., one nitrogen cylinder was observed in the Plant Operations Shop (Room L080). The cylinder was free standing and unsecured.

Providence Building
4. On 3/6/12 at 11:51 a.m., one carbon dioxide cylinder was observed in Room L420. The cylinder was free standing and unsecured.

Based on record review, the facility failed to maintain the relative humidity levels at their anesthetizing locations. This was evidenced by the facility's failure to maintain relative humidity levels at 35 percent or greater at their anesthetizing locations. This affected 12 of 12 Operating Rooms in the Merritt Building and 7 of 7 Operating Rooms in the Providence Building. This could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review with staff, the facility's relative humidity records for their anesthetizing locations were observed.

Merritt Building/Providence Building
1. On 3/7/12 at 11:34 a.m., the relative humidity records for the facility's anesthetizing locations were reviewed. 12 of 12 Operating Rooms in the Merritt Building and 7 of 7 Operating Rooms in the Providence Building had experienced relative humidity levels below thirty-five percent on multiple instances during the past twelve months. The facility policy for maintaining relative humidity levels at anesthetizing locations was requested. The humidity policy indicated that the facility will maintain relative humidity between 30 and 70 percent at their anesthetizing locations.

Based on record review, the facility failed to provide laboratory staff with department specific training. This was evidenced by the facility's failure to ensure laboratory staff review department specific emergency policies and procedures annually. This affected one of seven floors in the Merritt Building and could result in a delayed response to a laboratory emergency.

NFPA 101, 2000 edition
10-2.1.4 Orientation and Training.
10-2.1.4.1 New laboratory personnel shall be taught general safety practices for the laboratory and specific safety practices for the equipment and procedures they will use.
10-2.1.4.2 Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures shall be reviewed annually.

Findings:

During record review with staff, the laboratory staff training records were reviewed.

Merritt Building
1. On 3/8/12 at 9:45 a.m., training records for the laboratory staff were requested. There were no records that indicated the laboratory staff was reviewing laboratory specific emergency policies and procedures on an annual basis. Laboratory staff receive training on laboratory specific emergency policies and procedures when first hired. A general campus wide training on emergency policies and procedures is required to be completed by all staff annually. The general training does not discuss laboratory specific emergency policies and procedures in terms of location and use of spill kits, emergency showers, emergency eye wash stations, etc.

Based on record review and interview, the facility failed to establish required laboratory emergency procedures. This was evidenced by the facility's failure to establish an emergency procedure for extinguishing clothing fires. This affected one of seven floors in the Merritt Building and could result in clothing fire injury to laboratory staff.

NFPA 99, 1999 edition
10-2.1.3 Emergency Procedures.
10-2.1.3.2 Emergency procedures shall be established for controlling chemical spills.
10-2.1.3.3 Emergency procedures shall be established for extinguishing clothing fires.

NFPA 101, 2000 edition
19.3.2.2 Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

Findings:

During record review with staff, the facility's laboratory policies and procedures were reviewed.

Merritt Building
1. On 3/8/12 at 9:45 a.m., the laboratory specific emergency policies and procedures were reviewed. There was no emergency procedure regarding the extinguishment of clothing fires in the laboratory. Lab Staff 1 was interviewed at that time. Lab Staff 1 indicated that the facility does not have a specific procedure regarding extinguishment of clothing fires in the laboratory.

Based on observation and interview, the facility failed to maintain their emergency generator. This was evidenced by the facility's failure to maintain emergency generator alarm annunciators for five of seven emergency generators. This affected three of four buildings observed and could result in a delayed notification of a malfunctioning emergency generator.

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

Findings:

During a facility tour with staff, the facility's emergency generators were observed.

Merritt Building
1. On 3/8/12 from 10:00 a.m. to 10:40 a.m., the building had three diesel fueled emergency generators. There were no remote emergency generator alarm annunciators observed in the building. Engineer Staff 2 was interviewed at that time. Engineer Staff 2 indicated that the facility does not have alarm annunciators for the three emergency generators at a location regularly attended. Engineer Staff 2 indicated that the facility was in the process of having the three generators wired to a computer monitoring system located in the Plant Operations Department in the Providence Building.

Peralta Building
1. On 3/8/12 from 10:00 a.m. to 10:40 a.m., the building had one diesel fueled emergency generator. There was no remote emergency generator alarm annunciator observed in the building. Engineer Staff 2 was interviewed at that time. Engineer Staff 2 indicated that the facility does not have an alarm annunciator for the emergency generator at a location regularly attended.

3012 Summit Building
1. On 3/8/12 from 10:00 a.m. to 10:40 a.m., the building had one diesel fueled emergency generator. There was no remote emergency generator alarm annunciator observed in the building. Engineer Staff 2 was interviewed at that time. Engineer Staff 2 indicated that the facility does not have an alarm annunciator for the emergency generator at a location regularly attended.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70 and 1999 NFPA 99. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, the permanent use of extension cords and multiple outlet adapters, and improper clearance in front of electrical panels. This affected five of seven floors at the Merritt Building could potentially result in the ignition of fire.

NFPA 70, 1999 edition
110-26 (a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less.
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(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.
800-5. Access to Electrical Equipment Behind Panels Designed to Allow Access. Access to equipment shall not be denied by an accumulation of wires and cables that prevents removal of panels, including suspended ceiling panels.
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4)Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection\
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b)& 305-4 c)
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

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

Findings:

During a tour of the facility with Engineering Staff, electrical wiring and equipment were observed in the following locations:
1. On 3/5/12, at 11:55 a.m., the Office near Pulmonary Services had a coffee pot plugged into a power strip.

2. On 3/5/12, at 2:30 p.m., the Sterile Supply Office had a power strip suspended above the floor that was transferring tension to the joint and terminals.

3. On 3/5/12, at 4:30 p.m., the Main Electrical Room L195 in the Lower Level had seven electrical conduit bodies on the northeast wall that had the plate covers missing. There was also an approximately eight inch by eight inch junction box on the northwest wall that had the cover removed.


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Merritt Building
4. On 3/5/12, at 10:17 a.m., on the 5th floor East Wing room 5282, an extension cord was attached to the wall with fasteners.
5. On 3/5/12, at 10:55 a.m., on the 5th floor South Wing room 5114, the cover plate for the wall outlet on the left hand wall was not flush with the wall. There was a cable running under the cover plate that lifted the plate approximately one inch.
6. On 3/5/12, at 11:05 a.m., on the 5th floor South Wing room 5132, the cover plate for the wall outlet on the left hand wall was not flush with the wall. There was a cable running under the cover plate that lifted the plate approximately one inch.
7. On 3/5/12, at 1:15 p.m., on the 1st floor North Wing room 1344 ABG Lab, the printer was plugged into a power strip instead of directly into the wall outlet.
8. On 3/5/12, at 1:45 p.m., on the 1st floor North Wing Emergency Department Office, a microwave and a small refrigerator were plugged into a power strip instead of directly into the wall outlet.
9. On 3/5/12, at 1:46 p.m., on the 1st floor North Wing Emergency Department Office, a power strip was plugged into another power strip instead of directly into the wall outlet. One power strip was being used for computer equipment.
10. On 3/5/12, at 1:49 p.m., in the Merritt Building Pharmacy on the 1st floor, a small refrigerator and and a printer were plugged into a power strip instead of directly into the wall outlet.
11.On 3/5/12, at 1:51 p.m., in the Merritt Building Pharmacy, a small refrigerator was plugged into a power strip instead of directly into the wall outlet.
12. On 3/5/12, at 1:57 p.m., on the 1st floor in the Laboratory, an extension cord was used for a printer and two blood culture cookers.
13. On 3/5/12, at 2:27 p.m., on the 1st floor in room 1149, an IV pump and a cauterizing machine were plugged into a power strip instead of directly into the wall outlet.
14. On 3/5/12, at 2:36 p.m., in the X-Ray Core area, the outlet face plate cover was coming off the wall and was held in place with painters tape.

Providence Building
15. On 3/6/12, at 10:24 a.m., on the 2nd floor room 2564, a TractMaster treadmill was plugged into an extension cord instead of directly into the wall outlet.
16. On 3/6/12, at 10:40 a.m., on the 2nd floor in the Pantry Room 2435, a refrigerator was plugged into an extension cord instead of directly into the wall outlet.
17. On 3/6/12, at 10:43 a.m., on the 2nd floor Storage Room 2415, 1 of 2 electrical panels were blocked by two shred bins.
18. On 3/6/12, at 10:52 a.m., on the 2nd floor Med RFef/Storage room 2463, one of two electrical panels was blocked by a rolling cart.


27893

Merritt Building
19. On 3/5/12 at 11:32 a.m., office equipment in Room 3103 was plugged into a surge protected multi-outlet extension cord that was plugged into a black non-surge protected extension cord. A paper shredder at that location was plugged into a non-surge protected multi-outlet adapter.

20. On 3/5/12 at 12:08 p.m., television equipment in Rooms 3010, 3012, 3014, and 3016 was plugged into non-surge protected multi-outlet adapters.

Based on observation and interview, the facility failed to maintain the integrity of the walls and ceiling of the building in a condition that would resist the passage of smoke and fire. This was evidenced by observed unsealed penetrations. This affected three of seven floors at the Merrit Building and three of six floors in the Providence Building, and could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

NFPA 101 Life Safety Code, 2000 edition
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following
conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.


Findings:

During a tour of the facility with engineering staff, walls and ceilings were observed.

Merritt Building
1. On 3/5/12, at 11:20 a.m., Room 4303 had an approximately six inch by six inch ceiling tile that was out of place, creating an approximately two inch by six inch unsealed penetration in the ceiling.
When asked, Engineering Staff 1 confirmed that it was a fire-rated ceiling tile.


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Merritt Building
2. On 3/5/12, at 10:51 a.m., in the Merritt Building on the 5th floor South Wing, in the electrical closet, there was a 3" and a 2" pipe conduit that had not been sealed.
3. At 2:32 p.m., in the Merritt Building on the 1st floor North Wing in Radiology 5, there was a large circular hole above the doorway. The hole was approximately 7" in diameter.

Providence Building
4. On 3/6/12, at 9:50 a.m., in the Providence Building on the 5th floor room 5430, the clock junction box had not been sealed and a 4"X4" penetration in the wall was exposed.
5. On 3/6/12, at 10:55 a.m., in the Providence Building on the 3rd floor in room 3407, there was a cut out square in the sheet rock with two 1" penetrations in the middle.


27893


Providence Building:
6. On 3/6/12 at 11:58 a.m., there was one approximately four foot by two foot unsealed penetration in the hardtop ceiling of Room L454.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. This affected five of seven floors at the Merritt Building and one of six floors at the Providence Building. The failure of the corridor doors to close and latch could result in the spread of smoke and/or fire into other areas of the facility.

Findings:

During a tour of the facility with Engineering Staff 1, between 3/05/12 and 3/08/12, corridor doors were inspected throughout the facility.

Merritt Building
1. On 3/5/12, at 10:55 a.m., the corridor door to Patient Room 4274 could not be closed when tested by pulling the door shut. The metal door edge was damaged near the bottom of the door preventing it from closing.

2. On 3/5/12, at 10:55 a.m., the corridor door to Patient Room 4278 was impeded from closing by a linen hamper that was stored in the swing area of the door.

3. On 3/5/12, at 10:56 a.m., the corridor door to Patient Room 4254 was impeded from closing by a linen hamper that was stored in the swing area of the door.

4. On 3/5/12, at 10:56 a.m., the corridor door to Patient Room 4258 was impeded from closing by a linen hamper that was stored in the swing area of the door.

5. On 3/5/12, at 10:57 a.m., the corridor door to Patient Room 4266 was impeded from closing by a linen hamper that was stored in the swing area of the door.

6. On 3/5/12, at 10:57 a.m., the corridor door to Patient Room 4242 was impeded from closing by a linen hamper that was stored in the swing area of the door.

7. On 3/5/12, at 10:59 a.m., the corridor door to Patient Room 4234 was impeded from closing by a linen hamper that was stored in the swing area of the door.

8. On 3/5/12, at 11:00 a.m., the corridor door to Patient Room 4226 was impeded from closing by a linen hamper that was stored in the swing area of the door.

9. On 3/5/12, at 11:03 a.m., the corridor door to Patient Room 4222 was impeded from closing when tested by releasing the door from an open position. The metal door edge was damaged near the bottom of the door preventing it from closing.

10. On 3/5/12, at 11:05 a.m., the corridor door to Patient Room 4218 had a door hanger that was hooked over the top of the door. This hanger prevented the door from latching when it was tested by releasing the door from an open position.

11. On 3/5/12, at 11:25 a.m., the 1 1/2 hour fire-rated corridor door to Room 4317 did not positive latch when tested by releasing the door from an open position.

12. On 3/5/12, at 11:44 a.m., the door Lounge 4357 did not close when tested by releasing it from an open position.

13. On 3/5/12, at 1:25 p.m., the corridor door to Electric Room 4033 did not positive latch when tested by releasing the door from an open position.

14. On 3/5/12, at 1:26 p.m., the door to Patient Room 4018 was impeded from closing by a door hanger that was attached to the top of the door. This door could not be pulled shut. Engineering Staff 1 stated that the door hanger was attached to the door incorrectly. There was also a linen hamper that was stored in the swing area of the door that also prevented the door from closing.

15. On 3/5/12, at 1:36 p.m., door 4161 to the Intensive Care Unit 1 Lounge did not positive latch when tested by releasing the door from an open position.



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Merritt Building
16. On 3/5/12 at 10:33 a.m., in the Merritt Building on the 5th floor West Wing room 5052, the door was equipped with a self-closing mechanism and when released the door did not positively latch.

17. On 3/5/12 at 10:37 a.m., in the Merritt Building on the 5th floor West Wing room 5046, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

18. On 3/5/12 at 10:18 a.m., in the Merritt Building on the 5th floor South Wing room 5113, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

19. On 3/5/12 at 10:57 a.m., in the Merritt Building on the 5th floor South Wing room 5113, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

20. On 3/5/12 at 11:00 a.m., in the Merritt Building on the 5th floor South Wing room 5116, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

21. On 3/5/12 at 11:03 a.m., in the Merritt Building on the 5th floor South Wing room 5122, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

22. On 3/5/12 at 11:45 a.m., in the Merritt Building on the 2nd floor North Wing room 2386, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

23. On 3/5/12 at 11:47 a.m., in the Merritt Building on the 2nd floor North Wing room 2372, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

24. On 3/5/12 at 11:48 a.m., in the Merritt Building on the 2nd floor North Wing room 2368, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.

Providence Building
25. On 3/6/12 at 9:58 a.m., in the Providence Building on the 2nd floor Eastside room 2520, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.
26. On 3/6/12 at 10:10 a.m., in the Providence Building on the 2nd floor Eastside room 2532, the door was equipped with a self-closing mechanism and when released, the door did not positively latch.


27893

Merritt Building:
27. On 3/5/12 at 11:16 a.m., the corridor door to the Clean Dumbwaiter Room (Room 3135A) was equipped with an automatic closing device. The door was obstructed from closing by a cart located directly in the swing path of the door.

28. On 3/5/12 at 11:27 a.m., the corridor doors to the Cryogenic Freezer Room, located across from Room 3141, were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of two doors failed to latch. The door was obstructed from latching by the door frame.

29. On 3/5/12 at 11:28 a.m., the corridor door to the Housekeeping Closet (Room 3141) was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to a wad of white mesh stuffed inside the striker plate.

30. On 3/5/12 at 11:32 a.m., the corridor door to Staff Office Room 3103 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a door wedge.

31. On 3/5/12 at 1:28 p.m., the corridor door to Storage Room 3215 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The latching barrel had been removed from the latching hardware.

32. On 3/5/12 at 2:13 p.m., the corridor door to the Operator Room G275 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a door wedge.

Based on observation and interview, the facility failed to maintain all vertical openings between floors in accordance with 2000 NFPA 101. This was evidenced by a door in a trash chute that did not positive latch when tested. This affected six of seven floors at the Main Hospital Merritt Campus and could potentially result in the spread of smoke and/or fire from one story to another.

8.2.5 Vertical Openings.
8.2.5.1 Every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation. (See 3.3.182 for definition of Smoke Barrier.)
Exception: This requirement shall not apply where otherwise specified by 8.2.5.5, 8.2.5.6, or Chapters 11 through 42.

8.2.5.2* Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.
Exception No. 1: This requirement shall not apply where otherwise specified by 8.2.5.5, 8.2.5.6, 8.2.5.7, or Chapters 11 through 42.
Exception No. 2: This requirement shall not apply to escalators and moving walks protected in accordance with 8.2.5.11.
Exception No. 3:* This requirement shall not apply to expansion or seismic joints designed to prevent the penetration of fire and shown to have a fire resistance rating of not less than the required fire resistance rating of the floor when tested in accordance with ANSI/UL 2079, Test of Fire Resistance of Building Joint Systems.
Exception No. 4: Enclosure shall not be required for pneumatic tube conveyors protected in accordance with 8.2.3.2.4.2.
Exception No. 5: This requirement shall not apply to existing mail chutes where one of the following conditions is met:
(a) The cross-sectional area does not exceed 16 in.2 (103 cm2).
(b) The building is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.

8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door
Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

Merritt Building
During a tour of the facility with Engineering Staff on 3/5/12, the self-closing door to the Trash Chute in Room 4069 had the latching hardware taped back preventing the door from latching when closed. When asked, Engineering Staff 1 stated that the chute went all the way to the Lower Level.

Based on observation and interview, the facility failed to maintain and mark all exits with readily visible signs where the exit is not apparent in accordance with 2000 NFPA 101. This was evidenced by rooms with no exit signs, exit signs that were not visible from any direction of exit access, an exit sign that was not illuminated, and self-luminous exit sign that was expired. This affected three of seven floors at the Merritt Building and could potentially result delayed evacuation during an emergency.

SECTION 7.10 MARKING OF MEANS OF EGRESS
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations,interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.
7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be the nearest exit is not apparent.

Findings:

Merritt Building
During a tour of the facility with Engineering Staff, exit signs were inspected.

1. On 3/5/12, at 2:12 p.m., the two exit signs located in the Fourth Floor Intensive Care Unit (ICU) 3 and 4 could not be seen from approximately 80 percent of the ICU Unit. Engineering Staff 1 confirmed that the signs were not visible from most of the room.

2. On 3/5/12, at 2:40 p.m., the sterile processing area located in the Lower Level did not have any exit signs in it. This room was approximately 600 square feet in size and had approximately eight doors which could be confused as exit doors. The way to an exit was not obvious from any point in the room.

3. On 3/5/12, at 4:30 p.m., the exit sign at the end of the corridor could not be seen when standing in the corridor between Rooms L195 and L175 on the Lower Level.

4. On 3/8/12 at 10:40 a.m., the exit sign located at ground level Stairwell 9 was not illuminated.


Surveyor: 27893
Providence Building
5. On 3/7/12 at 8:57 a.m., a self-luminous exit sign was mounted to a wall near Room L533. The label on the sign indicated that the exit sign should be replaced by January 2006. The exit sign was approximately six years overdue for replacement.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in three smoke barrier walls. This affected two of six floors in the Providence Building and could result in the spread of smoke or fire to other smoke compartments.

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

Findings:

During a facility tour with staff, the smoke barrier walls in the facility were observed.

Providence Building
1. On 3/7/12 at 9:01 a.m., the two hour fire rated wall above the smoke barrier doors near Room L526 was observed. There were eight metal pipes running through the wall at that location. The diameter of the pipes ranged from a half inch to two and a half inches. There were unsealed penetrations in the two hour fire rated wall surrounding the pipes at that location.

2. On 3/7/12 at 9:39 a.m., the fire barrier wall above the smoke barrier doors near Room G450 was observed. There were two approximately two inch diameter unsealed penetrations in the wall with one cable running though each. There was an approximately two inch diameter metal pipe running through the wall at that location. There was an unsealed penetration in the wall surrounding the pipe at that location.

3. On 3/7/12 at 9:43 a.m., the two hour fire rated wall above the smoke barrier doors near Room G100A was observed. There was one approximately one inch diameter unsealed penetration in the wall at that location. The penetration was located just above a thin metal conduit running through the wall at that location.

Based on observation, the facility failed to maintain its fire doors to continuously serve as a barrier to prevent the spread of smoke and/or fire. This was evidenced by cross-corridor fire doors which were equipped with latching hardware and which failed to latch when tested. This affected four of seven floors at the Merritt Building and could potentially result in the spread of smoke and/or fire from one compartment to another.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

Merritt Building
During a tour of the facility with Engineering Staff, fire/smoke barrier doors were inspected.

1. On 3/5/12 at 11:25 a.m., the 1 1/2 hour fire-rated cross corridor doors separating Rooms 4026 through 4064 from the rest of the Merritt Campus did not positive latch when tested by releasing the doors from an open position.

2. On 3/5/12 at 1:36 p.m., the 1 1/2 hour fire-rated cross corridor doors separating fourth floor Ehmann from the South Tower did not close completely and latch when tested by releasing the doors from an open position.

3. On 3/6/12 at 1:44 p.m., the right leaf facing south of the 1 1/2 hour fire-rated cross corridor doors near Room 4193 did not positive latch when tested by activation of the fire alarm system.



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Merritt Building
4. On 3/5/12 at 1:42 p.m., in the Merritt Building 4th floor North Wing in the EKG Department by room 4371, the right hand fire door released upon activation of the fire alarm system and fully closed, but failed to positively latch.

5. On 3/5/12 at 2:03 p.m., in the Merritt Building on the 3rd floor in the Ehman Corridor by room 3301, the right hand fire door released upon activation of the fire alarm system and fully closed, but failed to positively latch.

6. On 3/5/12 at 2:17 p.m., in the Merritt Building on the 2nd floor in the Ehman Corridor by room 2340, the left hand fire door released upon activation of the fire alarm system and fully closed, but failed to positively latch.


27893

Providence Building
7. On 3/6/12 at 11:12 a.m., the smoke barrier door leading from Room L580D to L580C was equipped with a self-closing device. The door was located in a two hour fire rated wall. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

8. On 3/7/12 at 1:59 p.m., the smoke barrier doors near Room 2436 were equipped with self-closing devices and magnetic hold-open devices. The fire alarm system was tested in that area. The magnetic hold-open devices released the smoke barrier doors when the fire alarm system was activated. One of two smoke barrier doors failed to latch. The door was obstructed from latching by the astragal attachment on the opposing door leaf.

9. On 3/7/12 at 2:26 p.m., the smoke barrier doors near Room L600 were equipped with self-closing devices and magnetic hold-open devices. The fire alarm system was tested in that area. The magnetic hold-open devices released the smoke barrier doors when the fire alarm system was activated. One of two smoke barrier doors failed to latch. The door was obstructed from latching due to air pressure differences.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by one hazardous area door that was not equipped with a self-closing device. This affected one of seven floors in the Merrit Building and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff, the hazardous areas in the facility were observed.

Merritt Building
1. On 3/6/12 at 9:13 a.m., the door to the Soiled Utility Room 4119 across from Room 4120 was not equipped with a self-closing or automatic-closing device. The door was held open to the fullest extent and allowed to close. The door failed to close and remained in the open position.

Based on observation, the facility failed to maintain a fire rated exit passage way. This was evidenced by a two hour fire rated exit passageway that had unsealed penetrations. This affected one of seven floors in the Merritt Building and could result in the spread of smoke or fire into the exit passageway.

NFPA 101, 2000 edition
7.1.3.2 Exits.
7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) *The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) *The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
Exception No. 1: In existing non-high-rise buildings, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 2: In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 3: One-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.
Exception No. 1: Openings in exit passageways in covered mall buildings as provided in Chapters 36 and 37 shall be permitted.
Exception No. 2: In buildings of Type I or Type II construction, existing fire-protection rated doors shall be permitted to interstitial spaces provided that such space meets the following criteria:
(a) The space is used solely for distribution of pipes, ducts, and conduits.
(b) The space contains no storage.
(c) The space is separated from the exit enclosure in accordance with 8.2.3.
(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.
(f) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures.
7.1.3.2.2 An exit enclosure shall provide a continuous protected path of travel to an exit discharge.
7.1.3.2.3 An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a facility tour with staff, the exit passageways in the facility were observed.

Merritt Building
1. On 3/6/12 at 10:26 a.m., the two hour fire-rated wall above the cross-corridor doors near Room L145A was observed. The wall terminated at the ceiling and did not extend to the deck above. The two hour fire-rated wall was part of an exit discharge passageway from Stairway 3.

2. On 3/6/12 at 10:28 a.m., the two hour fire-rated wall near Room L110 was observed. The portion of the wall above the ceiling was observed. There were five metal pipes running through the wall at that location. The pipe diameters ranged from two to three inches. There were unsealed penetrations in the two hour fire-rated wall surrounding the pipes at that location. The two hour fire-rated wall was part of an exit discharge passageway from Stairway 3.

Based on observation, record review, and interview, the facility failed to maintain their emergency lighting units. This was evidenced by three emergency lighting units that failed to operate and the facility's failure to perform annual ninety minute tests on all their emergency lighting units equipped with battery back-up. This affected all patients in the Merritt Building and Providence Building and could result in a loss of visibility during a power failure in conjunction with a generator delay or malfunction.

NFPA 101, 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 1.5 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 record review and a facility tour with staff, the emergency lighting units in the facility were observed.

Merritt Building
1. On 3/5/12 at 10:53 a.m., the emergency lighting unit in Operating Room 4 was observed. The lighting unit failed to illuminate when tested. The word "BAD" was written on the side of the lighting unit in permanent black marker. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 did not know how long the lighting unit had been non-functional.

2. On 3/7/12 at 11:44 a.m., the facility was observed to have emergency lighting units equipped with battery back-up. The emergency lighting units were located throughout the facility but most notably in the Operating Rooms. The test records for the emergency lighting units were reviewed. The test records indicated that the emergency lighting units are tested monthly for function. There were no records that indicate that the emergency lighting units had been tested for a duration of ninety continuous minutes during the past twelve months. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 confirmed that the emergency lighting units are not tested annually for ninety minutes. The facility had twelve Operating Rooms. All twelve Operating Rooms were equipped with emergency lighting units.

Providence Building
3. On 3/7/12 at 11:44 a.m., the facility was observed to have emergency lighting units equipped with battery back-up. The emergency lighting units were located throughout the facility but most notably in the Operating Rooms. The test records for the emergency lighting units were reviewed. The test records indicated that the emergency lighting units are tested monthly for function. There were no records that indicated the emergency lighting units had been tested for a duration of ninety continuous minutes during the past twelve months. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 confirmed that the emergency lighting units are not tested annually for ninety minutes. The facility had seven Operating Rooms. All seven Operating Rooms were equipped with an emergency lighting unit.



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Merritt Building
4. On 3/5/12, at 2:33 p.m., the battery back-up egress/task light in the Sterile Supply Office did not function when tested.

5. On 3/5/12 at 2:40 p.m., the battery back-up egress/task light in the Sterile Supply near Room L170 did not function when tested.

Based on observation, the facility failed to maintain their fire alarm system. This was evidenced by one fire alarm chime that was muffled. This affected one of seven floors in the Merritt Building and could result in a delayed notification of a fire.

Findings:

During a facility tour with staff, the fire alarm system and components were observed.

Merritt Building
1. On 3/5/12 at 11:45 a.m., the fire alarm chime/strobe in Quality and Outcomes Room 3180 was observed. The chime speaker on the device had a paper wad taped over it.

Based on observation, interview, and document review, the facility fail to maintain its automatic sprinkler system in accordance with 1998 NFPA 25 and 1999 NFPA 13. This was evidenced by the failure to maintain a current five year certification for their automatic sprinkler system, missing quarterly sprinkler inspection and testing, and failing to provide sprinkler system Inspector's Test Valve identification signs. This affected two of five Buildings and could potentially result in the automatic sprinkler system failing extinguish a fire in the event that it does not function as designed.

NFPA 13
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.


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Findings:

During document review with facility staff on 3/06/12, the documents for the sprinkler system were observed.

Providence Building
1. At 11:00 a.m., the documents for the quarterly flow test were reviewed. The facility failed to provide documents for the 2nd quarter of 2011. During a staff interview, staff stated that in July 2011 the facility started testing the flow tests quarterly. Until then the flow tests were being conducted semi-annually.

2. At 11:30 a.m., the documents for the 5 year certification were reviewed. The 5 year certification was performed on 6/28/11. The previous five year sprinkler certification was performed on 3/31/2006.

The facility is currently working on completion of repairs of all deficiencies found during that inspection but has not completed the 5 year certification process. Documentation provided by the vendor stated that the repairs were approximately 30 percent completed.


27893

During a facility tour with staff, the facility's automatic fire sprinkler system was observed.

Merritt Building
3. On 3/6/12 at 2:12 p.m., the 2nd Floor East Inspector's Test Valve was observed. The valve was not equipped with an identification sign.

Providence Building
4. On 3/7/12 at 1:42 p.m., the 5th Floor Inspector's Test Valve was observed. The valve was not equipped with an identification sign.

Based on observation and interview, the facility failed to maintain all fire extinguishers in accordance with 1998 NFPA 10 Standard for Portable Fire Extinguishers. This was evidenced by fire extinguishers that had not been serviced in the past twelve months, extinguishers that had noted deficiencies from their annual inspection, and items that were stored in front of extinguishers which impeded access to the extinguisher. This affected four of seven floors at the Merritt Building and could potentially result in fire extinguishers failing to function properly in the event of a fire and/or a delay in access to the extinguisher when access to extinguishers are impeded.

1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

4-3 A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer 's service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 4-4.

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

4-4.4 Maintenance Record keeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Findings:

During a tour of the facility with Engineering Staff, fire extinguishers were inspected throughout the facility.

Merritt Building
1. On 3/5/12, at 2:55 p.m., the Halon fire extinguisher located in the Computer Information Technology Cold Room did not have a current annual inspection tag attached to it. The last two inspection tags were dated November 2009 and December 2010. Engineering Staff 1 confirmed the inspection dates on the extinguisher tank.
Documentation provided after the Exit Conference titled Suppression System Inspection Report dated 11/29/11, indicated that the Halon suppression system had been inspected annually, but that there were deficiencies noted.
In the comments section of the suppression system annual report the following was noted:
Note 3: stated that the tank pounds per square inch (PSI) pressure were low and that they should have been 360 PSI. The report noted that the tank pressure was 300 PSI.
Note 4: "This system releases Halon on manual pull station alarms only. Smoke detectors did not fire Halon release circuit. This is enough to fail the system".
Note 5: "One manual pull station operates intermittently".
Note 6: "Abort Station does not signal suppression panel".
When asked, Engineering Staff 1 stated that the Halon suppression system was going to be upgraded and was under an OSHPD permit.

2. On 3/6/12, at 2:54 p.m., the fire extinguisher/fire hose cabinet had pallets and boxes stored in front of it. Engineering Staff moved the boxes at that time.


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Merritt Building
3. On 3/5/12, at 10:50 a.m., on the 2nd floor South Wing, in the Medical Staff Office, the fire extinguisher was blocked by a rolling cart that was placed in front of the fire extinguisher.
4. On 3/5/2012, at 11:26 a.m., on the 2nd floor East Wing, the fire extinguisher across from shower room 2255 was blocked by a gurney.
5. On 3/5/12. at 11:30 a.m., on the 2nd floor East Wing, the fire extinguisher by room 2230 was blocked by a gurney.


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Merritt Building
6. On 3/5/12 at 11:19 a.m., a portable fire extinguisher was mounted to a wall near Room 3185B. The service tag on the fire extinguisher indicated that it had last been serviced on 2/10/11. The fire extinguisher was approximately one month overdue for an annual service and inspection.

7. On 3/5/12 at 11:19 a.m., a portable fire extinguisher was mounted to a wall in the Surgical Pathology Laboratory (Room 3113). The service tag on the fire extinguisher indicated that it had last been serviced on 2/3/11. The fire extinguisher was approximately one month overdue for an annual service and inspection.

Based on record review and interview, the facility failed to maintain its heating, ventilation, and air conditioning system, in accordance with NFPA 90A. This was evidenced by documentation indicating that dampers had not been inspected due to a lack of access to the dampers and dampers that did not function properly when tested. This finding affected three of three building surveyed and could potentially result in the spread of smoke and/or fire.

9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

2-1.1 Equipment shall be arranged to afford access for inspection, maintenance, and repair.

2-3.4 Air Duct Access and Inspection.
2-3.4.1* A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

2-3.4.5 Openings in walls or ceilings shall be provided so that service openings in air ducts are accessible for maintenance and inspection needs.

NFPA 90A 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review with Engineering Staff on 3/7/12, at 9:50 a.m., documentation for damper inspections was reviewed. Documentation indicated that dampers were inspected by Vendor 1 on 8/24/11 at the Merritt, Providence, and Peralta Buildings with the following deficiencies noted:

Merritt Building
1. Of the 915 dampers, 50 did not have access to the damper to be tested and 33 of the damper actuators did not function properly.

Providence
2. Of the approximately 571 dampers, 45 had dampers that either did not have access to or had problems with the actuator.

Peralta
3. Of the approximately 75 dampers, seven dampers were not accessible.

When asked, Engineering Staff 1 stated that the work and funding had been authorized, but there were no dates scheduled for the repairs to begin.

Based on record review, interview, and observation, the facility failed to protect its cooking facilities in accordance with 1998 NFPA 96. This was evidenced by the kitchen hood fire suppression system not being a UL-300 compliant system. This affected one of seven floors at the Merritt Building and could potentially result in the spread of smoke and/or fire.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations

7-2.2* Automatic fire-extinguishing systems shall comply with standard UL 300, Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with their listing.

Exception: Automatic fire-extinguishing equipment provided as part of listed recirculating systems complying with standard UL 197, Standard for Safety-Commercial Electric Cooking Appliances.

8-2* Inspection. An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Findings:

Merritt Building
During record review on 3/6/12 at 9:00 a.m., documentation provided for the last two semi-annual Kitchen hood fire suppression system inspections were reviewed. Documentation from Vendor 2 titled "Kitchen Fire System Service Reports" dated 4/23/11 and 10/24/11 indicated that the Cafe Kitchen Hood was not a UL-300 compliant fire suppression system, and that "a red tag was affixed to pull station to attest to this". Documentation for each inspection also indicated that the system was being maintained, but not certified.

Documentation provided from Vendor 2 dated 7/22/11 titled "Merritt Cafe UL-300 Upgrade Project Scope of Work" described work to be done to upgrade the R 102 system to a UL-300 compliant system. During an interview with Engineering Staff 1, Staff 1 stated that the work was approved to be done, but no date had been scheduled.
Observation on 3/8/12 at 10:45 a.m. of the red tag on the pull station showed a tag date of 10/20/11.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices in accordance with 2000 NFPA 101, 1999 NFPA 99, and 1999 NFPA 70. This was evidenced by unapproved portable heaters in non-sleeping staff areas of the facility that did not have proper clearance from combustible materials in accordance with the manufacturer's labeled instructions and portable space heaters that were not verified to not exceed 212 degrees Fahrenheit. This affected two of seven floors in the Merritt Building and could result in the ignition of fire.

NFPA 99, 1999 edition
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator 's, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

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

Findings:

During a facility tour with staff, electrical equipment was inspected throughout the facility.

Merritt Building
1. On 3/5/12 at 11:49 a.m., a portable space heater was observed in Staff Room 3069. The portable space heater was located within three feet of furnishings and combustibles.

2. On 3/5/12 at 1:33 p.m., a portable space heater was observed in Pre-Op Testing Room 3205. The portable space heater was within three feet of combustibles. The portable space heater had a coil heating element. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 could not confirm that the portable space heater would not exceed 212 degrees Fahrenheit.

3. On 3/5/12 at 3:01 p.m., a portable space heater was observed in Admitting Room 7 (Room G117). The portable space heater was within three feet of combustibles. The portable space heater had a coil heating element. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 could not confirm that the portable space heater would not exceed 212 degrees Fahrenheit.

4. On 3/5/12 at 3:04 p.m., a portable space heater was observed in Admissions/Bed Control Room G114. The portable space heater was within three feet of combustibles. The portable space heater had a coil heating element. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 could not confirm that the portable space heater would not exceed 212 degrees Fahrenheit. The portable space heater was plugged into a surge protected multi-outlet extension cord and not directly to an electrical wall receptacle.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items stored in an exit corridor that could impede egress during an evacuation. This affected one of seven floors at the Main Hospital Merritt Campus and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

During a tour of the facility with Engineering Staff on 3/5/12, exit corridors were inspected.

Merritt Building
1. At 4:45 p.m., the exit corridor located on the Lower Level near Stairwell 2 near Room L195 had two stacks of steel stored in the corridor against the southwest wall. One stack was pipe that was approximately eight feet long three feet wide and 18 inches high and the other one was approximately the same dimension, but was composed of square tubing. Engineering Staff 1 stated that the steel was from the new construction that was taking place.

Based on observation and interview, the facility failed to maintain safe storage of soiled linen receptacles. This was evidenced by four large soiled linen receptacles stored in a corridor and not inside a room protected as a hazardous area. This affected one of seven floors in the Merritt Building and could result in a fire to build and spread at that location.

Findings:

During a facility tour with staff, the trash and soiled linen receptacles were observed.

Merritt Building
1. On 3/5/12 at 11:23 a.m., four large soiled linen roller carts were located in the corridor near Room 3144. Each of the four soiled linen carts had a capacity greater than thirty-two gallons. Surgery Staff 1 was interviewed at that time. Surgery Staff 1 indicated that the soiled linen carts are kept at this location. Surgery Staff 1 indicated that the soiled linen carts are picked up approximately every four hours on a busy day. The soiled linen carts were not located inside a room protected as a hazardous area.

Based on observation, the facility failed to maintain safe storage of medical gas cylinders. This was evidenced by medical gas cylinders that were stored in a corridor alcove and not in a room protected as a hazardous area, light switches that were lower than five feet high from floor level, and medical gas cylinders that were free standing and unsecured. This affected three of seven floors in the Merritt Building and one of six floors in the Providence Building. This could result in a ruptured compressed gas cylinder or another medical gas cylinder initiated emergency.

NFPA 101, 2000 edition
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies
and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

NFPA 99, 1999 edition
4-3.1.1.2(a)2 Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
4-3.1.1.2(a) 3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
8-3.1.11.2(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Findings:

During a facility tour with staff, the medical gas cylinder storage locations were observed.

Merritt Building
1. On 3/5/12 at 11:03 a.m., medical gas cylinders were observed stored in a corridor alcove near Room 3125. 15 oxygen E cylinders, 12 carbon dioxide E cylinders, 4 compressed air E cylinders, 4 nitrous oxide E cylinders, 2 carbon dioxide H tanks, and 1 nitrogen H tank were located in that alcove. The medical gas cylinders were not stored inside a room protected as a hazardous area.

2. On 3/5/12 at 3:38 p.m., the Medical Gas Manifold/Storage Room L090A was observed. Two light switches in that room were mounted on the wall approximately four feet high from floor level.

3. On 3/5/12 at 3:46 p.m., one nitrogen cylinder was observed in the Plant Operations Shop (Room L080). The cylinder was free standing and unsecured.

Providence Building
4. On 3/6/12 at 11:51 a.m., one carbon dioxide cylinder was observed in Room L420. The cylinder was free standing and unsecured.

Based on record review, the facility failed to maintain the relative humidity levels at their anesthetizing locations. This was evidenced by the facility's failure to maintain relative humidity levels at 35 percent or greater at their anesthetizing locations. This affected 12 of 12 Operating Rooms in the Merritt Building and 7 of 7 Operating Rooms in the Providence Building. This could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review with staff, the facility's relative humidity records for their anesthetizing locations were observed.

Merritt Building/Providence Building
1. On 3/7/12 at 11:34 a.m., the relative humidity records for the facility's anesthetizing locations were reviewed. 12 of 12 Operating Rooms in the Merritt Building and 7 of 7 Operating Rooms in the Providence Building had experienced relative humidity levels below thirty-five percent on multiple instances during the past twelve months. The facility policy for maintaining relative humidity levels at anesthetizing locations was requested. The humidity policy indicated that the facility will maintain relative humidity between 30 and 70 percent at their anesthetizing locations.

Based on record review and interview, the facility failed to establish required laboratory emergency procedures. This was evidenced by the facility's failure to establish an emergency procedure for extinguishing clothing fires. This affected one of seven floors in the Merritt Building and could result in clothing fire injury to laboratory staff.

NFPA 99, 1999 edition
10-2.1.3 Emergency Procedures.
10-2.1.3.2 Emergency procedures shall be established for controlling chemical spills.
10-2.1.3.3 Emergency procedures shall be established for extinguishing clothing fires.

NFPA 101, 2000 edition
19.3.2.2 Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

Findings:

During record review with staff, the facility's laboratory policies and procedures were reviewed.

Merritt Building
1. On 3/8/12 at 9:45 a.m., the laboratory specific emergency policies and procedures were reviewed. There was no emergency procedure regarding the extinguishment of clothing fires in the laboratory. Lab Staff 1 was interviewed at that time. Lab Staff 1 indicated that the facility does not have a specific procedure regarding extinguishment of clothing fires in the laboratory.

Based on observation and interview, the facility failed to maintain their emergency generator. This was evidenced by the facility's failure to maintain emergency generator alarm annunciators for five of seven emergency generators. This affected three of four buildings observed and could result in a delayed notification of a malfunctioning emergency generator.

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

Findings:

During a facility tour with staff, the facility's emergency generators were observed.

Merritt Building
1. On 3/8/12 from 10:00 a.m. to 10:40 a.m., the building had three diesel fueled emergency generators. There were no remote emergency generator alarm annunciators observed in the building. Engineer Staff 2 was interviewed at that time. Engineer Staff 2 indicated that the facility does not have alarm annunciators for the three emergency generators at a location regularly attended. Engineer Staff 2 indicated that the facility was in the process of having the three generators wired to a computer monitoring system located in the Plant Operations Department in the Providence Building.

Peralta Building
1. On 3/8/12 from 10:00 a.m. to 10:40 a.m., the building had one diesel fueled emergency generator. There was no remote emergency generator alarm annunciator observed in the building. Engineer Staff 2 was interviewed at that time. Engineer Staff 2 indicated that the facility does not have an alarm annunciator for the emergency generator at a location regularly attended.

3012 Summit Building
1. On 3/8/12 from 10:00 a.m. to 10:40 a.m., the building had one diesel fueled emergency generator. There was no remote emergency generator alarm annunciator observed in the building. Engineer Staff 2 was interviewed at that time. Engineer Staff 2 indicated that the facility does not have an alarm annunciator for the emergency generator at a location regularly attended.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70 and 1999 NFPA 99. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, the permanent use of extension cords and multiple outlet adapters, and improper clearance in front of electrical panels. This affected five of seven floors at the Merritt Building could potentially result in the ignition of fire.

NFPA 70, 1999 edition
110-26 (a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less.
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(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.
800-5. Access to Electrical Equipment Behind Panels Designed to Allow Access. Access to equipment shall not be denied by an accumulation of wires and cables that prevents removal of panels, including suspended ceiling panels.
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4)Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection\
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b)& 305-4 c)
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

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

Findings:

During a tour of the facility with Engineering Staff, electrical wiring and equipment were observed in the following locations:
1. On 3/5/12, at 11:55 a.m., the Office near Pulmonary Services had a coffee pot plugged into a power strip.

2. On 3/5/12, at 2:30 p.m., the Sterile Supply Office had a power strip suspended above the floor that was transferring tension to the joint and terminals.

3. On 3/5/12, at 4:30 p.m., the Main Electrical Room L195 in the Lower Level had seven electrical conduit bodies on the northeast wall that had the plate covers missing. There was also an approximately eight inch by eight inch junction box on the northwest wall that had the cover removed.


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Merritt Building
4. On 3/5/12, at 10:17 a.m., on the 5th floor East Wing room 5282, an extension cord was attached to the wall with fasteners.
5. On 3/5/12, at 10:55 a.m., on the 5th floor South Wing room 5114, the cover plate for the wall outlet on the left hand wall was not flush with the wall. There was a cable running under the cover plate that lifted the plate approximately one inch.
6. On 3/5/12, at 11:05 a.m., on the 5th floor South Wing room 5132, the cover plate for the wall outlet on the left hand wall was not flush with the wall. There was a cable running under the cover plate that lifted the plate approximately one inch.
7. On 3/5/12, at 1:15 p.m., on the 1st floor North Wing room 1344 ABG Lab, the printer was plugged into a power strip instead of directly into the wall outlet.
8. On 3/5/12, at 1:45 p.m., on the 1st floor North Wing Emergency Department Office, a microwave and a small refrigerator were plugged into a power strip instead of directly into the wall outlet.
9. On 3/5/12, at 1:46 p.m., on the 1st floor North Wing Emergency Department Office, a power strip was plugged into another power strip instead of directly into the wall outlet. One power strip was being used for computer equipment.
10. On 3/5/12, at 1:49 p.m., in the Merritt Building Pharmacy on the 1st floor, a small refrigerator and and a printer were plugged into a power strip instead of directly into the wall outlet.
11.On 3/5/12, at 1:51 p.m., in the Merritt Building Pharmacy, a small refrigerator was plugged into a power strip instead of directly into the wall outlet.
12. On 3/5/12, at 1:57 p.m., on the 1st floor in the Laboratory, an extension cord was used for a printer and two blood culture cookers.
13. On 3/5/12, at 2:27 p.m., on the 1st floor in room 1149, an IV pump and a cauterizing machine were plugged into a power strip instead of directly into the wall outlet.
14. On 3/5/12, at 2:36 p.m., in the X-Ray Core area, the outlet face plate cover was coming off the wall and was held in place with painters tape.

Providence Building
15. On 3/6/12, at 10:24 a.m., on the 2nd floor room 2564, a TractMaster treadmill was plugged into an extension cord instead of directly into the wall outlet.
16. On 3/6/12, at 10:40 a.m., on the 2nd floor in the Pantry Room 2435, a refrigerator was plugged into an extension cord instead of directly into the wall outlet.
17. On 3/6/12, at 10:43 a.m., on the 2nd floor Storage Room 2415, 1 of 2 electrical panels were blocked by two shred bins.
18. On 3/6/12, at 10:52 a.m., on the 2nd floor Med RFef/Storage room 2463, one of two electrical panels was blocked by a rolling cart.


27893

Merritt Building
19. On 3/5/12 at 11:32 a.m., office equipment in Room 3103 was plugged into a surge protected multi-outlet extension cord that was plugged into a black non-surge protected extension cord. A paper shredder at that location was plugged into a non-surge protected multi-outlet adapter.

20. On 3/5/12 at 12:08 p.m., television equipment in Rooms 3010, 3012, 3014, and 3016 was plugged into non-surge protected multi-outlet adapters.