HospitalInspections.org

7/18/12 - Same Day Surgery (1401 Spanos Ct)
2. At 4:03 p.m., there was a 3/4 inch unsealed flexible conduit in the attic access of the separation wall in the hallway to the elevators. There was a 3/4 inch unsealed conduit around blue, red, white, gray and black wires. There was a 1/2 inch conduit around a brown wire penetrating the wall.




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Based on observation, the facility failed to maintain the fire barrier wall between buildings. This was evidenced by penetrations in two fire barrier walls in two of five buildings. This affected the wound clinic and the outpatient surgery center and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the main hospital and the outpatient clinics were observed.

7/18/12 - Wound Clinic (1329 Spanos)
1. At 2:55 p.m., there were two approximately 1 inch penetrations in the center of the fire barrier wall between the wound clinic and the adjacent suite.

Based on observation and interview, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in the walls and ceilings. This could result in the spread of smoke from one area to another, in the event of a fire, and affected 1 of 5 floors in the south tower and 4 of 8 floors in the north tower of the main hospital.

Findings:

During the facility tour with staff from 7/16/12 to 7/20/12, the ceilings and walls were observed.

7/18/12 - South Tower - 1st Floor
1. At 9:27 a.m., there were two approximately 3 to 4 inch unsealed pipe sleeves in the IT closet, in the Radiology Department. There were two bundles of wires inside the pipe sleeves. The pipe sleeves were on the left side of the room, penetrating the ceiling.

During an interview, Staff 3 reported that the open pipe sleeves were created during the EHR (Electrical Health Information Records) project that took place approximately 6 months ago.

2. At 9:56 a.m., there was an approximately 2 x 3 inch penetration in the Modular Cabinet room next to the nurses station in the Radiology Department. The penetration was on the left side.

3. At 11:20 a.m., there was an approximately 1 x 6 inch square cut out penetration in the right wall of the Physicians Dictation Room in the GI Lab. The penetration was underneath the first desk.


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4. At 1:32 p.m., there was an approximately 10 inch by 10 inch attic access in the ceiling of the C.S. Hallway electrical closet. One corner of the access was open at approximately 1/2 inch from the ceiling.

7/16/12 - North Tower
5. At 4:21 p.m., there was an approximately 1 1/2 inch penetration around a drain pipe, and an approximately 1 inch unsealed electrical conduit, in the ceiling of the seventh floor, North Tower.

6. At 4:24 p.m., there was an approximately 3 inch penetration around a vent pipe, in the ceiling of the seventh floor, North Tower. The penetration was partially sealed with yellow fiber-like substance.

During an interview at 4:25 p.m., Staff 5 stated that he was unsure what the fiber like substance was, or if it was fire-rated. He confirmed that the penetration was partially sealed.

7/17/12 - North Tower
7. At 2:01 p.m., there was an approximately 1 1/2 inch penetration behind the bed in Room N4224 on the fourth floor of the North Tower.

8. At 4:01 p.m., there were two approximately 2 inch conduits in the ceiling of the communication closet of the OR Conference Room on the third floor of the North Tower. The conduits were unsealed.

7/18/12 - North Tower
9. At 9:34 a.m., there were two approximately 2 inch conduits in the ceiling of the electrical closet in the Sierra Conference Room on the first floor of the North Tower. The conduits were unsealed.

10. At 9:37 a.m., there were two approximately 2 inch conduits in the ceiling of the electrical closet in the Foothill Conference Room on the first floor of the North Tower. The conduits were unsealed.

11. At 10:01 a.m., there was an approximately 1/2 inch penetration around two conduits, and an approximately 1/4 inch penetration around four conduits in the sterile processing soap room on the first floor of the North Tower.

12. At 10:16 a.m., there were six approximately 5 inch conduits in the ceiling of the basement telecom room. The conduits were unsealed.

7/17/12 - South Tower - 5th Floor
25. At 2:41 p.m., the self-closing corridor door to the DTC Nurses Station failed to fully close and latch. The door was tested three times.

7/17/12 - South Tower - 3rd Floor
26. At 4:03 p.m., the corridor door to Room S3315 was impeded from closing by a COW (computer on wheels), directly in the door's swing path.
During an interview, Staff 2 reported that the nursing staff indicated the COW was just brought into the room.
27. At 4:05 p.m., the corridor door to Room S3313 was impeded from closing by a trash can. The trash can was in the door's swing path.
28. At 4:22 p.m., the corridor door to Room S3703 was impeded from closing by a trash can directly in the door's swing path.
29. At 4:26 p.m., the corridor door to Room S3705 was impeded from closing. There was a Geri Chair directly in front of the door.

7/18/12 - South Tower - 3rd Floor
30. At 8:30 a.m., the self-closing corridor door to the shower room by Room 3743, closed but failed to latch. The door was tested four times.
31. At 8:34 a.m., the corridor door to Room S3745 closed and latched. There was an approximately 1 inch gap between the door and the door frame.

During an interview at 8:35 a.m., Staff 3 stated that the striker plate was missing.

32. At 8:56 a.m., the self-closing corridor door to the "Employees Only" Restroom failed to close and latch.
33. At 9 a.m., the corridor door to Room S3763 closed but failed to latch. The door was tested three times.
34. At 9:02 a.m., the self-closing corridor door to the clean linen closet, by Room S3765, failed to fully close and latch. The door was tested four times.

7/18/12 - South Tower - 1st Floor

35. At 9:54 a.m., the self-closing corridor door to the women's changing room, in Radiology, failed to fully close and latch. The door was tested three times.
36. At 9:55 a.m., the self-closing corridor door to the men's changing room, in Radiology, failed to fully close and latch. The door was tested three times.
37. At 10:33 a.m., the door inside the Data Collection office, in the Chest Pain Center Office, was held open with a shredder. The door was obstructed from closing.
38. At 10:37 a.m., the door to the Data Collection office storage room was obstructed from closing by a floor lamp.
39. At 11:50 a.m., the self-closing corridor door to the old OR Room 5 failed to fully close and latch. The door was tested four times.
40. At 11:52 a.m., the self-closing corridor door to the sterilizer room, by the old OR Room 5, closed but failed to latch. The door was tested four times.
41. At 2:10 p.m., the self-closing corridor door, to the office next to the Pain Chest Center, failed to close and latch. The self-closer was missing the arm part of the mechanism.

7/18/12 - Pulmonary Rehab Services (1800 Coffee Rd)

42. At 3:10 p.m., the corridor door to Pulmonary Rehab Ed Room closed but failed to latch. During an interview at 3:10 p.m., Staff 1 reported that the door was missing the striker plate.


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7/18/12 - South Tower - 1st Floor
43. At 2:10 p.m., the electrical closet, next to the Trauma Department, had a self-closing door. The door closed but failed to latch.
44. At 3:15 p.m., the janitorial closet in the outpatient surgery center, had a self-closing door. The door closed but failed to latch.
45. At 11:04 a.m., on 7/19/12, the door to the CT Room was held open by a magnetic automatic closing device. Upon activation of the fire alarm system, the door released from the magnet. The door closed but failed to latch.





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Based on observation and interview, the facility failed to maintain their corridor doors, as evidenced by self-closing doors that failed to latch, by doors obstructed from closing, and by doors that failed to latch when closed. This could result in the spread of smoke and fire in the event of a fire. This affected 5 of 5 floors in the South Tower, 2 of 8 floors in the North Tower, the Outpatient Surgery Center, and the Pulmonary Rehab Services.

Findings:

During the facility tour with staff, from 7/16/12 to 7/20/12, the corridor doors were observed.

7/17/12 - South Tower - 4th Floor

1. At 1:33 p.m., the door to Room S4729 failed to latch when closed. Three attempts were made to close and latch the door.
2. At 1:53 p.m., the door to the men's bathroom, near pediatrics, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to latch the door.

During an interview at 1:54 p.m., the Maintenance Engineer reported the door handle was in the upward position and a new spring was needed to close the door.

South Tower - 2nd Floor

3. At 1:55 p.m., the door to the Cardio Pulmonary Department, was equipped with a self-closing device. The door closed but failed to latch. The latch hit the strike plate. There was a sign posted on the door that read "work order submitted on 7/17/12."
4. At 2:34 p.m., the interior door to the Telecommunication Room was obstructed by a blue, three tier rack, with three 5 gallon water bottles in the rack. The door was prevented from closing. Maintenance Staff moved the rack.
5. At 2:47 p.m., the interior door to the Mechanical Room was obstructed by two gray 32 gallon plastic garbage cans. The garbage cans were labeled "Biohazard."
6. At 2:49 p.m., the door to the Mechanical Room was equipped with a self-closing device. The door closed but failed to latch. Three attempts were made to close and latch the door.
7. At 3 p.m., the door to Room S2757 was equipped with a self-closing device. The door closed but failed to latch. Three attempts were made to close and latch the door.
8. At 3:14 p.m., the fire door located at the ICU Nurses Station was obstructed by a BiPap machine.
9. At 3:22 p.m., the interior door in the Hospitalist Office was held open with a 30 inch beige garbage can. The door was obstructed from closing.

7/18/12 - South Tower - 1st Floor

10. At 8:40 a.m., the door located at the Charting Nurses Station, next to the Nursery, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
11. At 9:18 a.m., the door to the Emergency Educator Room was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
12. At 9:23 a.m., the door to Exam Room 20 was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
13. At 9:25 a.m., the door to the lab draw station was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
14. At 9:45 a.m., the door to the restroom located in C-POD 30-37 failed to latch when closed.
15. At 9:49 a.m., the door to the clean utility room, located in D-POD 38-45 Emergency Department (ED), was equipped with a self-closing device.
The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
16. At 9:52 a.m., the door to the soiled utility room, located in D-POD 38-45 ED, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
17. At 10:01 a.m., the door to the ED storage locker room, located next to Hall 10 Exam Room 14, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
18. At 10:04 a.m., the door to the storage room, located next to Exam Room 16-17, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
19. At 11:23 a.m., the door to Room 2, in the Non-Invasive Cardiology Department, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch.
20. At 11:28 a.m., the door to the Cath Lab soiled utility room was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch.
21. At 11:36 a.m., the double doors near PDCU were equipped with a self-closing device. The door closed but failed to latch.

7/18/12 - North Tower - 1st Floor

22. At 1:24 p.m., the interior door to the storage room was equipped with a self-closing device. The door closed but failed to latch. The latch hit the strike plate.
23. At 1:41 p.m., the door to the cardboard breakroom was equipped with a self-closing device. The door closed but failed to latch.

North Tower - Outside
24. On 7/19/12 at 1:38 p.m., the interior door located in the tissue room was obstructed by a 6 foot tall shelf and a double shelf wheeled cart.

7/17/12 - North Tower - 4th Floor

46. At 1:50 p.m., on 7/17/12, the restroom, near the visitor lobby, had a self-closing door. The door closed but failed to latch.

47. At 3:19 p.m., the door to the materials manager's office, on the third floor, had a self-closing door. The door closed but failed to latch.

Based on observation and interview, the facility failed to maintain their exit signs, as evidenced by two exit signs with unlit bulbs. This affected one of five floors of the South Tower and could result in a delay in evacuation, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

Findings:

During the facility tour with staff, from 7/16/12 to 7/20/12, the exit signs were observed.
7/18/12 - South Tower - 1st Floor

1. At 2:04 p.m., the exit sign on top of the smoke barrier door, in the old OR hallway, was not lit. During an interview at 2:05 p.m., Staff 5 stated that two of two bulbs in the exit sign needed to be replaced.

7/19/2 - South Tower - 1st Floor

2. At 11:24 a.m., the exit sign on top of the exit door in the radiotherapy department, was not lit. During an interview at 11:25 a.m., Staff 5 stated that two of two bulbs in the exit sign needed to be replaced.

Based on observation and interview, the facility failed to ensure that smoke barrier walls maintain a 1/2 hour fire resistance rating. This was evidenced by 9 smoke barrier walls that had penetrations around wires and pipes. This affected 3 of 5 floors in the in the South Tower and 1 of 8 floors in the North Tower, and could result in the spread of smoke from one compartment to another, in the event of a fire.

8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 of 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:
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 the facility tour with staff from 7/16/12 to 7/20/12, the smoke barrier walls in the facility were observed.

7/16/12 - South Tower - 3rd Floor

1. At 4:40 p.m., there was an approximately 1/4 inch penetration inside a 3/4 inch conduit, in the smoke barrier wall between the waiting room and the door marked "Stair S Down." The conduit was partially filled with red material. The conduit was in the smoke barrier wall directly in front of the attic access.
2. At 4:58 p.m., the fire damper inspection door was left open above the smoke barrier wall by the EKG/EEG Department.
During an interview, Staff 3 stated that maintenance staff probably checked the ventilation and left the door open.

7/17/12 - South Tower - 2nd Floor

3. At 8:25 a.m., there was an approximately 1/2 inch penetration on the left side of a 1/2 inch flexible, electrical conduit, in the smoke barrier wall by the hospital office and Exit Stair S Down.

7/17/12 - South Tower - 1st Floor

4. At 8:43 a.m., the smoke barrier wall by the Nourishment Room had an approximately 1/4 to 1/2 inch penetration inside a 3/4 inch conduit. There were 2 green wires, and 1 blue wire inside the conduit.
5. At 8:55 a.m., there was an approximately 3/4 to 1 inch penetration around wires, inside a 4 inch conduit in the smoke barrier wall by the Family Birthing Center.
6. At 10:35 a.m., there was an approximately 1 x 3 inch penetration on the upper right side of the wall, in the AMDC Building smoke barrier, by elevator 8.
7. At 10:50 a.m., there was an approximately 1/2 inch unsealed conduit in the smoke barrier wall between the Cardiology Department and Nuclear Medicine. A white and a green wire were inside the conduit. There was an approximately 1/4 to 1/2 inch penetration below the 1/2 conduit. The penetrations were directly at the attic access.
8. At 11:05 a.m., there was an approximately 2 inch unsealed pipe sleeve, penetrating the smoke barrier wall by the dietary storage area and the kitchen. To the left of the unsealed pipe sleeve, there was an approximately 1 inch round penetration around a blue wire.

7/17/12 - North Tower - 1st Floor

9. At 10:24 a.m., the smoke barrier wall in the administration corridor was observed. There was an approximately 1 1/2 inch penetration around a bundle of cables, and an approximately 1/2 inch penetration around an electrical conduit, in the center of the wall.

Based on observation and interview, the facility failed to ensure that the smoke barrier doors are capable of resisting the passage of smoke, and that the doors are self-closing. This was evidenced by nine smoke barrier doors that failed to fully close and latch during testing of the fire alarm system. This affected 4 of 5 floors in the South Tower, and could result in the spread of smoke or fire from one smoke compartment to another, in the event of a fire.

Findings:

During alarm testing with staff on 7/19/12, the smoke barrier doors were observed.

South Tower - 3rd Floor
1. At 9:33 a.m., the left side smoke barrier door, between by the nurse's station and Room S3711, closed but failed to latch after activation of the fire alarm system.

South Tower - 2nd Floor
2. At 10:17 a.m., the left side smoke barrier door, by Room S2711, closed but failed to latch after activation of the fire alarm system.

South Tower - 1st Floor
3. At 11:05 a.m., the left smoke barrier door, by Radiology, failed to fully close and latch after activation of the fire alarm system.
4. At 11:13 a.m., the right door to the smoke barrier door, by exam Room 22 in Radiology, failed to fully close and latch after activation of the fire alarm system. The right door remained partially open. There was an approximately 1 to 1 1/4 inch gap between the doors.
5. At 11:36 a.m., the left smoke barrier door by OR 8, closed but failed to latch, after activation of the fire alarm system.


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South Tower - 2nd Floor
6. At 10:23 a.m., the double doors to the elevator lobby were held open by magnetic automatic closing devices. Upon activation of the fire alarm system the doors released and closed. The left door failed to latch.


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South Tower - 4th Floor
7. At 9:07 a.m., the Conference Room smoke barrier double doors, near East Nurses Station, failed to latch during fire alarm testing.

South Tower - 3rd Floor
8. At 9:23 a.m., one side of the fire protection curtain doors, in front of Elevator 7, failed to latch during fire alarm testing. There was an approximately 3 1/2 inch gap at the left door.

During an interview, the Maintenance Engineer reported the smoke seal around the door was too thick.

South Tower - 1st Floor
9. At 10:30 a.m., the smoke barrier doors located in Labor and Delivery, near Room S1023, failed to latch during fire alarm testing. The left door failed to latch.
10. At 10:55 a.m., the smoke barrier door on the south side of the Radiology Department, near Room 30-37, failed to close completely during fire alarm testing. There was an approximately 1 1/2 foot gap.
11. At 10:57 a.m., the smoke barrier door marked 2, near the Emergency Room waiting area, failed to latch during fire alarm testing. The left door failed to latch.
12. At 11:27 a.m., the smoke barrier door to the ANDC Lobby near S191, failed to latch during fire alarm system testing.

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by smoke resistant partitions and self closing doors. This was evidenced by hazardous storage areas without self closing doors, by doors that self closed but failed to latch, and by wall penetrations in one hazardous storage area. This could result in the spread of smoke or fire affecting 1 of 5 floors in the South Tower, and in the Outpatient Surgery Center in the event of a fire.

Findings:

During a tour of the facility with staff on 7/18/12, the walls and doors to hazardous areas were observed. Combustible storage areas greater than 50 square feet in size are considered hazardous. The doors are required to self close and latch.

7/18/12 - South Tower - Third Floor
1. At 8:46 a.m., there was no self closing door on the equipment storage room S3757. The room is greater than 50 square feet in size and contained more than 45 cardboard boxes of office supplies, and three 4 shelf units, storing loose paper, binders and folders. There was a copy machine, a wheelchair with an "E" oxygen tank attached to the chair, office chairs, 6 COW (computer on wheels) units, patient equipment, and other miscellaneous storage in the room.

2. At 11:22 a.m., the soiled scope room, in the GI Lab, contained one soiled linen container, one linen container, and one trash container. There was no self closing hardware on the door. The room is greater than 50 square feet in size.



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7/18/12 - Outpatient Surgery Center
3. At 3:16 p.m., the equipment storage room was approximately 120 square feet in size. The room was approximately 60 percent filled with equipment wrapped in plastic. There was an approximately 1/2 inch penetration in the left wall of the room and the self-closing door of the room failed to latch.

Based on observation and interview, the facility failed to maintain their emergency lighting. This was evidenced by one emergency battery back-up light that failed to illuminate and by no records for maintaining the light. This affected one of four outpatient buildings, and could result in no lighting and a delay in evacuation, in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the emergency lighting units in the facility were observed.

7/18/12 - Wound Clinic
At 2:50 p.m., the battery bullfrog light, outside the Ostomy Room, failed to illuminate when tested.

During an interview at 2:51 p.m., Staff 2 stated that the lighting unit had not been maintained and that no records for testing were available.

5. At 2:30 p.m., the pull station located in the Central Supply Distribution Center did not have clear access. The pull station was obstructed by a copy machine that was directly in front of the pull station.



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Based on observation, the facility failed to maintain their fire alarm system in accordance with NFPA 72. This was evidenced by pull stations that were obstructed, and by alarm notification devices that failed. This affected two of five floors in the South Tower and could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code - 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.

NFPA 72 National Fire Alarm Code 1999 edition
2-8.1 Mounting. Each manual fire alarm box shall be securely mounted. The operable part of each manual fire alarm box shall be not less than 3 1/2 ft (1.1 m) and not more than 4 1/2 ft (1.37 m) above floor level.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the fire alarm system was observed.

7/18/12 - South Tower - 2nd Floor
1. At 8:29 a.m., on 7/18/12, the pull station in the microbiology lab was obstructed by a refrigerator.

7/19/12 - 2nd Floor
2. At 10:15 a.m., the combination audible/visual notification device, at the ICU nurses station across from Room 35, was observed during fire alarm testing. The chime failed to alarm upon activation of the fire alarm system.

7/19/12 - 1st Floor
3. At 11:15 a.m., the combination audible/visual notification device near the men's bathroom in the ED waiting room, was observed during fire alarm testing. The chime failed to alarm upon activation of the fire alarm system.

4. At 11:36 a.m., the combination audible/visual notification device near the dictation office, in the observation department, was observed during fire alarm testing. The chime failed to alarm upon activation of the fire alarm system.

Based on observation and interview, the facility failed to maintain their smoke detectors. This was evidenced by one smoke detector that failed to alarm when tested. This affected the one of four outpatient buildings, and could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code.

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

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the smoke detectors were observed in the facility.

At 2:41 p.m., on 7/18/12, the single station smoke detector in the Wound Clinic hallway was tested using the push-button. The smoke detector failed to alarm.

During an interview at 2:42 p.m., records were requested for maintenance and testing of the smoke detector. Staff 2 stated that the detector had not been tested as required. Staff 2 reported there were no records for testing the detector or changing the batteries.

7/17/12 - South Tower - 5th Floor

7. At 1:41 p.m., there was an approximately 1 inch gap between the escutcheon ring and the ceiling, inside Restroom S5325, exposing an approximately 1/2 inch penetration around the sprinkler pipe.
8. At 1:56 p.m., there was an approximately 1/2 to 3/4 inch gap between the escutcheon ring and ceiling in the Renal Tally Management Office. This exposed an approximately 1/4 to 1/2 inch penetration around the sprinkler pipe.
9. At 2:02 p.m., there was an approximately 1 inch gap between the escutcheon ring and the ceiling, in the corridor near Room S 5709. This exposed an approximately 1/2 inch penetration around the sprinkler pipe.
10. At 2:18 p.m., the escutcheon ring in the Renal Dialysis Break Room was missing, exposing an approximately 1 inch penetration around the sprinkler pipe.
11. At 2:27 p.m., the escutcheon ring in the RO Room (Reverse Osmosis) was missing, exposing an approximately 2 1/2 inch penetration around the sprinkler pipe.

7/18/12 - South Tower - 3rd Floor

12. At 8:22 a.m., the sprinkler deflector in Room S3719 was contaminated with lint and dust. The sprinkler deflector outside Room S3719 had a thick layer of lint and dust.

7/18/12 - South Tower - 1st Floor

13. At 10:30 a.m., there was an approximately 1/2 inch gap between the escutcheon ring and the ceiling in the GI Endoscopy Office waiting area. This exposed an approximately 1/4 inch penetration around the sprinkler pipe.


7/18/12 - Pulmonary Rehab Services
14. At 3:08 p.m., two of eight escutcheon rings in the office area had an approximately 3/4 to 1 inch gap between the escutcheon ring and the ceiling. This exposed an approximately 1/2 inch penetration around the sprinkler pipes.


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7/18/12 - South Tower - 1st Floor

15. At 1:37 p.m., the escutcheon ring in the paint room, was approximately 1 inch from the ceiling.









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Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by sprinkler escutcheon rings that were not flush to the ceiling, by missing escutcheon rings and by one sprinkler head coated with foreign material. Escutcheon rings are used to cover penetrations around sprinkler pipes and sprinkler heads. This could result in the spread of smoke or an obstruction of the sprinkler spray pattern. This affected 4 of 5 floors in the South Tower, 1 of 8 floors in the North Tower, and the Pulmonary Rehab Services.

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

Findings:

During the facility tour with staff on 7/17 and 7/18/12, the complete sprinkler system was observed.

7/17/12 - South Tower - 2nd Floor

1. At 2:43 p.m., the escutcheon ring was missing, in the laboratory outpatient bathroom.
2. At 2:52 p.m., the escutcheon ring was not flush to the ceiling, exposing an approximately 2 1/2 inch penetration around the sprinkler, in the supply closet near Room S2735.
3. At 2:55 p.m., the escutcheon ring was not flush to the ceiling, exposing an approximately 3 inch penetration, in the clean linen closet near Room S2745.
4. At 3:12 p.m., the escutcheon ring was not flush, in the Assistant ICU Manager's Office. This exposed an approximately 2 inch penetration around the sprinkler.

7/18/12 - South Tower - 1st Floor

5. At 9:14 a.m., the escutcheon ring was not flush to the wall, exposing an approximately 2 1/2 inch penetration around the sprinkler head, in the Chapel.

7/18/12 - South Tower - 2nd Floor

6. At 11:25 a.m., the escutcheon ring was not flush to the ceiling, exposing an approximately 2 inch penetration around the sprinkler, in the bathroom in the Non-Invasive Cardiology Department.

7/17/12 - North Tower - 5th Floor

16. At 11:51 a.m., the sprinkler head was missing an escutcheon ring, revealing an approximately 1 inch penetration around the sprinkler pipe, in the corridor outside the telecom room.

7/16/12 - North Tower

3. At 4:09 p.m., a fire extinguisher, in the penthouse of the North Tower was unsecured on the floor. The tag on the extinguisher indicated that it had not been serviced since 4/3/07 and that no monthly checks were conducted.

4. At 4:20 p.m., the fire extinguisher was obstructed by six mattresses, near the bed storage area on the sixth floor, of the North Tower.

Based on observation, the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This was evidenced by fire extinguishers that were unsecured, by one fire extinguisher that was obstructed, and by one fire extinguisher that was not serviced annually. This affected one of five floors of the South Tower and two of eight floors of the North Tower. This could result in a delay in extinguishing a fire, in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

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

4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
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.

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the fire extinguishers were observed.
7/18/12 - South Tower - 1st Floor

1. At 1:36 p.m., the fire extinguisher was standing unsecured on the floor, in the elevator equipment room, near the CS Hallway.

2. At 1:56 p.m., the tag on the fire extinguisher, in the clean linen room, indicated that the last annual service on the extinguisher was conducted on 6/13/08. There were three monthly checks on the tag dated 8/5/08, 9/5/08, and 10/6/08. There were no current monthly checks for the extinguisher and no current annual certification.

Based on observation, the facility failed to ensure that a capacity of 32 gallons of soiled linen or trash collection receptacles is not exceeded within any 64 square foot area. This was evidenced by multiple receptacles placed in three areas in the facility. The facility also failed to ensure that these receptacles when not attended are located in a room protected as a hazardous area. This failure could result in a fire, in an unprotected area, on 2 of 5 floors in the South Tower.

Findings:

During the facility tour with facility staff on 7/17 and 7/18/12, soiled linen and trash receptacles (carts) were observed.

7/17/12 - South Tower - 3rd floor

1. At 4:10 p.m., there were a trash and a Biohazard container lined up, side by side, against the wall in patient Room 3303. The containers were 23 gallons in size.

2. At 4:11 p.m., there were a trash and a Biohazard container lined up, side by side, against the wall in patient Room 3301. The containers were 23 gallons in size.

7/18/12 - South Tower - 1st floor
3. At 10:55 a.m., there were two soiled linen containers, one trash container and one Biohazard bin lined up, side by side, against the wall in the GI Post Lab. The containers were 23 gallons in size.

3. 7/17/25 - South Tower - 3rd Floor
At 3:58 p.m., the oxygen storage room had full and empty E size cylinders stored in the same rack. During an interview, nursing staff identified two empty cylinders, two nearly empty, four half full and one 1/3 full.

7/18/12 - South Tower - 3rd Floor
4. At 8:53 a.m., the oxygen storage room had full and empty E size cylinders stored in the same rack. During an interview, nursing staff confirmed that the empty rack had 2 empty cylinders, three 3/4 full cylinders and one nearly empty cylinder.






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Based on observation and interview, the facility failed to maintain their medical gas storage. This was evidenced by light switches that were less than 5 feet from the floor in two medical gas storage rooms, by combustibles stored adjacent to oxygen cylinders, and by empty and full cylinders stored together. This affected the oxygen storage room for the main hospital, the medical gas supply room for the ambulatory surgery center, and 1 of 5 floors on the South Tower. This could result in damage to the electrical outlets and an increased risk of a fire and result in a delay in providing residents with full cylinders of oxygen in an emergency.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.

4-3.5.2.2 Storage of Cylinders and Containers. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the medical gas storage areas were observed.

1. At 2:47 p.m., on 7/17/12, the exterior concrete oxygen storage room, across from central plant, was observed. The inside of the room was divided by a wire fence and there were more than 75 oxygen E cylinders stored in one half of the room. The light switch in the room was approximately 4 feet from the floor. Immediately adjacent to the oxygen cylinders, on the other side of the fence, was an area designated for combustible housekeeping storage. More than 10 mattresses and five cardboard boxes of supplies were in the storage area.

7/18/12
2. At 4:15 p.m., the medical gas supply room, on the floor below the ambulatory surgery center, was observed. The light switch in the room was approximately 4 feet from the floor.

Based on observations and interview, the facility failed to maintain their electrical equipment and utilities in accordance with NFPA 70 and NFPA 99. This was evidenced by electrical panels that were not maintained with 36 inch clearance, by the use of extension cords and surge protectors, by high amp machines that were plugged into surge protectors, by the use of adapters, and by missing electrical cover plates. This affected 3 of 5 floors in the South Tower, 6 of 8 floors in the North Tower, the Wound Clinic, and Cardiac Rehab Services and Pulmonary Rehab Services. This could result in an increased risk of an electrical fire to occur.

NFPA 70 National Electrical Code 1999 Edition
110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of suck equipment. Where energized parts are exposed, the minimum clear work space shall not e less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.
(a) Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

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

240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

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

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.

NFPA 99
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patients care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

3-3.3.3 Receptacle Testing in Patient Care Areas
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces).

Findings:

During the facility tour with staff on 7/17 and 7/18/12, the electrical equipment and wiring were observed.

7/17/12 - South Tower - 1st Floor

1. At 9:20 a.m., there was an approximately 4 x 4 inch electrical box, above the ceiling tile, by the smoke barrier wall at the Director of Imaging Office. There was no cover on the electrical box.
2. At 10:18 a.m., there was an approximately 4 x 4 inch electrical box with no cover, above the ceiling tile, by the smoke barrier wall at EAU, Recovery/Observation.
3. At 10:51 a.m., there was an approximately 4 x 4 inch electrical box with no cover, above the ceiling tile, by the smoke barrier wall between Cardiology and Nuclear Medicine.
4. At 10:55 a.m., there were four approximately 4 x 4 inch electrical boxes with no covers, above the ceiling tile, by the smoke barrier wall near the Mail Room. The covers were laying on the ceiling tile.

7/17/25 - South Tower - 5th Floor

5. At 1:35 p.m., there was a surge protector connecting a mid size refrigerator to the electrical outlet, in the Nurse Educator Cancer Services Office.
6. At 1:38 p.m., there was a food cart parked directly in front of electrical panel 5NLB.
7. At 2 p.m., there was a surge protector connecting a blanket warmer and a personal wipe warmer to the electrical outlet in Room S5705.
8. At 2:25 p.m., there was a 6 foot ladder, ceiling tile and 2 boxes of light bulbs stored directly in front of electrical panel C-5B in the Dialysis Electrical Room. The 6 foot ladder was leaning against the panel.

7/17/12 - South Tower - 3rd Floor

9. At 3:17 p.m., there was a mid size refrigerator, a laptop, and a desk light connected to a six plug surge protector in the Service Line Coordinator's Office.
10. At 3:27 p.m., there was a broken electrical receptacle cover plate in Room S3343.
11. At 3:39 p.m., there was a refrigerator, a water cooler, and a monitor connected to a six plug surge protector in the nourishment room in the Nurses Station, across from Room S3335.
12. At 3:50 p.m., there was a broken electrical receptacle cover plate inside the ICU Classroom.
13. At 3:51 p.m., there was an electrical receptacle cover plate missing in the ICU Classroom.

7/18/12 - South Tower - 3rd Floor

14. At 8:38 a.m., there an approximately 3 x 9 inch square penetration on the left wall of the Cardiac Independence Program, Room S3753.
During an interview, Staff 3 reported that the cover plates for the phone line and control box for lighting were missing.
15. At 8:39 a.m., there was an approximately 3 x 9 inch square penetration on the right wall in Room S3755.
During an interview, Staff 3 reported that the cover plates for the phone line and control box for lighting were missing.
16. At 9:04 a.m., there were two 6 foot ladders leaning against the electrical panel J-3 inside the Janitor's Closet.

7/18/12 - South Tower - 1st Floor

17. At 9:50 a.m., the X-Ray Processor was directly in front of electrical panel R 4, inside the room door labeled "Darkroom Do Not Enter."
18. At 10:39 a.m., there was a white extension cord, without overcurrent protection, in the Admitting Office. The extension cord was connecting a fan, a phone charger, and a laptop to the wall outlet.
19. At 11:30 a.m., there was a six-plug adapter in "Kelly's" Office (GI Lab Office), connecting a laminator, a 3 hole punch, a coffee pot, and a scanner to the wall outlet. There was a six plug surge protector connecting a mid size refrigerator to the wall outlet.
20. At 11:47 a.m., there was an approximately 2 x 5 inch electrical box with no cover in the Old OR Room 5. The electrical box was on the left wall. During an interview, Staff 3 reported that the electrical box was used to power a clock that was removed.
21. At 1:42 p.m., the clock circuit electrical box was missing the cover plate in the Old OR Room 3, creating an approximately 10 1/2 x 10 1/2 inch penetration on the left wall.
22. At 1:45 p.m., there was a box and a 6 foot ladder stored directly in front of the electrical panel in Cardio I, Bio Med Room, off old OR 2. The ladder was leaning against the panel.
23. At 1:48 p.m., there was a bed directly in front of Electrical panel 10 in OR 11.
24. At 1:59 p.m., there was a mid size refrigerator, a microwave, a water cooler and a phone charger connected to a surge protector in the Administrative Supervisor's Office.
25. At 2:05 p.m., there was a microwave connected to a surge protector in the Painters Room.

7/18/12 - Cardiac Rehab Services Building

26. At 2:50 p.m., there was a microwave and a mid size refrigerator connected to a surge protector on the right side of the room.
27. At 2:56 p.m., there was a white extension cord, without overcurrent protection, used to connect the TV to the wall outlet in the left corner of the room. The extension cord was strung over the tile ceiling.

7/18/12 - Pulmonary Rehab Services - Suite 28

28. At 3:03 p.m., there were two electrical cover plates missing on the right wall, in the Club Data office.

The Fire and Life Safety Inspection Manual states "Extension cords should be used only to connect temporary portable equipment, not as part of permanent wiring. Nor should they be used to supply equipment that will load them beyond their rated capacity."


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33. At 1:59 p.m., there was an approximately 8 by 6 inch electrical box with no cover, above the lockers in the men's room of the old OR department.

7/18/12 - Wound Clinic
34. At 2:50 p.m., there was an approximately 3 by 1 1/2 inch electrical box with no cover, behind the work station at the wound clinic .









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7/18/12 - South Tower - 1st Floor

29. At 9:36 a.m., the data outlet was missing a solid faceplate cover, in the Paramedics Lounge located in the Emergency Dept.
30. At 9:58 a.m., the heating sensor was missing a faceplate cover exposing 3 small wires, in the hospital Staff Lounge, located in the Emergency Department.
31. At 10:17 a.m., the heating sensor was missing a faceplate cover exposing 3 small wires, in the Radiology file room.
32. At 9:44 a.m., the door to the Electrical Panel, marked RAD, was ajar and failed to latch closed. The panel was located in the corridor of the Emergency Room. During an interview, the Maintenance Engineer stated that the lock was stuck.

7/16/12 - North Tower

35. At 4:11 p.m., the cover for Relay Box 17-17 was not flush to the electrical box, in the North Tower penthouse. Wires in the box were exposed.
36. At 4:27 p.m., there was an approximately 3 by 1 inch electrical box near the elevator of the seventh floor. There was no cover on the box exposing electrical wires.

7/17/12 - North Tower

37. At 8:55 a.m., there were two approximately 3 by 3 inch electrical boxes with no covers and exposed wires, in the wall above the ceiling, near the elevator lobby on the fourth floor.
38. At 9:29 a.m., there was an approximately 4 by 4 inch electrical box with no cover and exposed wires, in the wall above the ceiling, near the OR entrance of the third floor.
39. At 9:46 a.m., there was an approximately 3 by 3 inch electrical box with no cover and exposed wires, in the wall above the ceiling, near the main lobby entrance on the second floor.
40. At 1:31 p.m., there were two sets of three 6-plug surge protectors plugged into each other, in Surgical Closet 5334, on the fifth floor. The surge protectors were daisy chained together.
42. At 3:14 p.m., the electrical box in the first cubicle of the third floor billing office, was missing a cover. Wires were exposed inside the box.
43. At 4:12 p.m., there was a refrigerator plugged into a 6-plug surge protector in the pathology room, on the second floor.

7/18/12 - North Tower

44. At 9:11 a.m., there was an approximately 8 by 8 inch electrical box, with a hinged cover that was open, under the desk in the X-ray Room on the second floor. Wires inside the electrical box were exposed.
45. At 9:52 a.m., there was an approximately 2 inch crack in the cover of an electrical box, in the back wall of the environmental services closet. The closet was near the gift shop, on the first floor.

Based on observation and interview, the facility failed to comply with the installation requirements for Alcohol Based Hand Rub (ABHR) dispensers. This was evidenced by one ABHR dispenser mounted next to an ignition source. Staff and residents could potentially be harmed from a static discharge and a fire. This affected 1 of 5 floors in the South Tower of the Main Hospital.

Findings:

During the facility tour with staff from 7/16/12 to 7/20/12, the ABHR dispensers were observed.

7/18/12 - South Tower - 1st Floor
At 10:57 a.m., there was an ABHR dispenser in the GI Endoscopy post op area mounted approximately 2-3 inches from an electrical ignition source. The ABHR was mounted on the right wall, near a bed.

7/18/12 - Same Day Surgery (1401 Spanos Ct)
2. At 4:03 p.m., there was a 3/4 inch unsealed flexible conduit in the attic access of the separation wall in the hallway to the elevators. There was a 3/4 inch unsealed conduit around blue, red, white, gray and black wires. There was a 1/2 inch conduit around a brown wire penetrating the wall.




29665

Based on observation, the facility failed to maintain the fire barrier wall between buildings. This was evidenced by penetrations in two fire barrier walls in two of five buildings. This affected the wound clinic and the outpatient surgery center and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the main hospital and the outpatient clinics were observed.

7/18/12 - Wound Clinic (1329 Spanos)
1. At 2:55 p.m., there were two approximately 1 inch penetrations in the center of the fire barrier wall between the wound clinic and the adjacent suite.

Based on observation and interview, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in the walls and ceilings. This could result in the spread of smoke from one area to another, in the event of a fire, and affected 1 of 5 floors in the south tower and 4 of 8 floors in the north tower of the main hospital.

Findings:

During the facility tour with staff from 7/16/12 to 7/20/12, the ceilings and walls were observed.

7/18/12 - South Tower - 1st Floor
1. At 9:27 a.m., there were two approximately 3 to 4 inch unsealed pipe sleeves in the IT closet, in the Radiology Department. There were two bundles of wires inside the pipe sleeves. The pipe sleeves were on the left side of the room, penetrating the ceiling.

During an interview, Staff 3 reported that the open pipe sleeves were created during the EHR (Electrical Health Information Records) project that took place approximately 6 months ago.

2. At 9:56 a.m., there was an approximately 2 x 3 inch penetration in the Modular Cabinet room next to the nurses station in the Radiology Department. The penetration was on the left side.

3. At 11:20 a.m., there was an approximately 1 x 6 inch square cut out penetration in the right wall of the Physicians Dictation Room in the GI Lab. The penetration was underneath the first desk.


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4. At 1:32 p.m., there was an approximately 10 inch by 10 inch attic access in the ceiling of the C.S. Hallway electrical closet. One corner of the access was open at approximately 1/2 inch from the ceiling.

7/16/12 - North Tower
5. At 4:21 p.m., there was an approximately 1 1/2 inch penetration around a drain pipe, and an approximately 1 inch unsealed electrical conduit, in the ceiling of the seventh floor, North Tower.

6. At 4:24 p.m., there was an approximately 3 inch penetration around a vent pipe, in the ceiling of the seventh floor, North Tower. The penetration was partially sealed with yellow fiber-like substance.

During an interview at 4:25 p.m., Staff 5 stated that he was unsure what the fiber like substance was, or if it was fire-rated. He confirmed that the penetration was partially sealed.

7/17/12 - North Tower
7. At 2:01 p.m., there was an approximately 1 1/2 inch penetration behind the bed in Room N4224 on the fourth floor of the North Tower.

8. At 4:01 p.m., there were two approximately 2 inch conduits in the ceiling of the communication closet of the OR Conference Room on the third floor of the North Tower. The conduits were unsealed.

7/18/12 - North Tower
9. At 9:34 a.m., there were two approximately 2 inch conduits in the ceiling of the electrical closet in the Sierra Conference Room on the first floor of the North Tower. The conduits were unsealed.

10. At 9:37 a.m., there were two approximately 2 inch conduits in the ceiling of the electrical closet in the Foothill Conference Room on the first floor of the North Tower. The conduits were unsealed.

11. At 10:01 a.m., there was an approximately 1/2 inch penetration around two conduits, and an approximately 1/4 inch penetration around four conduits in the sterile processing soap room on the first floor of the North Tower.

12. At 10:16 a.m., there were six approximately 5 inch conduits in the ceiling of the basement telecom room. The conduits were unsealed.

7/17/12 - South Tower - 5th Floor
25. At 2:41 p.m., the self-closing corridor door to the DTC Nurses Station failed to fully close and latch. The door was tested three times.

7/17/12 - South Tower - 3rd Floor
26. At 4:03 p.m., the corridor door to Room S3315 was impeded from closing by a COW (computer on wheels), directly in the door's swing path.
During an interview, Staff 2 reported that the nursing staff indicated the COW was just brought into the room.
27. At 4:05 p.m., the corridor door to Room S3313 was impeded from closing by a trash can. The trash can was in the door's swing path.
28. At 4:22 p.m., the corridor door to Room S3703 was impeded from closing by a trash can directly in the door's swing path.
29. At 4:26 p.m., the corridor door to Room S3705 was impeded from closing. There was a Geri Chair directly in front of the door.

7/18/12 - South Tower - 3rd Floor
30. At 8:30 a.m., the self-closing corridor door to the shower room by Room 3743, closed but failed to latch. The door was tested four times.
31. At 8:34 a.m., the corridor door to Room S3745 closed and latched. There was an approximately 1 inch gap between the door and the door frame.

During an interview at 8:35 a.m., Staff 3 stated that the striker plate was missing.

32. At 8:56 a.m., the self-closing corridor door to the "Employees Only" Restroom failed to close and latch.
33. At 9 a.m., the corridor door to Room S3763 closed but failed to latch. The door was tested three times.
34. At 9:02 a.m., the self-closing corridor door to the clean linen closet, by Room S3765, failed to fully close and latch. The door was tested four times.

7/18/12 - South Tower - 1st Floor

35. At 9:54 a.m., the self-closing corridor door to the women's changing room, in Radiology, failed to fully close and latch. The door was tested three times.
36. At 9:55 a.m., the self-closing corridor door to the men's changing room, in Radiology, failed to fully close and latch. The door was tested three times.
37. At 10:33 a.m., the door inside the Data Collection office, in the Chest Pain Center Office, was held open with a shredder. The door was obstructed from closing.
38. At 10:37 a.m., the door to the Data Collection office storage room was obstructed from closing by a floor lamp.
39. At 11:50 a.m., the self-closing corridor door to the old OR Room 5 failed to fully close and latch. The door was tested four times.
40. At 11:52 a.m., the self-closing corridor door to the sterilizer room, by the old OR Room 5, closed but failed to latch. The door was tested four times.
41. At 2:10 p.m., the self-closing corridor door, to the office next to the Pain Chest Center, failed to close and latch. The self-closer was missing the arm part of the mechanism.

7/18/12 - Pulmonary Rehab Services (1800 Coffee Rd)

42. At 3:10 p.m., the corridor door to Pulmonary Rehab Ed Room closed but failed to latch. During an interview at 3:10 p.m., Staff 1 reported that the door was missing the striker plate.


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7/18/12 - South Tower - 1st Floor
43. At 2:10 p.m., the electrical closet, next to the Trauma Department, had a self-closing door. The door closed but failed to latch.
44. At 3:15 p.m., the janitorial closet in the outpatient surgery center, had a self-closing door. The door closed but failed to latch.
45. At 11:04 a.m., on 7/19/12, the door to the CT Room was held open by a magnetic automatic closing device. Upon activation of the fire alarm system, the door released from the magnet. The door closed but failed to latch.





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Based on observation and interview, the facility failed to maintain their corridor doors, as evidenced by self-closing doors that failed to latch, by doors obstructed from closing, and by doors that failed to latch when closed. This could result in the spread of smoke and fire in the event of a fire. This affected 5 of 5 floors in the South Tower, 2 of 8 floors in the North Tower, the Outpatient Surgery Center, and the Pulmonary Rehab Services.

Findings:

During the facility tour with staff, from 7/16/12 to 7/20/12, the corridor doors were observed.

7/17/12 - South Tower - 4th Floor

1. At 1:33 p.m., the door to Room S4729 failed to latch when closed. Three attempts were made to close and latch the door.
2. At 1:53 p.m., the door to the men's bathroom, near pediatrics, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to latch the door.

During an interview at 1:54 p.m., the Maintenance Engineer reported the door handle was in the upward position and a new spring was needed to close the door.

South Tower - 2nd Floor

3. At 1:55 p.m., the door to the Cardio Pulmonary Department, was equipped with a self-closing device. The door closed but failed to latch. The latch hit the strike plate. There was a sign posted on the door that read "work order submitted on 7/17/12."
4. At 2:34 p.m., the interior door to the Telecommunication Room was obstructed by a blue, three tier rack, with three 5 gallon water bottles in the rack. The door was prevented from closing. Maintenance Staff moved the rack.
5. At 2:47 p.m., the interior door to the Mechanical Room was obstructed by two gray 32 gallon plastic garbage cans. The garbage cans were labeled "Biohazard."
6. At 2:49 p.m., the door to the Mechanical Room was equipped with a self-closing device. The door closed but failed to latch. Three attempts were made to close and latch the door.
7. At 3 p.m., the door to Room S2757 was equipped with a self-closing device. The door closed but failed to latch. Three attempts were made to close and latch the door.
8. At 3:14 p.m., the fire door located at the ICU Nurses Station was obstructed by a BiPap machine.
9. At 3:22 p.m., the interior door in the Hospitalist Office was held open with a 30 inch beige garbage can. The door was obstructed from closing.

7/18/12 - South Tower - 1st Floor

10. At 8:40 a.m., the door located at the Charting Nurses Station, next to the Nursery, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
11. At 9:18 a.m., the door to the Emergency Educator Room was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
12. At 9:23 a.m., the door to Exam Room 20 was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
13. At 9:25 a.m., the door to the lab draw station was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
14. At 9:45 a.m., the door to the restroom located in C-POD 30-37 failed to latch when closed.
15. At 9:49 a.m., the door to the clean utility room, located in D-POD 38-45 Emergency Department (ED), was equipped with a self-closing device.
The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
16. At 9:52 a.m., the door to the soiled utility room, located in D-POD 38-45 ED, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
17. At 10:01 a.m., the door to the ED storage locker room, located next to Hall 10 Exam Room 14, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
18. At 10:04 a.m., the door to the storage room, located next to Exam Room 16-17, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch. Three attempts were made to close and latch the door.
19. At 11:23 a.m., the door to Room 2, in the Non-Invasive Cardiology Department, was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch.
20. At 11:28 a.m., the door to the Cath Lab soiled utility room was equipped with a self-closing device. The door was held open to the fullest extent and released. The door closed but failed to latch.
21. At 11:36 a.m., the double doors near PDCU were equipped with a self-closing device. The door closed but failed to latch.

7/18/12 - North Tower - 1st Floor

22. At 1:24 p.m., the interior door to the storage room was equipped with a self-closing device. The door closed but failed to latch. The latch hit the strike plate.
23. At 1:41 p.m., the door to the cardboard breakroom was equipped with a self-closing device. The door closed but failed to latch.

North Tower - Outside
24. On 7/19/12 at 1:38 p.m., the interior door located in the tissue room was obstructed by a 6 foot tall shelf and a double shelf wheeled cart.

7/17/12 - North Tower - 4th Floor

46. At 1:50 p.m., on 7/17/12, the restroom, near the visitor lobby, had a self-closing door. The door closed but failed to latch.

47. At 3:19 p.m., the door to the materials manager's office, on the third floor, had a self-closing door. The door closed but failed to latch.

Based on observation and interview, the facility failed to maintain their exit signs, as evidenced by two exit signs with unlit bulbs. This affected one of five floors of the South Tower and could result in a delay in evacuation, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

Findings:

During the facility tour with staff, from 7/16/12 to 7/20/12, the exit signs were observed.
7/18/12 - South Tower - 1st Floor

1. At 2:04 p.m., the exit sign on top of the smoke barrier door, in the old OR hallway, was not lit. During an interview at 2:05 p.m., Staff 5 stated that two of two bulbs in the exit sign needed to be replaced.

7/19/2 - South Tower - 1st Floor

2. At 11:24 a.m., the exit sign on top of the exit door in the radiotherapy department, was not lit. During an interview at 11:25 a.m., Staff 5 stated that two of two bulbs in the exit sign needed to be replaced.

Based on observation and interview, the facility failed to ensure that smoke barrier walls maintain a 1/2 hour fire resistance rating. This was evidenced by 9 smoke barrier walls that had penetrations around wires and pipes. This affected 3 of 5 floors in the in the South Tower and 1 of 8 floors in the North Tower, and could result in the spread of smoke from one compartment to another, in the event of a fire.

8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 of 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:
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 the facility tour with staff from 7/16/12 to 7/20/12, the smoke barrier walls in the facility were observed.

7/16/12 - South Tower - 3rd Floor

1. At 4:40 p.m., there was an approximately 1/4 inch penetration inside a 3/4 inch conduit, in the smoke barrier wall between the waiting room and the door marked "Stair S Down." The conduit was partially filled with red material. The conduit was in the smoke barrier wall directly in front of the attic access.
2. At 4:58 p.m., the fire damper inspection door was left open above the smoke barrier wall by the EKG/EEG Department.
During an interview, Staff 3 stated that maintenance staff probably checked the ventilation and left the door open.

7/17/12 - South Tower - 2nd Floor

3. At 8:25 a.m., there was an approximately 1/2 inch penetration on the left side of a 1/2 inch flexible, electrical conduit, in the smoke barrier wall by the hospital office and Exit Stair S Down.

7/17/12 - South Tower - 1st Floor

4. At 8:43 a.m., the smoke barrier wall by the Nourishment Room had an approximately 1/4 to 1/2 inch penetration inside a 3/4 inch conduit. There were 2 green wires, and 1 blue wire inside the conduit.
5. At 8:55 a.m., there was an approximately 3/4 to 1 inch penetration around wires, inside a 4 inch conduit in the smoke barrier wall by the Family Birthing Center.
6. At 10:35 a.m., there was an approximately 1 x 3 inch penetration on the upper right side of the wall, in the AMDC Building smoke barrier, by elevator 8.
7. At 10:50 a.m., there was an approximately 1/2 inch unsealed conduit in the smoke barrier wall between the Cardiology Department and Nuclear Medicine. A white and a green wire were inside the conduit. There was an approximately 1/4 to 1/2 inch penetration below the 1/2 conduit. The penetrations were directly at the attic access.
8. At 11:05 a.m., there was an approximately 2 inch unsealed pipe sleeve, penetrating the smoke barrier wall by the dietary storage area and the kitchen. To the left of the unsealed pipe sleeve, there was an approximately 1 inch round penetration around a blue wire.

7/17/12 - North Tower - 1st Floor

9. At 10:24 a.m., the smoke barrier wall in the administration corridor was observed. There was an approximately 1 1/2 inch penetration around a bundle of cables, and an approximately 1/2 inch penetration around an electrical conduit, in the center of the wall.

Based on observation and interview, the facility failed to ensure that the smoke barrier doors are capable of resisting the passage of smoke, and that the doors are self-closing. This was evidenced by nine smoke barrier doors that failed to fully close and latch during testing of the fire alarm system. This affected 4 of 5 floors in the South Tower, and could result in the spread of smoke or fire from one smoke compartment to another, in the event of a fire.

Findings:

During alarm testing with staff on 7/19/12, the smoke barrier doors were observed.

South Tower - 3rd Floor
1. At 9:33 a.m., the left side smoke barrier door, between by the nurse's station and Room S3711, closed but failed to latch after activation of the fire alarm system.

South Tower - 2nd Floor
2. At 10:17 a.m., the left side smoke barrier door, by Room S2711, closed but failed to latch after activation of the fire alarm system.

South Tower - 1st Floor
3. At 11:05 a.m., the left smoke barrier door, by Radiology, failed to fully close and latch after activation of the fire alarm system.
4. At 11:13 a.m., the right door to the smoke barrier door, by exam Room 22 in Radiology, failed to fully close and latch after activation of the fire alarm system. The right door remained partially open. There was an approximately 1 to 1 1/4 inch gap between the doors.
5. At 11:36 a.m., the left smoke barrier door by OR 8, closed but failed to latch, after activation of the fire alarm system.


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South Tower - 2nd Floor
6. At 10:23 a.m., the double doors to the elevator lobby were held open by magnetic automatic closing devices. Upon activation of the fire alarm system the doors released and closed. The left door failed to latch.


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South Tower - 4th Floor
7. At 9:07 a.m., the Conference Room smoke barrier double doors, near East Nurses Station, failed to latch during fire alarm testing.

South Tower - 3rd Floor
8. At 9:23 a.m., one side of the fire protection curtain doors, in front of Elevator 7, failed to latch during fire alarm testing. There was an approximately 3 1/2 inch gap at the left door.

During an interview, the Maintenance Engineer reported the smoke seal around the door was too thick.

South Tower - 1st Floor
9. At 10:30 a.m., the smoke barrier doors located in Labor and Delivery, near Room S1023, failed to latch during fire alarm testing. The left door failed to latch.
10. At 10:55 a.m., the smoke barrier door on the south side of the Radiology Department, near Room 30-37, failed to close completely during fire alarm testing. There was an approximately 1 1/2 foot gap.
11. At 10:57 a.m., the smoke barrier door marked 2, near the Emergency Room waiting area, failed to latch during fire alarm testing. The left door failed to latch.
12. At 11:27 a.m., the smoke barrier door to the ANDC Lobby near S191, failed to latch during fire alarm system testing.

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by smoke resistant partitions and self closing doors. This was evidenced by hazardous storage areas without self closing doors, by doors that self closed but failed to latch, and by wall penetrations in one hazardous storage area. This could result in the spread of smoke or fire affecting 1 of 5 floors in the South Tower, and in the Outpatient Surgery Center in the event of a fire.

Findings:

During a tour of the facility with staff on 7/18/12, the walls and doors to hazardous areas were observed. Combustible storage areas greater than 50 square feet in size are considered hazardous. The doors are required to self close and latch.

7/18/12 - South Tower - Third Floor
1. At 8:46 a.m., there was no self closing door on the equipment storage room S3757. The room is greater than 50 square feet in size and contained more than 45 cardboard boxes of office supplies, and three 4 shelf units, storing loose paper, binders and folders. There was a copy machine, a wheelchair with an "E" oxygen tank attached to the chair, office chairs, 6 COW (computer on wheels) units, patient equipment, and other miscellaneous storage in the room.

2. At 11:22 a.m., the soiled scope room, in the GI Lab, contained one soiled linen container, one linen container, and one trash container. There was no self closing hardware on the door. The room is greater than 50 square feet in size.



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7/18/12 - Outpatient Surgery Center
3. At 3:16 p.m., the equipment storage room was approximately 120 square feet in size. The room was approximately 60 percent filled with equipment wrapped in plastic. There was an approximately 1/2 inch penetration in the left wall of the room and the self-closing door of the room failed to latch.

Based on observation and interview, the facility failed to maintain their emergency lighting. This was evidenced by one emergency battery back-up light that failed to illuminate and by no records for maintaining the light. This affected one of four outpatient buildings, and could result in no lighting and a delay in evacuation, in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the emergency lighting units in the facility were observed.

7/18/12 - Wound Clinic
At 2:50 p.m., the battery bullfrog light, outside the Ostomy Room, failed to illuminate when tested.

During an interview at 2:51 p.m., Staff 2 stated that the lighting unit had not been maintained and that no records for testing were available.

5. At 2:30 p.m., the pull station located in the Central Supply Distribution Center did not have clear access. The pull station was obstructed by a copy machine that was directly in front of the pull station.



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Based on observation, the facility failed to maintain their fire alarm system in accordance with NFPA 72. This was evidenced by pull stations that were obstructed, and by alarm notification devices that failed. This affected two of five floors in the South Tower and could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code - 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.

NFPA 72 National Fire Alarm Code 1999 edition
2-8.1 Mounting. Each manual fire alarm box shall be securely mounted. The operable part of each manual fire alarm box shall be not less than 3 1/2 ft (1.1 m) and not more than 4 1/2 ft (1.37 m) above floor level.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the fire alarm system was observed.

7/18/12 - South Tower - 2nd Floor
1. At 8:29 a.m., on 7/18/12, the pull station in the microbiology lab was obstructed by a refrigerator.

7/19/12 - 2nd Floor
2. At 10:15 a.m., the combination audible/visual notification device, at the ICU nurses station across from Room 35, was observed during fire alarm testing. The chime failed to alarm upon activation of the fire alarm system.

7/19/12 - 1st Floor
3. At 11:15 a.m., the combination audible/visual notification device near the men's bathroom in the ED waiting room, was observed during fire alarm testing. The chime failed to alarm upon activation of the fire alarm system.

4. At 11:36 a.m., the combination audible/visual notification device near the dictation office, in the observation department, was observed during fire alarm testing. The chime failed to alarm upon activation of the fire alarm system.

Based on observation and interview, the facility failed to maintain their smoke detectors. This was evidenced by one smoke detector that failed to alarm when tested. This affected the one of four outpatient buildings, and could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code.

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

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the smoke detectors were observed in the facility.

At 2:41 p.m., on 7/18/12, the single station smoke detector in the Wound Clinic hallway was tested using the push-button. The smoke detector failed to alarm.

During an interview at 2:42 p.m., records were requested for maintenance and testing of the smoke detector. Staff 2 stated that the detector had not been tested as required. Staff 2 reported there were no records for testing the detector or changing the batteries.

7/17/12 - South Tower - 5th Floor

7. At 1:41 p.m., there was an approximately 1 inch gap between the escutcheon ring and the ceiling, inside Restroom S5325, exposing an approximately 1/2 inch penetration around the sprinkler pipe.
8. At 1:56 p.m., there was an approximately 1/2 to 3/4 inch gap between the escutcheon ring and ceiling in the Renal Tally Management Office. This exposed an approximately 1/4 to 1/2 inch penetration around the sprinkler pipe.
9. At 2:02 p.m., there was an approximately 1 inch gap between the escutcheon ring and the ceiling, in the corridor near Room S 5709. This exposed an approximately 1/2 inch penetration around the sprinkler pipe.
10. At 2:18 p.m., the escutcheon ring in the Renal Dialysis Break Room was missing, exposing an approximately 1 inch penetration around the sprinkler pipe.
11. At 2:27 p.m., the escutcheon ring in the RO Room (Reverse Osmosis) was missing, exposing an approximately 2 1/2 inch penetration around the sprinkler pipe.

7/18/12 - South Tower - 3rd Floor

12. At 8:22 a.m., the sprinkler deflector in Room S3719 was contaminated with lint and dust. The sprinkler deflector outside Room S3719 had a thick layer of lint and dust.

7/18/12 - South Tower - 1st Floor

13. At 10:30 a.m., there was an approximately 1/2 inch gap between the escutcheon ring and the ceiling in the GI Endoscopy Office waiting area. This exposed an approximately 1/4 inch penetration around the sprinkler pipe.


7/18/12 - Pulmonary Rehab Services
14. At 3:08 p.m., two of eight escutcheon rings in the office area had an approximately 3/4 to 1 inch gap between the escutcheon ring and the ceiling. This exposed an approximately 1/2 inch penetration around the sprinkler pipes.


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7/18/12 - South Tower - 1st Floor

15. At 1:37 p.m., the escutcheon ring in the paint room, was approximately 1 inch from the ceiling.









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Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by sprinkler escutcheon rings that were not flush to the ceiling, by missing escutcheon rings and by one sprinkler head coated with foreign material. Escutcheon rings are used to cover penetrations around sprinkler pipes and sprinkler heads. This could result in the spread of smoke or an obstruction of the sprinkler spray pattern. This affected 4 of 5 floors in the South Tower, 1 of 8 floors in the North Tower, and the Pulmonary Rehab Services.

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

Findings:

During the facility tour with staff on 7/17 and 7/18/12, the complete sprinkler system was observed.

7/17/12 - South Tower - 2nd Floor

1. At 2:43 p.m., the escutcheon ring was missing, in the laboratory outpatient bathroom.
2. At 2:52 p.m., the escutcheon ring was not flush to the ceiling, exposing an approximately 2 1/2 inch penetration around the sprinkler, in the supply closet near Room S2735.
3. At 2:55 p.m., the escutcheon ring was not flush to the ceiling, exposing an approximately 3 inch penetration, in the clean linen closet near Room S2745.
4. At 3:12 p.m., the escutcheon ring was not flush, in the Assistant ICU Manager's Office. This exposed an approximately 2 inch penetration around the sprinkler.

7/18/12 - South Tower - 1st Floor

5. At 9:14 a.m., the escutcheon ring was not flush to the wall, exposing an approximately 2 1/2 inch penetration around the sprinkler head, in the Chapel.

7/18/12 - South Tower - 2nd Floor

6. At 11:25 a.m., the escutcheon ring was not flush to the ceiling, exposing an approximately 2 inch penetration around the sprinkler, in the bathroom in the Non-Invasive Cardiology Department.

7/17/12 - North Tower - 5th Floor

16. At 11:51 a.m., the sprinkler head was missing an escutcheon ring, revealing an approximately 1 inch penetration around the sprinkler pipe, in the corridor outside the telecom room.

7/16/12 - North Tower

3. At 4:09 p.m., a fire extinguisher, in the penthouse of the North Tower was unsecured on the floor. The tag on the extinguisher indicated that it had not been serviced since 4/3/07 and that no monthly checks were conducted.

4. At 4:20 p.m., the fire extinguisher was obstructed by six mattresses, near the bed storage area on the sixth floor, of the North Tower.

Based on observation, the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This was evidenced by fire extinguishers that were unsecured, by one fire extinguisher that was obstructed, and by one fire extinguisher that was not serviced annually. This affected one of five floors of the South Tower and two of eight floors of the North Tower. This could result in a delay in extinguishing a fire, in the event of a fire.


NFPA 101, Life Safety Code, 2000 Edition.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

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

4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
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.

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the fire extinguishers were observed.
7/18/12 - South Tower - 1st Floor

1. At 1:36 p.m., the fire extinguisher was standing unsecured on the floor, in the elevator equipment room, near the CS Hallway.

2. At 1:56 p.m., the tag on the fire extinguisher, in the clean linen room, indicated that the last annual service on the extinguisher was conducted on 6/13/08. There were three monthly checks on the tag dated 8/5/08, 9/5/08, and 10/6/08. There were no current monthly checks for the extinguisher and no current annual certification.

Based on observation, the facility failed to ensure that a capacity of 32 gallons of soiled linen or trash collection receptacles is not exceeded within any 64 square foot area. This was evidenced by multiple receptacles placed in three areas in the facility. The facility also failed to ensure that these receptacles when not attended are located in a room protected as a hazardous area. This failure could result in a fire, in an unprotected area, on 2 of 5 floors in the South Tower.

Findings:

During the facility tour with facility staff on 7/17 and 7/18/12, soiled linen and trash receptacles (carts) were observed.

7/17/12 - South Tower - 3rd floor

1. At 4:10 p.m., there were a trash and a Biohazard container lined up, side by side, against the wall in patient Room 3303. The containers were 23 gallons in size.

2. At 4:11 p.m., there were a trash and a Biohazard container lined up, side by side, against the wall in patient Room 3301. The containers were 23 gallons in size.

7/18/12 - South Tower - 1st floor
3. At 10:55 a.m., there were two soiled linen containers, one trash container and one Biohazard bin lined up, side by side, against the wall in the GI Post Lab. The containers were 23 gallons in size.

3. 7/17/25 - South Tower - 3rd Floor
At 3:58 p.m., the oxygen storage room had full and empty E size cylinders stored in the same rack. During an interview, nursing staff identified two empty cylinders, two nearly empty, four half full and one 1/3 full.

7/18/12 - South Tower - 3rd Floor
4. At 8:53 a.m., the oxygen storage room had full and empty E size cylinders stored in the same rack. During an interview, nursing staff confirmed that the empty rack had 2 empty cylinders, three 3/4 full cylinders and one nearly empty cylinder.






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Based on observation and interview, the facility failed to maintain their medical gas storage. This was evidenced by light switches that were less than 5 feet from the floor in two medical gas storage rooms, by combustibles stored adjacent to oxygen cylinders, and by empty and full cylinders stored together. This affected the oxygen storage room for the main hospital, the medical gas supply room for the ambulatory surgery center, and 1 of 5 floors on the South Tower. This could result in damage to the electrical outlets and an increased risk of a fire and result in a delay in providing residents with full cylinders of oxygen in an emergency.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.

4-3.5.2.2 Storage of Cylinders and Containers. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings:

During a facility tour with staff from 7/16/12 to 7/20/12, the medical gas storage areas were observed.

1. At 2:47 p.m., on 7/17/12, the exterior concrete oxygen storage room, across from central plant, was observed. The inside of the room was divided by a wire fence and there were more than 75 oxygen E cylinders stored in one half of the room. The light switch in the room was approximately 4 feet from the floor. Immediately adjacent to the oxygen cylinders, on the other side of the fence, was an area designated for combustible housekeeping storage. More than 10 mattresses and five cardboard boxes of supplies were in the storage area.

7/18/12
2. At 4:15 p.m., the medical gas supply room, on the floor below the ambulatory surgery center, was observed. The light switch in the room was approximately 4 feet from the floor.

Based on observations and interview, the facility failed to maintain their electrical equipment and utilities in accordance with NFPA 70 and NFPA 99. This was evidenced by electrical panels that were not maintained with 36 inch clearance, by the use of extension cords and surge protectors, by high amp machines that were plugged into surge protectors, by the use of adapters, and by missing electrical cover plates. This affected 3 of 5 floors in the South Tower, 6 of 8 floors in the North Tower, the Wound Clinic, and Cardiac Rehab Services and Pulmonary Rehab Services. This could result in an increased risk of an electrical fire to occur.

NFPA 70 National Electrical Code 1999 Edition
110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of suck equipment. Where energized parts are exposed, the minimum clear work space shall not e less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.
(a) Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

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

240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

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

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.

NFPA 99
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patients care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

3-3.3.3 Receptacle Testing in Patient Care Areas
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces).

Findings:

During the facility tour with staff on 7/17 and 7/18/12, the electrical equipment and wiring were observed.

7/17/12 - South Tower - 1st Floor

1. At 9:20 a.m., there was an approximately 4 x 4 inch electrical box, above the ceiling tile, by the smoke barrier wall at the Director of Imaging Office. There was no cover on the electrical box.
2. At 10:18 a.m., there was an approximately 4 x 4 inch electrical box with no cover, above the ceiling tile, by the smoke barrier wall at EAU, Recovery/Observation.
3. At 10:51 a.m., there was an approximately 4 x 4 inch electrical box with no cover, above the ceiling tile, by the smoke barrier wall between Cardiology and Nuclear Medicine.
4. At 10:55 a.m., there were four approximately 4 x 4 inch electrical boxes with no covers, above the ceiling tile, by the smoke barrier wall near the Mail Room. The covers were laying on the ceiling tile.

7/17/25 - South Tower - 5th Floor

5. At 1:35 p.m., there was a surge protector connecting a mid size refrigerator to the electrical outlet, in the Nurse Educator Cancer Services Office.
6. At 1:38 p.m., there was a food cart parked directly in front of electrical panel 5NLB.
7. At 2 p.m., there was a surge protector connecting a blanket warmer and a personal wipe warmer to the electrical outlet in Room S5705.
8. At 2:25 p.m., there was a 6 foot ladder, ceiling tile and 2 boxes of light bulbs stored directly in front of electrical panel C-5B in the Dialysis Electrical Room. The 6 foot ladder was leaning against the panel.

7/17/12 - South Tower - 3rd Floor

9. At 3:17 p.m., there was a mid size refrigerator, a laptop, and a desk light connected to a six plug surge protector in the Service Line Coordinator's Office.
10. At 3:27 p.m., there was a broken electrical receptacle cover plate in Room S3343.
11. At 3:39 p.m., there was a refrigerator, a water cooler, and a monitor connected to a six plug surge protector in the nourishment room in the Nurses Station, across from Room S3335.
12. At 3:50 p.m., there was a broken electrical receptacle cover plate inside the ICU Classroom.
13. At 3:51 p.m., there was an electrical receptacle cover plate missing in the ICU Classroom.

7/18/12 - South Tower - 3rd Floor

14. At 8:38 a.m., there an approximately 3 x 9 inch square penetration on the left wall of the Cardiac Independence Program, Room S3753.
During an interview, Staff 3 reported that the cover plates for the phone line and control box for lighting were missing.
15. At 8:39 a.m., there was an approximately 3 x 9 inch square penetration on the right wall in Room S3755.
During an interview, Staff 3 reported that the cover plates for the phone line and control box for lighting were missing.
16. At 9:04 a.m., there were two 6 foot ladders leaning against the electrical panel J-3 inside the Janitor's Closet.

7/18/12 - South Tower - 1st Floor

17. At 9:50 a.m., the X-Ray Processor was directly in front of electrical panel R 4, inside the room door labeled "Darkroom Do Not Enter."
18. At 10:39 a.m., there was a white extension cord, without overcurrent protection, in the Admitting Office. The extension cord was connecting a fan, a phone charger, and a laptop to the wall outlet.
19. At 11:30 a.m., there was a six-plug adapter in "Kelly's" Office (GI Lab Office), connecting a laminator, a 3 hole punch, a coffee pot, and a scanner to the wall outlet. There was a six plug surge protector connecting a mid size refrigerator to the wall outlet.
20. At 11:47 a.m., there was an approximately 2 x 5 inch electrical box with no cover in the Old OR Room 5. The electrical box was on the left wall. During an interview, Staff 3 reported that the electrical box was used to power a clock that was removed.
21. At 1:42 p.m., the clock circuit electrical box was missing the cover plate in the Old OR Room 3, creating an approximately 10 1/2 x 10 1/2 inch penetration on the left wall.
22. At 1:45 p.m., there was a box and a 6 foot ladder stored directly in front of the electrical panel in Cardio I, Bio Med Room, off old OR 2. The ladder was leaning against the panel.
23. At 1:48 p.m., there was a bed directly in front of Electrical panel 10 in OR 11.
24. At 1:59 p.m., there was a mid size refrigerator, a microwave, a water cooler and a phone charger connected to a surge protector in the Administrative Supervisor's Office.
25. At 2:05 p.m., there was a microwave connected to a surge protector in the Painters Room.

7/18/12 - Cardiac Rehab Services Building

26. At 2:50 p.m., there was a microwave and a mid size refrigerator connected to a surge protector on the right side of the room.
27. At 2:56 p.m., there was a white extension cord, without overcurrent protection, used to connect the TV to the wall outlet in the left corner of the room. The extension cord was strung over the tile ceiling.

7/18/12 - Pulmonary Rehab Services - Suite 28

28. At 3:03 p.m., there were two electrical cover plates missing on the right wall, in the Club Data office.

The Fire and Life Safety Inspection Manual states "Extension cords should be used only to connect temporary portable equipment, not as part of permanent wiring. Nor should they be used to supply equipment that will load them beyond their rated capacity."


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33. At 1:59 p.m., there was an approximately 8 by 6 inch electrical box with no cover, above the lockers in the men's room of the old OR department.

7/18/12 - Wound Clinic
34. At 2:50 p.m., there was an approximately 3 by 1 1/2 inch electrical box with no cover, behind the work station at the wound clinic .









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7/18/12 - South Tower - 1st Floor

29. At 9:36 a.m., the data outlet was missing a solid faceplate cover, in the Paramedics Lounge located in the Emergency Dept.
30. At 9:58 a.m., the heating sensor was missing a faceplate cover exposing 3 small wires, in the hospital Staff Lounge, located in the Emergency Department.
31. At 10:17 a.m., the heating sensor was missing a faceplate cover exposing 3 small wires, in the Radiology file room.
32. At 9:44 a.m., the door to the Electrical Panel, marked RAD, was ajar and failed to latch closed. The panel was located in the corridor of the Emergency Room. During an interview, the Maintenance Engineer stated that the lock was stuck.

7/16/12 - North Tower

35. At 4:11 p.m., the cover for Relay Box 17-17 was not flush to the electrical box, in the North Tower penthouse. Wires in the box were exposed.
36. At 4:27 p.m., there was an approximately 3 by 1 inch electrical box near the elevator of the seventh floor. There was no cover on the box exposing electrical wires.

7/17/12 - North Tower

37. At 8:55 a.m., there were two approximately 3 by 3 inch electrical boxes with no covers and exposed wires, in the wall above the ceiling, near the elevator lobby on the fourth floor.
38. At 9:29 a.m., there was an approximately 4 by 4 inch electrical box with no cover and exposed wires, in the wall above the ceiling, near the OR entrance of the third floor.
39. At 9:46 a.m., there was an approximately 3 by 3 inch electrical box with no cover and exposed wires, in the wall above the ceiling, near the main lobby entrance on the second floor.
40. At 1:31 p.m., there were two sets of three 6-plug surge protectors plugged into each other, in Surgical Closet 5334, on the fifth floor. The surge protectors were daisy chained together.
42. At 3:14 p.m., the electrical box in the first cubicle of the third floor billing office, was missing a cover. Wires were exposed inside the box.
43. At 4:12 p.m., there was a refrigerator plugged into a 6-plug surge protector in the pathology room, on the second floor.

7/18/12 - North Tower

44. At 9:11 a.m., there was an approximately 8 by 8 inch electrical box, with a hinged cover that was open, under the desk in the X-ray Room on the second floor. Wires inside the electrical box were exposed.
45. At 9:52 a.m., there was an approximately 2 inch crack in the cover of an electrical box, in the back wall of the environmental services closet. The closet was near the gift shop, on the first floor.