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Based on observation, the facility failed to maintain the corridor construction with at least a one-half hour fire rating. This was evidenced by one unsealed penetration in the corridor wall above the drop down ceiling. This affected one of seven smoke compartments within the facility and could potentially result in the spread of smoke and/or fire

Findings:

During a tour of the facility with Engineering Staff on 4/17/12, corridor walls were inspected.

1. At 2:47 p.m., the west corridor wall near the laboratory entrance to The Blood Draw Station had a one-quarter inch by one-half inch unsealed penetration on the bottom edge of a junction box.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This affected staff and patients in three of seven smoke compartments.

Findings:

During a tour of the facility with Engineering Staff on 4/16/12, doors were inspected.

1. At 12:25 p.m., the roll down fire door protecting the corridor opening in Financial Services was impeded from closing by a ball point pen lying on the countertop in the area in which the door closes.

2. At 1:20 p.m., the door between the Volunteer Office and the Gift Shop was impeded from closing by a floor mat placed in the swing area of the door. This door was equipped with a magnetic hold-open device designed to release with activation of the fire alarm system.

3. At 1:35 p.m., the roll down fire doors to the reception desk at the Quick Stay Emergency Room Department was impeded from closing by a box and data cables on the top of the counter in the area in which the door closes.

During a tour of the facility with Engineering Staff on 4/17/12, doors were inspected.

4. At 10:50 a.m., the 20 minute fire-rated door separating the Doctors' Exam Room and the Nursery was impeded from closing by a serving table located within the swing area of the door.

Based on observation and interview, the facility failed to insure that all exit signs would be placed in locations that would guide occupants of the building to a safe and unobstructed path to the public way. This was evidenced by an exit sign that was placed in an area that was not an exit. This affected all staff, patients, and visitors in one of seven smoke compartments within the facility and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

During a tour of the facility on 4/17/12, exit access was inspected.

1. At 10:56 a.m., there were two exit signs located at the west exit near the Loading Dock. One exit sign directed the building occupants in a straight path to the public way. The other exit sign directed the building's occupants onto the loading dock which did not have a path to the public way. The loading dock was approximately 50 inches above the ground level. Staff stated that the Inspector of Records agreed that the sign should not have been placed in that location.

Based on observation and interview, the facility failed to protect its hazardous area enclosure in accordance with 2000 NFPA 101. This was evidenced by an enclosure which contained a degree of hazard greater than that normal to the general occupancy of the building with a door which was not equipped with a self-closing mechanism. This deficient practice affected one of seven smoke compartments and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the Laboratory with Engineering Staff on 4/17/12, smoke barrier doors were inspected.

1. At 2:45 p.m., the one hour fire-rated door separating the Laboratory from the Blood Draw Station had the self-closing device removed from the door.

Based on record review, the facility failed to provide documentation of maintenance, inspection, and testing of smoke detectors in accordance with 2000 NFPA 72. This was evidenced by the failure to provide current documentation for smoke-sensitivity testing. This affected all staff and patients in seven of seven smoke compartments and could potentially result in false alarms or no alarms in the event of smoke and/or fire smoke.

7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer 's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review on 4/17/12 with Engineering Staff, documentation for fire alarm system devices was reviewed.

Findings:

1. At 4:05 p.m., documentation for bi-annual smoke-sensitivity testing dated 12/8/2008 was provided. When asked, Engineering Staff stated that this was the last time that the sensitivity testing was performed.

Based on record review and staff interview, the facility failed to periodically test its automatic sprinkler system in accordance with NFPA 101, 4.6.12 and NFPA 25. This was evidenced by a lack of documentation for the quarterly sprinkler testing and inspection of its dry pipe sprinkler system. This deficient practice affected all exterior sprinklered areas of the facility and could potentially result in the spread of smoke and/or fire.

4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

2-3.3.2* Testing the waterflow alarm on dry pipe, preaction, or deluge systems shall be accomplished by using the bypass connection.

Findings:

During record review on 4/16/12, sprinkler system testing and inspection records were reviewed.

1. At 4:00 p.m., the facility failed to provide documentation for quarterly sprinkler inspection and testing of its dry pipe system. Engineering Staff stated that they were not testing the flow alarm quarterly for the dry pipe system. Staff stated that they were not sure if the dry pipe system had a bypass connection and did not want to test the system using the Inspector's Test Connection which might trip and fill the dry system with water.

Based on observation and interview, the facility failed to provide a portable fire extinguisher at their heliport in accordance with NFPA 10 and 1995 NFPA 418. This was evidenced by a portable fire extinguisher for Class B fires that was not within the maximum allowed distance from the landing pad or potential ingintion source, and was not located and marked conspicuously. This could potentially result in a delay in accessing the fire extinguisher resulting in the spread of fire.

NFPA 10 Standard for Portable Fire Extinguishers
1-6.5 Cabinets housing fire extinguishers shall not be locked.
Exception: Where fire extinguishers are subject to malicious use, locked cabinets shall be permitted to be used, provided they include means of emergency access.

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

1-6.7* Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.

1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.

1-6.9 Fire extinguishers installed under conditions where they are subject to physical damage, (e.g., from impact, vibration, the environment) shall be adequately protected.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)

1-6.13* Where fire extinguishers are installed in closed cabinets that are exposed to elevated temperatures, the cabinets shall be provided with screened openings and drains.

2-4 Application for Specific Locations. Where portable fire extinguishers are required to be installed, the following documents shall be reviewed for the occupancies outlined in their respective scopes. However, in no case shall the requirements be less than those specified in this standard.
NFPA 418, Standard for Heliports

3-3* Fire Extinguisher Size and Placement for Class B Fires Other Than for Fires in Flammable Liquids of Appreciable Depth.

3-3.1 Minimal sizes of fire extinguishers for the listed grades of hazard shall be provided on the basis of Table 3-3.1. Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in the table used. (See Appendix E.)
Exception: Fire extinguishers of lesser rating, desired for small specific hazards within the general hazard area, can be used, but shall not be considered as fulfilling any part of the requirements of Table 3-3.1.

3-3.2 Two or more fire extinguishers of lower rating shall not be used to fulfill the protection requirements of Table 3-3.1.
Exception No. 1: Up to three AFFF or FFFP fire extinguishers of at least 2 1/2 -gal (9.46-L) capacity shall be permitted to be used to fulfill extra (high) hazard requirements.
Exception No. 2: Two AFFF or FFFP fire extinguishers of at least 1 1/2 -gal (6-L) capacity shall be permitted to be used to fulfill ordinary (moderate) hazard requirements.

3-3.3 The protection requirements shall be permitted to be fulfilled with fire extinguishers of higher ratings, provided the travel distance to such larger fire extinguishers does not exceed 50 ft (15.25 m).

NFPA 418 Standard From Heliports
Chapter 5 Portable Fire Extinguishers
5-1 Quantity and Rating. At least one portable fire extinguisher as specified in Table 5-1 shall be provided for each takeoff and landing area, parking area, and fuel storage area.
Exception: This requirement shall not apply to unattended ground level heliports.

Table 5-1 Minimum Ratings of Portable Fire Extinguishers for Heliport Categories Helicopter
Catagory H-1

Overall Length1 Up to but not including 50 ft (15.2)

Minimum Rating 4-A:80-B

1Helicopter length, including the tail boom and the rotors


Findings:

During a tour of the facility on 4/16/12, fire extinguishers were inspected.

1. The fire extinguisher located at the Heliport was located 157 feet from the edge the the helicopter landing pad. This fire extinguisher was also not conspicuously located and did not have identifying signage that was visible from a distance.

Fire extinguishers for Class B flammable liquids are required to be within 50 feet of the potential hazard.

Based on observation, interview, and document review, the facility failed to protect their anesthetizing locations in accordance with NFPA 99, the Standard for Healthcare Facilities. This was evidenced by the failure to maintain the relative humidity in three of three anesthetizing locations. This was also evidenced by the failure to provide battery-powered emergency lighting units in anesthetizing locations. This affected one of seven smoke compartments within the facility and three of three operating rooms. This could also potentially result in a loss of lighting in the Operating Room during surgical procedures within the ten seconds of time that is allowed for the back-up generator to transfer power during power outages (or longer, if the generator fails to start).

19.3.2.3 Anesthetizing Locations. Anesthetizing locations
shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

5-4.1.1 Ventilation in anesthetizing locations
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

NFPA 700-12 (e)
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:

During Document Review on 4/17/12, documentation for humidity levels in three operating rooms was reviewed.

1. At 4:00 p.m., documentation for humidity levels indicated that the levels dropped below 35 percent.

The number of days per month in a six month period that humidity levels were below 35 percent in Operating Rooms 1, 2, and 3 was as follows:

Operating Room 1
2012
January 22 of 22 days ranging between 7 and 27 percent
February 20 of 21 days ranging between 9 and 40 percent
March 23 of 23 days ranging between 11 and 27 percent

2011
October 10 of 21 days ranging between 21 and 68 percent
November 20 of 20 days ranging between 8 and 25 percent
December 22 of 24 days ranging between 8 and 26 percent

Operating Room 2
2012
January 23 of 24 days ranging between 6 and 27 percent
February 18 of 20 days ranging between 17 and 65
March 23 of 23 days ranging from 8 and 26 percent

2011
October 11 of 21 days ranging from 68 to 22 percent
November 21 of 21 days ranging between 9 and 26 percent
December 23 of 23 days ranging between 9 and 14 percent

Operating Room 3
2012
January 22 of 22 days ranging between 6 and 25 percent
February 21 of 21 days ranging between 11 and 32 percent
March 21 of 22 days ranging between 14 and 43 percent

2011
October 13 of 20 days ranging between 14 and 16 percent
November 23 of 23 days ranging between 8 and 26 percent
December 25 of 25 days ranging between 7 and 15 percent

During a tour of the facility with Engineering Staff on 4/16/12, Operating Rooms were inspected.

2. Between 2:05 and 2:30 p.m., this surveyor observed that Operating Rooms 1, 2, and 3 did not have battery powered back-up lighting units in them. When asked, Engineering Staff 1 stated that the operating rooms did not have battery back-up lights.

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

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

Findings:

During record review on 4/17/12 with Staff, the facility's laboratory policies and procedures were reviewed

1. At 2:55 p.m., the laboratory specific emergency policies and procedures were reviewed. The facility failed to provide an emergency procedure regarding the extinguishment of clothing fires in the laboratory. Lab Staff 1 was interviewed at that time. Lab Staff 1 indicated that the facility does not have a specific procedure regarding extinguishment of clothing fires in the laboratory.

Based on document review and interview, the facility failed to maintain its emergency generator in accordance with 1999 NFPA 110. This was evidence by a noted trouble alarm during a annual load bank test that had not been repaired. This affected all staff and patients in the facility and could potentially result in a trouble alarm failing to notify staff to a potential problem during a power outage.


NFPA 110
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.
The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer

Findings:

During document review on 4/17/12, generator testing records were reviewed.

1. At 10:50 a.m., the generator two hour load bank test noted in the comments section that the low oil light came on when the coolant temperature reached 185 degrees Fahrenheit. Documentation was not provided indicating that the oil pressure sensor false alarm had been replaced or repaired. Further review of the documentation indicated that the oil pressure was still within the normal range during the low oil pressure alarm. When asked, Engineering Staff 1 stated that the alarm does not come on during normal monthly full load testing.

Based on observation, the facility failed to install alcohol-based hand rub (ABHR) dispensers in locations not above sources of potential ignition. This was evidenced by an ABHR dispenser located above a plug outlet. This finding affected one of seven smoke compartments within the facility and could potentially result in the ignition of fire.

Findings:

During a tour of the facility with Engineering Staff on 4/16/12, at 1:30 p.m., their was an ABHR dispenser attached to the wall approximately 21 inches above a plug outlet. This dispenser was located in the corridor between two drinking fountains across from Restroom 310.

Based on observation, the facility failed to maintain the corridor construction with at least a one-half hour fire rating. This was evidenced by one unsealed penetration in the corridor wall above the drop down ceiling. This affected one of seven smoke compartments within the facility and could potentially result in the spread of smoke and/or fire

Findings:

During a tour of the facility with Engineering Staff on 4/17/12, corridor walls were inspected.

1. At 2:47 p.m., the west corridor wall near the laboratory entrance to The Blood Draw Station had a one-quarter inch by one-half inch unsealed penetration on the bottom edge of a junction box.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This affected staff and patients in three of seven smoke compartments.

Findings:

During a tour of the facility with Engineering Staff on 4/16/12, doors were inspected.

1. At 12:25 p.m., the roll down fire door protecting the corridor opening in Financial Services was impeded from closing by a ball point pen lying on the countertop in the area in which the door closes.

2. At 1:20 p.m., the door between the Volunteer Office and the Gift Shop was impeded from closing by a floor mat placed in the swing area of the door. This door was equipped with a magnetic hold-open device designed to release with activation of the fire alarm system.

3. At 1:35 p.m., the roll down fire doors to the reception desk at the Quick Stay Emergency Room Department was impeded from closing by a box and data cables on the top of the counter in the area in which the door closes.

During a tour of the facility with Engineering Staff on 4/17/12, doors were inspected.

4. At 10:50 a.m., the 20 minute fire-rated door separating the Doctors' Exam Room and the Nursery was impeded from closing by a serving table located within the swing area of the door.

Based on observation and interview, the facility failed to insure that all exit signs would be placed in locations that would guide occupants of the building to a safe and unobstructed path to the public way. This was evidenced by an exit sign that was placed in an area that was not an exit. This affected all staff, patients, and visitors in one of seven smoke compartments within the facility and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

During a tour of the facility on 4/17/12, exit access was inspected.

1. At 10:56 a.m., there were two exit signs located at the west exit near the Loading Dock. One exit sign directed the building occupants in a straight path to the public way. The other exit sign directed the building's occupants onto the loading dock which did not have a path to the public way. The loading dock was approximately 50 inches above the ground level. Staff stated that the Inspector of Records agreed that the sign should not have been placed in that location.

Based on observation and interview, the facility failed to protect its hazardous area enclosure in accordance with 2000 NFPA 101. This was evidenced by an enclosure which contained a degree of hazard greater than that normal to the general occupancy of the building with a door which was not equipped with a self-closing mechanism. This deficient practice affected one of seven smoke compartments and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the Laboratory with Engineering Staff on 4/17/12, smoke barrier doors were inspected.

1. At 2:45 p.m., the one hour fire-rated door separating the Laboratory from the Blood Draw Station had the self-closing device removed from the door.

Based on record review, the facility failed to provide documentation of maintenance, inspection, and testing of smoke detectors in accordance with 2000 NFPA 72. This was evidenced by the failure to provide current documentation for smoke-sensitivity testing. This affected all staff and patients in seven of seven smoke compartments and could potentially result in false alarms or no alarms in the event of smoke and/or fire smoke.

7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer 's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review on 4/17/12 with Engineering Staff, documentation for fire alarm system devices was reviewed.

Findings:

1. At 4:05 p.m., documentation for bi-annual smoke-sensitivity testing dated 12/8/2008 was provided. When asked, Engineering Staff stated that this was the last time that the sensitivity testing was performed.

Based on record review and staff interview, the facility failed to periodically test its automatic sprinkler system in accordance with NFPA 101, 4.6.12 and NFPA 25. This was evidenced by a lack of documentation for the quarterly sprinkler testing and inspection of its dry pipe sprinkler system. This deficient practice affected all exterior sprinklered areas of the facility and could potentially result in the spread of smoke and/or fire.

4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

2-3.3.2* Testing the waterflow alarm on dry pipe, preaction, or deluge systems shall be accomplished by using the bypass connection.

Findings:

During record review on 4/16/12, sprinkler system testing and inspection records were reviewed.

1. At 4:00 p.m., the facility failed to provide documentation for quarterly sprinkler inspection and testing of its dry pipe system. Engineering Staff stated that they were not testing the flow alarm quarterly for the dry pipe system. Staff stated that they were not sure if the dry pipe system had a bypass connection and did not want to test the system using the Inspector's Test Connection which might trip and fill the dry system with water.

Based on observation and interview, the facility failed to provide a portable fire extinguisher at their heliport in accordance with NFPA 10 and 1995 NFPA 418. This was evidenced by a portable fire extinguisher for Class B fires that was not within the maximum allowed distance from the landing pad or potential ingintion source, and was not located and marked conspicuously. This could potentially result in a delay in accessing the fire extinguisher resulting in the spread of fire.

NFPA 10 Standard for Portable Fire Extinguishers
1-6.5 Cabinets housing fire extinguishers shall not be locked.
Exception: Where fire extinguishers are subject to malicious use, locked cabinets shall be permitted to be used, provided they include means of emergency access.

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

1-6.7* Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.

1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.

1-6.9 Fire extinguishers installed under conditions where they are subject to physical damage, (e.g., from impact, vibration, the environment) shall be adequately protected.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)

1-6.13* Where fire extinguishers are installed in closed cabinets that are exposed to elevated temperatures, the cabinets shall be provided with screened openings and drains.

2-4 Application for Specific Locations. Where portable fire extinguishers are required to be installed, the following documents shall be reviewed for the occupancies outlined in their respective scopes. However, in no case shall the requirements be less than those specified in this standard.
NFPA 418, Standard for Heliports

3-3* Fire Extinguisher Size and Placement for Class B Fires Other Than for Fires in Flammable Liquids of Appreciable Depth.

3-3.1 Minimal sizes of fire extinguishers for the listed grades of hazard shall be provided on the basis of Table 3-3.1. Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in the table used. (See Appendix E.)
Exception: Fire extinguishers of lesser rating, desired for small specific hazards within the general hazard area, can be used, but shall not be considered as fulfilling any part of the requirements of Table 3-3.1.

3-3.2 Two or more fire extinguishers of lower rating shall not be used to fulfill the protection requirements of Table 3-3.1.
Exception No. 1: Up to three AFFF or FFFP fire extinguishers of at least 2 1/2 -gal (9.46-L) capacity shall be permitted to be used to fulfill extra (high) hazard requirements.
Exception No. 2: Two AFFF or FFFP fire extinguishers of at least 1 1/2 -gal (6-L) capacity shall be permitted to be used to fulfill ordinary (moderate) hazard requirements.

3-3.3 The protection requirements shall be permitted to be fulfilled with fire extinguishers of higher ratings, provided the travel distance to such larger fire extinguishers does not exceed 50 ft (15.25 m).

NFPA 418 Standard From Heliports
Chapter 5 Portable Fire Extinguishers
5-1 Quantity and Rating. At least one portable fire extinguisher as specified in Table 5-1 shall be provided for each takeoff and landing area, parking area, and fuel storage area.
Exception: This requirement shall not apply to unattended ground level heliports.

Table 5-1 Minimum Ratings of Portable Fire Extinguishers for Heliport Categories Helicopter
Catagory H-1

Overall Length1 Up to but not including 50 ft (15.2)

Minimum Rating 4-A:80-B

1Helicopter length, including the tail boom and the rotors


Findings:

During a tour of the facility on 4/16/12, fire extinguishers were inspected.

1. The fire extinguisher located at the Heliport was located 157 feet from the edge the the helicopter landing pad. This fire extinguisher was also not conspicuously located and did not have identifying signage that was visible from a distance.

Fire extinguishers for Class B flammable liquids are required to be within 50 feet of the potential hazard.

Based on observation, interview, and document review, the facility failed to protect their anesthetizing locations in accordance with NFPA 99, the Standard for Healthcare Facilities. This was evidenced by the failure to maintain the relative humidity in three of three anesthetizing locations. This was also evidenced by the failure to provide battery-powered emergency lighting units in anesthetizing locations. This affected one of seven smoke compartments within the facility and three of three operating rooms. This could also potentially result in a loss of lighting in the Operating Room during surgical procedures within the ten seconds of time that is allowed for the back-up generator to transfer power during power outages (or longer, if the generator fails to start).

19.3.2.3 Anesthetizing Locations. Anesthetizing locations
shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

5-4.1.1 Ventilation in anesthetizing locations
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

NFPA 700-12 (e)
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:

During Document Review on 4/17/12, documentation for humidity levels in three operating rooms was reviewed.

1. At 4:00 p.m., documentation for humidity levels indicated that the levels dropped below 35 percent.

The number of days per month in a six month period that humidity levels were below 35 percent in Operating Rooms 1, 2, and 3 was as follows:

Operating Room 1
2012
January 22 of 22 days ranging between 7 and 27 percent
February 20 of 21 days ranging between 9 and 40 percent
March 23 of 23 days ranging between 11 and 27 percent

2011
October 10 of 21 days ranging between 21 and 68 percent
November 20 of 20 days ranging between 8 and 25 percent
December 22 of 24 days ranging between 8 and 26 percent

Operating Room 2
2012
January 23 of 24 days ranging between 6 and 27 percent
February 18 of 20 days ranging between 17 and 65
March 23 of 23 days ranging from 8 and 26 percent

2011
October 11 of 21 days ranging from 68 to 22 percent
November 21 of 21 days ranging between 9 and 26 percent
December 23 of 23 days ranging between 9 and 14 percent

Operating Room 3
2012
January 22 of 22 days ranging between 6 and 25 percent
February 21 of 21 days ranging between 11 and 32 percent
March 21 of 22 days ranging between 14 and 43 percent

2011
October 13 of 20 days ranging between 14 and 16 percent
November 23 of 23 days ranging between 8 and 26 percent
December 25 of 25 days ranging between 7 and 15 percent

During a tour of the facility with Engineering Staff on 4/16/12, Operating Rooms were inspected.

2. Between 2:05 and 2:30 p.m., this surveyor observed that Operating Rooms 1, 2, and 3 did not have battery powered back-up lighting units in them. When asked, Engineering Staff 1 stated that the operating rooms did not have battery back-up lights.

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

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

Findings:

During record review on 4/17/12 with Staff, the facility's laboratory policies and procedures were reviewed

1. At 2:55 p.m., the laboratory specific emergency policies and procedures were reviewed. The facility failed to provide an emergency procedure regarding the extinguishment of clothing fires in the laboratory. Lab Staff 1 was interviewed at that time. Lab Staff 1 indicated that the facility does not have a specific procedure regarding extinguishment of clothing fires in the laboratory.

Based on document review and interview, the facility failed to maintain its emergency generator in accordance with 1999 NFPA 110. This was evidence by a noted trouble alarm during a annual load bank test that had not been repaired. This affected all staff and patients in the facility and could potentially result in a trouble alarm failing to notify staff to a potential problem during a power outage.


NFPA 110
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.
The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer

Findings:

During document review on 4/17/12, generator testing records were reviewed.

1. At 10:50 a.m., the generator two hour load bank test noted in the comments section that the low oil light came on when the coolant temperature reached 185 degrees Fahrenheit. Documentation was not provided indicating that the oil pressure sensor false alarm had been replaced or repaired. Further review of the documentation indicated that the oil pressure was still within the normal range during the low oil pressure alarm. When asked, Engineering Staff 1 stated that the alarm does not come on during normal monthly full load testing.