HospitalInspections.org

Based on observation and interview it was determined that the facility did not ensure that corridor doors did not have any impediments to closing. Corridor doors that are not able to be efficiently closed can allow smoke and fire gases to enter the corridor in the event of a fire occurring in the room.

Findings include:

#1. During the tour of the facility on January 8, 2014, at 11:35 AM, observation of the door to the nuclear medicine office revealed that the door was equipped with a drop down style door stop and was being held in the open position. When this deficient practice was discussed with the Facility Services Manager he stated that he did not know that corridor doors could not have any impediments to closing.

#2. During the tour of the facility on January 8, 2014, at 1:55 PM, observation of the #1 North waiting room revealed that the door was being propped open with a chair. When this deficient practice was discussed with the Engineering Manager he stated that he was aware of the chair being utilized to keep the door open and that the facility was in the process of installing an appropriate hold open device for the door.

Actual NFPA Standard:
NFPA 101 ? Life Safety Code ? 2000 Edition

19.3.6.3
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted.

Based on observation, operational testing and interview it was determined that the facility did not ensure that hazardous areas were provided with self closing doors that positively latch and remain closed. This deficiency can allow smoke and fire gases to spread beyond the hazardous area in the event of a fire occurring in the room.

Findings include:

#1. During the tour of the facility on January 8, 2014 at 10:42 AM, observation of operational testing of the door to the soiled linen room in the short stay department revealed that the door would not latch and remain in the closed position. Further observation of the door revealed that the door latching bolt had been taped into the retracted position with clear tape. When questioned about the door latch the Facility Services Manager stated that he was unaware that the door latch had been taped over.

#2. During the tour of the facility on January 8, 2014 at 10:50 AM, observation of operational testing of the door to the soiled linen room in the emergency department revealed that the door would not latch and remain in the closed position. Further observation of the door revealed that the door latching bolt had been taped into the retracted position with clear tape. When questioned about the door latch the Facility Services Manager stated that he was unaware that the door latch had been taped over.

Actual NFPA Standard:
NFPA 101 ? Life Safety Code ? 2000 Edition

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

Based on observation and interview, it was determined that the facility had not ensured exit doors are arranged to be opened readily from the egress side. Failure to provide accessible exits can slow or prevent egress to a public way.

Findings include:

#1. During a tour of the facility on January 7, 2014 at 11:33 AM, observation of the door to the clinical imaging engineering office on the third floor revealed that the door was equipped with a key operated deadbolt on the corridor side of the door. Further observation of the door revealed that the location of the lock on the room side of the door was covered with a metal plate preventing access to the working mechanisms for locking or unlocking the door. When this deficiency was discussed with the Facility Services Manager he acknowledged that the lock was only operable from the corridor side of the door.

#2. During a tour of the facility on January 7, 2014 at 2:02 PM, observation of the door to room #356 revealed that the door was equipped with a key operated lockset with the keyed side on the room side of the door, and the unlocking mechanism on the corridor side of the door. When this deficiency was discussed with the Facility Services Manager he acknowledged that the lock was not operable from the egress side of the door with the use of a key.

#3. During a tour of the facility on January 7 and January 8, 2014, between the hours of 8:00 AM and 5:00 PM, observation of the following doors revealed that they were equipped with magnetic door locks with electronic key card reader overrides to release the locks from the egress sides. The 14 doors observed were as follows: Pediatric Unit entry and exit, CICU entry and exit, Heart Center East and South entry end exit, CVOR corridor entry, ICU North and South entry and exit, Pre-Op entry, OB Unit entry, #2 North entry, ED entry and #1 North exit. During the tour of the facility on these days the Facility Services Manager was questioned about the magnetic door locks and he stated that they were installed in order to control staff, patient and visitor access to the various departments throughout the hospital and was not for the clinical needs of the patients in these departments.

Actual NFPA Standard:
NFPA 101 ? Life Safety Code ? 2000 Edition

19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

7.2.1.5.1
Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Based on record review and interview it was revealed that the facility did not ensure that emergency light testing for 30 seconds a month and 90 minutes once a year was being completed and documented. Failure to test the emergency lights can result in a nonoperational unit not being discovered until needed during an emergency or electrical outage.

Findings include:

During record review on January 7, 2014, at 9:22 AM, the facility was unable to provide documented testing records for the emergency lights for thirty seconds a month or ninety minutes once annually for the previous 12 month period. When this deficiency was discussed with the Facility Services Manager he stated that he was aware of the lack of documented emergency light testing records and was currently working on instituting a policy to address the issue.

Actual NFPA Standard:
NFPA 101? Life Safety Code ? 2000 Edition

19.2.9.1
Emergency lighting shall be provided in accordance with Section 7.9.

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.

Based on record review and interview it was determined that the facility did not ensure that the facility had a fire safety plan with the required eight components. This deficiency can endanger patients, staff, visitors, and slow an emergency response to fires or other emergencies.

Findings include:

During record review on January 7, 2014, at 8:35 AM, it was determined that the facility could not produce a fire safety plan that contained all of the required eight components. The fire safety plan that was reviewed did not contain transmission of alarm to fire department, evacuation of smoke compartment or preparation of floors and building for evacuation. When questioned about the fire safety plan the Facility Services Manager stated that he was unaware that the facility did not have the required eight components in the fire safety plan.

Actual NFPA Standard:
NFPA 101? Life Safety Code ? 2000 Edition

19.7.2.1*
For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

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

Based on observation and interview the facility did not ensure that the automatic fire sprinkler system was installed in accordance with NFPA 13. Failure to ensure complete automatic fire sprinkler protection can allow a fire to grow, accelerate and spread.

Findings include:

#1. During the tour of the facility on January 7, 2014, at 10:50 AM, observation of the roof top penthouse that contains an air handler revealed that the penthouse was not provided with sprinkler protection. When the deficient practice was discussed with the Facility Services Manager he stated that they were aware of the lack of sprinkler protection and are currently in the process of working with a contractor to get the sprinkler system system installed.

#2. During the tour of the facility on January 7, 2014, at 3:20 PM, observation of the CVOR corridor revealed 9 vertical skylight shafts that measured 34"x34"x10' deep that extended to the roof and did not have any sprinkler protection installed at the top of the shafts. When this deficiency was discussed with the Facility Services Manager he stated that he had not noticed that the shafts did not have any sprinkler protection installed in them.

#3. During the tour of the facility on January 7, 2014, at 3:25 PM, observation of the CVOR corridor revealed 3 vertical skylight shafts that measured 34"x34"x6'7"' deep that extended to the roof and did not have any sprinkler protection installed at the top of the shafts. When this deficiency was discussed with the Facility Services Manager he stated that he had not noticed that the shafts did not have any sprinkler protection installed in them.

#4. During the tour of the facility on January 8, 2014, at 9:05 AM, observation of the Labor Lounge revealed a vertical skylight shaft that measured 40"x40"x9'9" deep that extended to the roof and did not have any sprinkler protection installed at the top of the shaft. When this deficiency was discussed with the Facility Services Manager he stated that he had not noticed that the shaft did not have any sprinkler protection installed in it.

#5. During the tour of the facility on January 8, 2014, at 10:00 AM, observation of the kitchen revealed 3 quick response sprinkler heads mixed with ordinary response sprinkler heads. When this deficiency was discussed with the Facility Services Manager he stated that a walk in cooler had been removed from the area and that the new sprinkler heads were added after the removal of the cooler.

#6. During the tour of the facility on January 8, 2014, at 1:20 PM, observation of the Adult Psychiatric Unit electrical room revealed that the room did not have any sprinkler protection installed in it. When this deficiency was discussed with the Engineering Supervisor he stated that he was unaware that the room did not have any sprinkler protection installed in it.

#7. During the tour of the facility on January 8, 2014, at 2:35 PM, observation of the electrical room in the basement next to the maintenance shop revealed that the room did not have any sprinkler protection installed in it. When this deficiency was discussed with the Engineering Supervisor he stated that he was unaware that the room did not have any sprinkler protection installed in it.

#8. During the tour of the facility on January 8, 2014, at 8:55 AM, observation of LDR room #5 revealed a sprinkler head that did not have an escutcheon ring installed, leaving an opening in the ceiling that was approximately two inches in size. When this deficiency was discussed with the Facility Services Manager he stated that he was unaware that the escutcheon ring was not installed with the sprinkler head.


Actual NFPA Standard:
NFPA 13 Standard for the Installation of Sprinkler Systems 1999 Edition

Finding #1)
5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Findings #2, 3, and 4 )
5-13.2 Vertical Shafts.
5-13.2.1
One sprinkler shall be installed at the top of shafts.
Exception No. 1: Noncombustible or limited-combustible, nonaccessible vertical duct shafts.
Exception No. 2: Noncombustible or limited-combustible, nonaccessible vertical electrical or mechanical shafts.

Finding #5)
5-4.5.3
Where residential sprinklers are installed in a compartment as defined in 1-4.2, all sprinklers within the compartment shall be of the fast-response type that meets the criteria of 1-4.5.1(a)1.

Findings #6 and 7)
5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Finding #8)
3-2.7 Escutcheon Plates.
3-2.7.1
Nonmetallic escutcheon plates shall be listed.
3-2.7.2*
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on record review and interview it was determined that the facility did not ensure that the sprinkler system was being maintained in accordance NFPA 25. Properly maintaining the sprinkler system helps to ensure system reliability.

Findings include:

During record review on January 7, 2014 at 9:05 AM, the facility was unable to produce a documented 5-year automatic fire sprinkler system obstruction investigation inspection report. When questioned about the 5-year internal inspection the Facility Services Manager stated that he did not know if an inspection had been completed in the last 5 years.

Actual NFPA Standard:
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Obstruction investigation - 5 years or as needed

Based on observation and interview it was determined that the facility did not ensure that portable fire extinguishers were readily accessible and immediately available. This deficiency can cause a delay to access a portable fire extinguisher in the event one was needed.

Findings include:

During a tour of the facility on January 8, 2014, at 9:40 AM, observation of OR #9 revealed a suction unit, anesthesia machine and a cauterizing machine placed three deep in front of and against the fire extinguisher cabinet. When this deficiency was discussed with the Facility Services Manager he stated that storage room for the equipment in the OR's has been an ongoing issue and he has spoken to department heads about this issue in the past.

Actual NFPA Standard:
NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition

1-6.3
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

1-6.6*
Fire extinguishers shall not be obstructed or obscured from view.

Based on record review and interview it was determined that the facility did not ensure that the Air-Conditioning and Ventilating systems were being maintained in accordance with NFPA 90A. Properly maintaining the ventilation systems helps to ensure system reliability to control air movement that can spread smoke and fire gasses.

Findings include:

During record review on January 7, 2014 at 9:50 AM, a review of the damper testing records dated February 28, 2011 indicated a total of 36 dampers had failed to operate correctly or were inaccessible. Review of the revised damper test report dated August 21, 2013 indicated a total of 14 dampers remained to be repaired. When questioned about the damper repairs the Facility Services Manager stated that the facility was aware that 14 dampers had yet to be repaired and the facility was currently in the process of accessing and repairing the remaining 14 dampers.

Actual NFPA Standard:
NFPA 101 ? Life Safety Code ? 2000 Edition

19.5.2.1
Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications.

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

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems 1999 Edition
3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on record review and interview it was determined that the facility did not ensure that the kitchen hood was being maintained in accordance with NFPA 96. Maintaining the hood helps to ensure the automatic fire suppression system functions as designed.

Findings include:

During record review on January 7, 2014 at 9:16 AM, it was revealed that the last two kitchen hood fire suppression system inspection reports were dated December 20, 2012 and October 17, 2013. When the Facility Services Manager was questioned about the overdue inspections he stated that he was unsure why the inspections exceeded the six month time frame.

Actual NFPA Standard:
NFPA 101? Life Safety Code ? 2000 Edition

19.3.2.6 Cooking Facilities.
Cooking facilities shall be protected in accordance with 9.2.3.
9.2.3 Commercial Cooking Equipment.
Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2001 Edition

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

Based on observation and interview it was determined that the facility failed to maintain the means of egress free of all obstructions. Obstructions in the means of egress slows evacuation and can create an unsafe exit path.

Findings include:

During a tour of the facility on January 7, 2014 and January 8, 2014 between the hours of 8:00 AM and 5:00 PM, observations revealed the following obstructed corridors:
#3 South corridor had 2 chairs, 2 beds, an air purifier that was plugged in and running, 5 soiled linen carts, and a scale spread out along the corridor;
#3 North corridor had a scale, 6 soiled linen carts, 2 computers on wheels, 3 wheelchairs and a chair spread out along the corridor;
CVOR corridor had 2 C-Arms, 1 Mini C-Arm, and 4 beds spread out along the corridor, in addition the wall was labeled with signs identifying the place to store each of the C-Arms;
Back OR corridor had 3 beds, a linen cart, 7 supply carts, and 2 blue PALS stirrups spread out along the corridor;
Sterile corridor had 14 storage racks, 3 storage carts and 3 rolling trays spread out along the corridor;
During the tour of the facility on these days the Facility Services Manager was questioned about the equipment throughout the above corridors and he stated that the facility did not have any place else to store the equipment.

Actual NFPA Standard:
NFPA 101? Life Safety Code ? 2000 Edition

19.2 MEANS OF EGRESS REQUIREMENTS
19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

7.1.10 Means of Egress Reliability.
7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview it was determined that the facility did not ensure that gas systems and cylinder storage were in accordance with NFPA 99. Inaccessible system shut-off valves and improperly storing cylinders can endanger people and slow an emergency response to a system malfunction requiring access to shut-off valves.

Findings include:

#1. During the tour of the facility on January 8, 2014 at 9:25 AM, observation of the CVOR suite revealed a bed, 5 supply carts, an IV pole, a computer on wheels, and 3 medication pumps placed 3 deep in front of and against 3 gas shut-off valve boxes located on a wall. When questioned about the equipment blocking the gas shut-off valves the Facility Services Manager stated that equipment storage in that location has been an ongoing issue with facility staff that work in that area.

#2. During the tour of the facility on January 8, 2014 at 11:05 AM, observation of the medical gas storage room in the ambulance bay revealed 8 K sized Carbon Dioxide cylinders, 12 K sized Nitrous Oxide cylinders, and 16 K sized Nitrogen cylinders that were not individually secured. When questioned about the cylinders the Facility Services Manager stated that he was unaware that the cylinders were required to be individually secured.

#3. During the tour of the facility on January 8, 2014 at 1:00 PM, observation of the medical gas storage room revealed 8 K sized Carbon Dioxide cylinders, 3 K sized Nitrous Oxide cylinders, 5 K sized Compressed Air cylinders, 4 K sized Argon cylinders, 4 K sized Oxygen, and 2 K sized Helium cylinders that were not individually secured. When questioned about the cylinders the Facility Services Manager stated that he was unaware that the cylinders were required to be individually secured.

Actual NFPA Standard:
NFPA 99 Standard for Health Care Facilities 1999 Edition

Finding #1)
4-3.1.2.3 Gas Shutoff Valves.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings #2 and #3)
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

#1.
Based on record review and interview it was revealed that the facility did not ensure that emergency light testing for 30 seconds a month and 90 minutes once a year was being completed and documented. Failure to test the emergency lights can result in a nonoperational unit not being discovered until needed during an emergency or electrical outage.

Findings include:

During record review on January 9, 2014, at 8:45 AM, the facility was unable to provide documented testing records for the emergency lights for thirty seconds a month or ninety minutes once annually for the previous 12 month period. When this deficiency was discussed with the Facility Services Manager he stated that he was aware of the lack of documented emergency light testing records and was currently working on instituting a policy to address the issue.

Actual NFPA Standard:
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.

#2.
Based on record review and interview it was determined that the facility failed to ensure that the fire alarm was being maintained in accordance with NFPA 72. Failure to conduct sensitivity testing could result in the fire alarm system not functioning as designed.

Findings include:

During record review on January 9, 2014 at 8:47 AM, it was revealed that the facility could not produce a documented record of smoke detector sensitivity testing. When questioned about the sensitivity testing the Facility Services Manager stated that he was unsure if smoke detector sensitivity testing had been conducted.

Actual NFPA Standard:
NFPA 72 National Fire Alarm Code?1999 Edition

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.

#3.
Based on observation and interview it was determined that the facility did not ensure that doors that subdivide the building were self closing doors that positively latch and remain closed. This deficiency can allow smoke and fire gases to spread in the event of a fire occurring in one of the rooms.

Findings include:

During the tour of the facility on January 9, 2014 between 9:50 AM and 9:55 AM, observation of the doors to a storage room, mechanical room door and an office on the lower level, three offices and two exam rooms on the upper level revealed that the doors were being held open with drop down door stops. When questioned about the door stops the Facility Services Manager stated that he was unaware that the doors could not have any impediments to be self closing.

Actual NFPA Standard:
21.3.7.1
Ambulatory health care facilities shall be separated from other tenants and occupancies by walls having not less than a 1-hour fire resistance rating. Such walls shall extend from the floor slab below to the floor or roof slab above. Doors shall be constructed of not less than 13/4-in. (4.4-cm) thick, solid-bonded wood core or the equivalent and shall be equipped with positive latches. These doors shall be self-closing and shall be kept in the closed position except when in use. Any vision panels shall be of fixed fire window assemblies in accordance with 8.2.3.2.2.

#1.
Based on record review and interview the facility did not ensure that the emergency generator was being inspected on a weekly basis and the generator was being load tested on a monthly basis in accordance with NFPA 110. Failure to load test the generator monthly and inspect the generator on a weekly basis could result in the generator not starting or functioning properly in the event of a power outage.

Findings include:

During record review on January 9, 2014 at 10:50 AM, the facility was unable to provide documented weekly inspections or a monthly load test for the month of December 2013. When questioned about the weekly inspections and monthly load test the Facility Services manager stated that the generator inspections and test had not been conducted.

Actual NFPA Standard:
NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition.

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.


#2.
Based on record review and interview it was revealed that the facility did not ensure that emergency light testing for 30 seconds a month was being completed and documented. Failure to test the emergency lights can result in a nonoperational unit not being discovered until needed during an emergency or electrical outage.

Findings include:

During record review on January 9, 2014, at 8:42 AM, the facility was unable to provide documented testing records for the emergency lights for the month of December 2013. When this deficiency was discussed with the Facility Services Manager he stated that the testing had not been conducted.

Actual NFPA Standard:
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.

#1.
Based on record review and interview it was revealed that the facility did not ensure that emergency light testing for 30 seconds a month and 90 minutes once a year was being completed and documented. Failure to test the emergency lights can result in a nonoperational unit not being discovered until needed during an emergency or electrical outage.

Findings include:

During record review on January 9, 2014, at 8:50 AM, the facility was unable to provide documented testing records for the emergency lights for thirty seconds a month or ninety minutes once annually for the previous 12 month period. When this deficiency was discussed with the Facility Services Manager he stated that he was aware of the lack of documented emergency light testing records and was currently working on instituting a policy to address the issue.

Actual NFPA Standard:
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.

#2.
Based on record review and interview it was determined that the facility failed to ensure that the fire alarm was being maintained in accordance with NFPA 72. Failure to conduct annual inspections and smoke detector sensitivity testing could result in the fire alarm system not functioning as designed.

Findings include:

During record review on January 9, 2014 at 9:27 AM, it was revealed that the facility could not produce a documented annual inspection or record of smoke detector sensitivity testing. When questioned about the inspection and testing the Facility Services Manager stated that he was unsure if the inspection and testing had occurred.

Actual NFPA Standard:
NFPA 72 National Fire Alarm Code?1999 Edition

7-3.2* Testing.
Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

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.

#3.
Based on record review and interview it was determined that the facility did not ensure that the sprinkler system was being maintained in accordance NFPA 25. Properly maintaining the sprinkler system helps to ensure system reliability.

Findings include:

1. During record review on January 9, 2014 at 9:10 AM, it was revealed that the last annual sprinkler system inspection was conducted on December 21, 2012. When questioned about the inspection the Facility Services Manager stated that he was aware that the annual inspection was overdue.

2. During record review on January 9, 2014 at 9:12 AM, the facility was unable to provide documented quarterly sprinkler system inspections for the previous twelve month period. When questioned about the inspection the Facility Services Manager stated that he was unsure why the inspections had not been completed and documented.

Actual NFPA Standard:

NFPA 101? Life Safety Code ? 2000 Edition
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition

2-1 General.
This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

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

#1.
Based on record review and interview it was revealed that the facility did not ensure that emergency light testing for 30 seconds a month and 90 minutes once a year was being completed and documented. Failure to test the emergency lights can result in a nonoperational unit not being discovered until needed during an emergency or electrical outage.

Findings include:

During record review on January 9, 2014, at 8:50 AM, the facility was unable to provide documented testing records for the emergency lights for thirty seconds a month or ninety minutes once annually for the previous 12 month period. When this deficiency was discussed with the Facility Services Manager he stated that he was aware of the lack of documented emergency light testing records and was currently working on instituting a policy to address the issue.

Actual NFPA Standard:
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.

#2.
Based on record review and interview it was determined that the facility failed to ensure that the fire alarm was being maintained in accordance with NFPA 72. Failure to conduct sensitivity testing could result in the fire alarm system not functioning as designed.

Findings include:

During record review on January 9, 2014 at 8:55 AM, it was revealed that the facility could not produce a documented record of smoke detector sensitivity testing. When questioned about the sensitivity testing the Facility Services Manager stated that he was unsure if smoke detector sensitivity testing had been conducted.

Actual NFPA Standard:
NFPA 72 National Fire Alarm Code?1999 Edition

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.

Based on observation and interview the facility did not ensure adequate electrical safety in accordance with NFPA 70.

Findings include:

#1. During a tour of the facility on January 8, 2014 at 1:58 PM, observation of #1 North breakroom revealed a bookcase against a wall blocking access to the circuit breaker panel. When questioned about the blocked circuit breaker panel the Engineering Supervisor stated that he did not know that a bookcase had been placed in front of the panel.

#2. During a tour of the facility on January 8, 2014 at 1:48 PM, observation of the IS Cold Room revealed an open junction box with exposed electrical wiring. When questioned about the open junction box the Engineering Supervisor stated that he did not know why the cover had been removed and not replaced on the box.

#3. During a tour of the facility on January 7, 2014 and January 8, 2014 between the hours of 8:00 AM and 5:00 PM, observations revealed the following:
A refrigerator plugged into a relocatable power tap at the plastic surgery nursing station, a bread toaster plugged into a relocatable power tap in the CICU breakroom, an EKOS and an ultrasound machine plugged into a relocatable power tap in Cathlab #2, 5 IV pumps plugged into a relocatable power tap in OB Pre-Admit, 2 piggy backed relocatable power taps powering lamps in the gift shop, and 2 piggy backed relocatable power taps powering computer equipment in the staffing office. After these findings no further notations were made, as it was determined to be a systemic problem.
Interview with the Electrical Engineering staff member during the tour confirmed that the relocatable power taps powering patient care equipment was not listed for that use.

Actual NFPA Standard:
NFPA 70 National Electrical Code 1999 Edition

Finding #1)
110-26. Spaces About Electrical Equipment
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(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.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
Table 110-26(a). Working Spaces
Minimum Clear Distance (ft)
Nominal Voltage to Ground
0-150 3
151-600 3

Finding #2)
314.28 Pull and Junction Boxes and Conduit Bodies.
(C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of 250.110. An extension from the cover of an exposed box shall comply with 314.22, Exception.


Finding #3)
110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

UL 1363
RELOCATABLE POWER TAPS (XBYS)
Relocatable Power TapsXBYSUSE AND INSTALLATION
This category covers relocatable power taps rated 250 V ac or less, 20 A or less. They are intended for indoor use as relocatable multiple outlet extensions of a single branch circuit to supply laboratory equipment, home workshops, home movie lighting controls, musical instrumentation, and to provide outlet receptacles for computers, audio and video equipment, and other equipment. They consist of one attachment plug and a single length of flexible cord terminated in a single enclosure in which one or more receptacles are mounted. They may, in addition, be provided with fuses or other supplementary overcurrent protection, switches, suppression components and/or indicator lights in any combination, or connections for cable, communications, telephone and/or antenna.
Relocatable power taps are intended to be directly connected to a permanently installed branch circuit receptacle. Relocatable power taps are not intended to be series connected (daisy chained) to other relocatable power taps or to extension cords.
Relocatable power taps are not intended for use at construction sites and similar locations.
Relocatable power taps are not intended to be permanently secured to building structures, tables, work benches or similar structures, nor are they intended to be used as a substitute for fixed wiring. The cords of relocatable power taps are not intended to be routed through walls, windows, ceilings, floors or similar openings.
Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, "National Electrical Code."

Based on observation and interview it was determined that the facility did not ensure that corridor doors did not have any impediments to closing. Corridor doors that are not able to be efficiently closed can allow smoke and fire gases to enter the corridor in the event of a fire occurring in the room.

Findings include:

#1. During the tour of the facility on January 8, 2014, at 11:35 AM, observation of the door to the nuclear medicine office revealed that the door was equipped with a drop down style door stop and was being held in the open position. When this deficient practice was discussed with the Facility Services Manager he stated that he did not know that corridor doors could not have any impediments to closing.

#2. During the tour of the facility on January 8, 2014, at 1:55 PM, observation of the #1 North waiting room revealed that the door was being propped open with a chair. When this deficient practice was discussed with the Engineering Manager he stated that he was aware of the chair being utilized to keep the door open and that the facility was in the process of installing an appropriate hold open device for the door.

Actual NFPA Standard:
NFPA 101 ? Life Safety Code ? 2000 Edition

19.3.6.3
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted.

Based on observation, operational testing and interview it was determined that the facility did not ensure that hazardous areas were provided with self closing doors that positively latch and remain closed. This deficiency can allow smoke and fire gases to spread beyond the hazardous area in the event of a fire occurring in the room.

Findings include:

#1. During the tour of the facility on January 8, 2014 at 10:42 AM, observation of operational testing of the door to the soiled linen room in the short stay department revealed that the door would not latch and remain in the closed position. Further observation of the door revealed that the door latching bolt had been taped into the retracted position with clear tape. When questioned about the door latch the Facility Services Manager stated that he was unaware that the door latch had been taped over.

#2. During the tour of the facility on January 8, 2014 at 10:50 AM, observation of operational testing of the door to the soiled linen room in the emergency department revealed that the door would not latch and remain in the closed position. Further observation of the door revealed that the door latching bolt had been taped into the retracted position with clear tape. When questioned about the door latch the Facility Services Manager stated that he was unaware that the door latch had been taped over.

Actual NFPA Standard:
NFPA 101 ? Life Safety Code ? 2000 Edition

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

Based on observation and interview, it was determined that the facility had not ensured exit doors are arranged to be opened readily from the egress side. Failure to provide accessible exits can slow or prevent egress to a public way.

Findings include:

#1. During a tour of the facility on January 7, 2014 at 11:33 AM, observation of the door to the clinical imaging engineering office on the third floor revealed that the door was equipped with a key operated deadbolt on the corridor side of the door. Further observation of the door revealed that the location of the lock on the room side of the door was covered with a metal plate preventing access to the working mechanisms for locking or unlocking the door. When this deficiency was discussed with the Facility Services Manager he acknowledged that the lock was only operable from the corridor side of the door.

#2. During a tour of the facility on January 7, 2014 at 2:02 PM, observation of the door to room #356 revealed that the door was equipped with a key operated lockset with the keyed side on the room side of the door, and the unlocking mechanism on the corridor side of the door. When this deficiency was discussed with the Facility Services Manager he acknowledged that the lock was not operable from the egress side of the door with the use of a key.

#3. During a tour of the facility on January 7 and January 8, 2014, between the hours of 8:00 AM and 5:00 PM, observation of the following doors revealed that they were equipped with magnetic door locks with electronic key card reader overrides to release the locks from the egress sides. The 14 doors observed were as follows: Pediatric Unit entry and exit, CICU entry and exit, Heart Center East and South entry end exit, CVOR corridor entry, ICU North and South entry and exit, Pre-Op entry, OB Unit entry, #2 North entry, ED entry and #1 North exit. During the tour of the facility on these days the Facility Services Manager was questioned about the magnetic door locks and he stated that they were installed in order to control staff, patient and visitor access to the various departments throughout the hospital and was not for the clinical needs of the patients in these departments.

Actual NFPA Standard:
NFPA 101 ? Life Safety Code ? 2000 Edition

19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

7.2.1.5.1
Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Based on record review and interview it was revealed that the facility did not ensure that emergency light testing for 30 seconds a month and 90 minutes once a year was being completed and documented. Failure to test the emergency lights can result in a nonoperational unit not being discovered until needed during an emergency or electrical outage.

Findings include:

During record review on January 7, 2014, at 9:22 AM, the facility was unable to provide documented testing records for the emergency lights for thirty seconds a month or ninety minutes once annually for the previous 12 month period. When this deficiency was discussed with the Facility Services Manager he stated that he was aware of the lack of documented emergency light testing records and was currently working on instituting a policy to address the issue.

Actual NFPA Standard:
NFPA 101? Life Safety Code ? 2000 Edition

19.2.9.1
Emergency lighting shall be provided in accordance with Section 7.9.

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.

Based on record review and interview it was determined that the facility did not ensure that the facility had a fire safety plan with the required eight components. This deficiency can endanger patients, staff, visitors, and slow an emergency response to fires or other emergencies.

Findings include:

During record review on January 7, 2014, at 8:35 AM, it was determined that the facility could not produce a fire safety plan that contained all of the required eight components. The fire safety plan that was reviewed did not contain transmission of alarm to fire department, evacuation of smoke compartment or preparation of floors and building for evacuation. When questioned about the fire safety plan the Facility Services Manager stated that he was unaware that the facility did not have the required eight components in the fire safety plan.

Actual NFPA Standard:
NFPA 101? Life Safety Code ? 2000 Edition

19.7.2.1*
For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

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

Based on observation and interview the facility did not ensure that the automatic fire sprinkler system was installed in accordance with NFPA 13. Failure to ensure complete automatic fire sprinkler protection can allow a fire to grow, accelerate and spread.

Findings include:

#1. During the tour of the facility on January 7, 2014, at 10:50 AM, observation of the roof top penthouse that contains an air handler revealed that the penthouse was not provided with sprinkler protection. When the deficient practice was discussed with the Facility Services Manager he stated that they were aware of the lack of sprinkler protection and are currently in the process of working with a contractor to get the sprinkler system system installed.

#2. During the tour of the facility on January 7, 2014, at 3:20 PM, observation of the CVOR corridor revealed 9 vertical skylight shafts that measured 34"x34"x10' deep that extended to the roof and did not have any sprinkler protection installed at the top of the shafts. When this deficiency was discussed with the Facility Services Manager he stated that he had not noticed that the shafts did not have any sprinkler protection installed in them.

#3. During the tour of the facility on January 7, 2014, at 3:25 PM, observation of the CVOR corridor revealed 3 vertical skylight shafts that measured 34"x34"x6'7"' deep that extended to the roof and did not have any sprinkler protection installed at the top of the shafts. When this deficiency was discussed with the Facility Services Manager he stated that he had not noticed that the shafts did not have any sprinkler protection installed in them.

#4. During the tour of the facility on January 8, 2014, at 9:05 AM, observation of the Labor Lounge revealed a vertical skylight shaft that measured 40"x40"x9'9" deep that extended to the roof and did not have any sprinkler protection installed at the top of the shaft. When this deficiency was discussed with the Facility Services Manager he stated that he had not noticed that the shaft did not have any sprinkler protection installed in it.

#5. During the tour of the facility on January 8, 2014, at 10:00 AM, observation of the kitchen revealed 3 quick response sprinkler heads mixed with ordinary response sprinkler heads. When this deficiency was discussed with the Facility Services Manager he stated that a walk in cooler had been removed from the area and that the new sprinkler heads were added after the removal of the cooler.

#6. During the tour of the facility on January 8, 2014, at 1:20 PM, observation of the Adult Psychiatric Unit electrical room revealed that the room did not have any sprinkler protection installed in it. When this deficiency was discussed with the Engineering Supervisor he stated that he was unaware that the room did not have any sprinkler protection installed in it.

#7. During the tour of the facility on January 8, 2014, at 2:35 PM, observation of the electrical room in the basement next to the maintenance shop revealed that the room did not have any sprinkler protection installed in it. When this deficiency was discussed with the Engineering Supervisor he stated that he was unaware that the room did not have any sprinkler protection installed in it.

#8. During the tour of the facility on January 8, 2014, at 8:55 AM, observation of LDR room #5 revealed a sprinkler head that did not have an escutcheon ring installed, leaving an opening in the ceiling that was approximately two inches in size. When this deficiency was discussed with the Facility Services Manager he stated that he was unaware that the escutcheon ring was not installed with the sprinkler head.


Actual NFPA Standard:
NFPA 13 Standard for the Installation of Sprinkler Systems 1999 Edition

Finding #1)
5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Findings #2, 3, and 4 )
5-13.2 Vertical Shafts.
5-13.2.1
One sprinkler shall be installed at the top of shafts.
Exception No. 1: Noncombustible or limited-combustible, nonaccessible vertical duct shafts.
Exception No. 2: Noncombustible or limited-combustible, nonaccessible vertical electrical or mechanical shafts.

Finding #5)
5-4.5.3
Where residential sprinklers are installed in a compartment as defined in 1-4.2, all sprinklers within the compartment shall be of the fast-response type that meets the criteria of 1-4.5.1(a)1.

Findings #6 and 7)
5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Finding #8)
3-2.7 Escutcheon Plates.
3-2.7.1
Nonmetallic escutcheon plates shall be listed.
3-2.7.2*
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on record review and interview it was determined that the facility did not ensure that the sprinkler system was being maintained in accordance NFPA 25. Properly maintaining the sprinkler system helps to ensure system reliability.

Findings include:

During record review on January 7, 2014 at 9:05 AM, the facility was unable to produce a documented 5-year automatic fire sprinkler system obstruction investigation inspection report. When questioned about the 5-year internal inspection the Facility Services Manager stated that he did not know if an inspection had been completed in the last 5 years.

Actual NFPA Standard:
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Obstruction investigation - 5 years or as needed

Based on observation and interview it was determined that the facility did not ensure that portable fire extinguishers were readily accessible and immediately available. This deficiency can cause a delay to access a portable fire extinguisher in the event one was needed.

Findings include:

During a tour of the facility on January 8, 2014, at 9:40 AM, observation of OR #9 revealed a suction unit, anesthesia machine and a cauterizing machine placed three deep in front of and against the fire extinguisher cabinet. When this deficiency was discussed with the Facility Services Manager he stated that storage room for the equipment in the OR's has been an ongoing issue and he has spoken to department heads about this issue in the past.

Actual NFPA Standard:
NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition

1-6.3
Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

1-6.6*
Fire extinguishers shall not be obstructed or obscured from view.

Based on record review and interview it was determined that the facility did not ensure that the Air-Conditioning and Ventilating systems were being maintained in accordance with NFPA 90A. Properly maintaining the ventilation systems helps to ensure system reliability to control air movement that can spread smoke and fire gasses.

Findings include:

During record review on January 7, 2014 at 9:50 AM, a review of the damper testing records dated February 28, 2011 indicated a total of 36 dampers had failed to operate correctly or were inaccessible. Review of the revised damper test report dated August 21, 2013 indicated a total of 14 dampers remained to be repaired. When questioned about the damper repairs the Facility Services Manager stated that the facility was aware that 14 dampers had yet to be repaired and the facility was currently in the process of accessing and repairing the remaining 14 dampers.

Actual NFPA Standard:
NFPA 101 ? Life Safety Code ? 2000 Edition

19.5.2.1
Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications.

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

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems 1999 Edition
3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on record review and interview it was determined that the facility did not ensure that the kitchen hood was being maintained in accordance with NFPA 96. Maintaining the hood helps to ensure the automatic fire suppression system functions as designed.

Findings include:

During record review on January 7, 2014 at 9:16 AM, it was revealed that the last two kitchen hood fire suppression system inspection reports were dated December 20, 2012 and October 17, 2013. When the Facility Services Manager was questioned about the overdue inspections he stated that he was unsure why the inspections exceeded the six month time frame.

Actual NFPA Standard:
NFPA 101? Life Safety Code ? 2000 Edition

19.3.2.6 Cooking Facilities.
Cooking facilities shall be protected in accordance with 9.2.3.
9.2.3 Commercial Cooking Equipment.
Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2001 Edition

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

Based on observation and interview it was determined that the facility failed to maintain the means of egress free of all obstructions. Obstructions in the means of egress slows evacuation and can create an unsafe exit path.

Findings include:

During a tour of the facility on January 7, 2014 and January 8, 2014 between the hours of 8:00 AM and 5:00 PM, observations revealed the following obstructed corridors:
#3 South corridor had 2 chairs, 2 beds, an air purifier that was plugged in and running, 5 soiled linen carts, and a scale spread out along the corridor;
#3 North corridor had a scale, 6 soiled linen carts, 2 computers on wheels, 3 wheelchairs and a chair spread out along the corridor;
CVOR corridor had 2 C-Arms, 1 Mini C-Arm, and 4 beds spread out along the corridor, in addition the wall was labeled with signs identifying the place to store each of the C-Arms;
Back OR corridor had 3 beds, a linen cart, 7 supply carts, and 2 blue PALS stirrups spread out along the corridor;
Sterile corridor had 14 storage racks, 3 storage carts and 3 rolling trays spread out along the corridor;
During the tour of the facility on these days the Facility Services Manager was questioned about the equipment throughout the above corridors and he stated that the facility did not have any place else to store the equipment.

Actual NFPA Standard:
NFPA 101? Life Safety Code ? 2000 Edition

19.2 MEANS OF EGRESS REQUIREMENTS
19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

7.1.10 Means of Egress Reliability.
7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview it was determined that the facility did not ensure that gas systems and cylinder storage were in accordance with NFPA 99. Inaccessible system shut-off valves and improperly storing cylinders can endanger people and slow an emergency response to a system malfunction requiring access to shut-off valves.

Findings include:

#1. During the tour of the facility on January 8, 2014 at 9:25 AM, observation of the CVOR suite revealed a bed, 5 supply carts, an IV pole, a computer on wheels, and 3 medication pumps placed 3 deep in front of and against 3 gas shut-off valve boxes located on a wall. When questioned about the equipment blocking the gas shut-off valves the Facility Services Manager stated that equipment storage in that location has been an ongoing issue with facility staff that work in that area.

#2. During the tour of the facility on January 8, 2014 at 11:05 AM, observation of the medical gas storage room in the ambulance bay revealed 8 K sized Carbon Dioxide cylinders, 12 K sized Nitrous Oxide cylinders, and 16 K sized Nitrogen cylinders that were not individually secured. When questioned about the cylinders the Facility Services Manager stated that he was unaware that the cylinders were required to be individually secured.

#3. During the tour of the facility on January 8, 2014 at 1:00 PM, observation of the medical gas storage room revealed 8 K sized Carbon Dioxide cylinders, 3 K sized Nitrous Oxide cylinders, 5 K sized Compressed Air cylinders, 4 K sized Argon cylinders, 4 K sized Oxygen, and 2 K sized Helium cylinders that were not individually secured. When questioned about the cylinders the Facility Services Manager stated that he was unaware that the cylinders were required to be individually secured.

Actual NFPA Standard:
NFPA 99 Standard for Health Care Facilities 1999 Edition

Finding #1)
4-3.1.2.3 Gas Shutoff Valves.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings #2 and #3)
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

#1.
Based on record review and interview it was revealed that the facility did not ensure that emergency light testing for 30 seconds a month and 90 minutes once a year was being completed and documented. Failure to test the emergency lights can result in a nonoperational unit not being discovered until needed during an emergency or electrical outage.

Findings include:

During record review on January 9, 2014, at 8:45 AM, the facility was unable to provide documented testing records for the emergency lights for thirty seconds a month or ninety minutes once annually for the previous 12 month period. When this deficiency was discussed with the Facility Services Manager he stated that he was aware of the lack of documented emergency light testing records and was currently working on instituting a policy to address the issue.

Actual NFPA Standard:
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.

#2.
Based on record review and interview it was determined that the facility failed to ensure that the fire alarm was being maintained in accordance with NFPA 72. Failure to conduct sensitivity testing could result in the fire alarm system not functioning as designed.

Findings include:

During record review on January 9, 2014 at 8:47 AM, it was revealed that the facility could not produce a documented record of smoke detector sensitivity testing. When questioned about the sensitivity testing the Facility Services Manager stated that he was unsure if smoke detector sensitivity testing had been conducted.

Actual NFPA Standard:
NFPA 72 National Fire Alarm Code?1999 Edition

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.

#3.
Based on observation and interview it was determined that the facility did not ensure that doors that subdivide the building were self closing doors that positively latch and remain closed. This deficiency can allow smoke and fire gases to spread in the event of a fire occurring in one of the rooms.

Findings include:

During the tour of the facility on January 9, 2014 between 9:50 AM and 9:55 AM, observation of the doors to a storage room, mechanical room door and an office on the lower level, three offices and two exam rooms on the upper level revealed that the doors were being held open with drop down door stops. When questioned about the door stops the Facility Services Manager stated that he was unaware that the doors could not have any impediments to be self closing.

Actual NFPA Standard:
21.3.7.1
Ambulatory health care facilities shall be separated from other tenants and occupancies by walls having not less than a 1-hour fire resistance rating. Such walls shall extend from the floor slab below to the floor or roof slab above. Doors shall be constructed of not less than 13/4-in. (4.4-cm) thick, solid-bonded wood core or the equivalent and shall be equipped with positive latches. These doors shall be self-closing and shall be kept in the closed position except when in use. Any vision panels shall be of fixed fire window assemblies in accordance with 8.2.3.2.2.

#1.
Based on record review and interview the facility did not ensure that the emergency generator was being inspected on a weekly basis and the generator was being load tested on a monthly basis in accordance with NFPA 110. Failure to load test the generator monthly and inspect the generator on a weekly basis could result in the generator not starting or functioning properly in the event of a power outage.

Findings include:

During record review on January 9, 2014 at 10:50 AM, the facility was unable to provide documented weekly inspections or a monthly load test for the month of December 2013. When questioned about the weekly inspections and monthly load test the Facility Services manager stated that the generator inspections and test had not been conducted.

Actual NFPA Standard:
NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition.

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.


#2.
Based on record review and interview it was revealed that the facility did not ensure that emergency light testing for 30 seconds a month was being completed and documented. Failure to test the emergency lights can result in a nonoperational unit not being discovered until needed during an emergency or electrical outage.

Findings include:

During record review on January 9, 2014, at 8:42 AM, the facility was unable to provide documented testing records for the emergency lights for the month of December 2013. When this deficiency was discussed with the Facility Services Manager he stated that the testing had not been conducted.

Actual NFPA Standard:
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.

#1.
Based on record review and interview it was revealed that the facility did not ensure that emergency light testing for 30 seconds a month and 90 minutes once a year was being completed and documented. Failure to test the emergency lights can result in a nonoperational unit not being discovered until needed during an emergency or electrical outage.

Findings include:

During record review on January 9, 2014, at 8:50 AM, the facility was unable to provide documented testing records for the emergency lights for thirty seconds a month or ninety minutes once annually for the previous 12 month period. When this deficiency was discussed with the Facility Services Manager he stated that he was aware of the lack of documented emergency light testing records and was currently working on instituting a policy to address the issue.

Actual NFPA Standard:
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.

#2.
Based on record review and interview it was determined that the facility failed to ensure that the fire alarm was being maintained in accordance with NFPA 72. Failure to conduct annual inspections and smoke detector sensitivity testing could result in the fire alarm system not functioning as designed.

Findings include:

During record review on January 9, 2014 at 9:27 AM, it was revealed that the facility could not produce a documented annual inspection or record of smoke detector sensitivity testing. When questioned about the inspection and testing the Facility Services Manager stated that he was unsure if the inspection and testing had occurred.

Actual NFPA Standard:
NFPA 72 National Fire Alarm Code?1999 Edition

7-3.2* Testing.
Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

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.

#3.
Based on record review and interview it was determined that the facility did not ensure that the sprinkler system was being maintained in accordance NFPA 25. Properly maintaining the sprinkler system helps to ensure system reliability.

Findings include:

1. During record review on January 9, 2014 at 9:10 AM, it was revealed that the last annual sprinkler system inspection was conducted on December 21, 2012. When questioned about the inspection the Facility Services Manager stated that he was aware that the annual inspection was overdue.

2. During record review on January 9, 2014 at 9:12 AM, the facility was unable to provide documented quarterly sprinkler system inspections for the previous twelve month period. When questioned about the inspection the Facility Services Manager stated that he was unsure why the inspections had not been completed and documented.

Actual NFPA Standard:

NFPA 101? Life Safety Code ? 2000 Edition
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition

2-1 General.
This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

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

#1.
Based on record review and interview it was revealed that the facility did not ensure that emergency light testing for 30 seconds a month and 90 minutes once a year was being completed and documented. Failure to test the emergency lights can result in a nonoperational unit not being discovered until needed during an emergency or electrical outage.

Findings include:

During record review on January 9, 2014, at 8:50 AM, the facility was unable to provide documented testing records for the emergency lights for thirty seconds a month or ninety minutes once annually for the previous 12 month period. When this deficiency was discussed with the Facility Services Manager he stated that he was aware of the lack of documented emergency light testing records and was currently working on instituting a policy to address the issue.

Actual NFPA Standard:
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.

#2.
Based on record review and interview it was determined that the facility failed to ensure that the fire alarm was being maintained in accordance with NFPA 72. Failure to conduct sensitivity testing could result in the fire alarm system not functioning as designed.

Findings include:

During record review on January 9, 2014 at 8:55 AM, it was revealed that the facility could not produce a documented record of smoke detector sensitivity testing. When questioned about the sensitivity testing the Facility Services Manager stated that he was unsure if smoke detector sensitivity testing had been conducted.

Actual NFPA Standard:
NFPA 72 National Fire Alarm Code?1999 Edition

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.

Based on observation and interview the facility did not ensure adequate electrical safety in accordance with NFPA 70.

Findings include:

#1. During a tour of the facility on January 8, 2014 at 1:58 PM, observation of #1 North breakroom revealed a bookcase against a wall blocking access to the circuit breaker panel. When questioned about the blocked circuit breaker panel the Engineering Supervisor stated that he did not know that a bookcase had been placed in front of the panel.

#2. During a tour of the facility on January 8, 2014 at 1:48 PM, observation of the IS Cold Room revealed an open junction box with exposed electrical wiring. When questioned about the open junction box the Engineering Supervisor stated that he did not know why the cover had been removed and not replaced on the box.

#3. During a tour of the facility on January 7, 2014 and January 8, 2014 between the hours of 8:00 AM and 5:00 PM, observations revealed the following:
A refrigerator plugged into a relocatable power tap at the plastic surgery nursing station, a bread toaster plugged into a relocatable power tap in the CICU breakroom, an EKOS and an ultrasound machine plugged into a relocatable power tap in Cathlab #2, 5 IV pumps plugged into a relocatable power tap in OB Pre-Admit, 2 piggy backed relocatable power taps powering lamps in the gift shop, and 2 piggy backed relocatable power taps powering computer equipment in the staffing office. After these findings no further notations were made, as it was determined to be a systemic problem.
Interview with the Electrical Engineering staff member during the tour confirmed that the relocatable power taps powering patient care equipment was not listed for that use.

Actual NFPA Standard:
NFPA 70 National Electrical Code 1999 Edition

Finding #1)
110-26. Spaces About Electrical Equipment
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(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.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
Table 110-26(a). Working Spaces
Minimum Clear Distance (ft)
Nominal Voltage to Ground
0-150 3
151-600 3

Finding #2)
314.28 Pull and Junction Boxes and Conduit Bodies.
(C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of 250.110. An extension from the cover of an exposed box shall comply with 314.22, Exception.


Finding #3)
110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

UL 1363
RELOCATABLE POWER TAPS (XBYS)
Relocatable Power TapsXBYSUSE AND INSTALLATION
This category covers relocatable power taps rated 250 V ac or less, 20 A or less. They are intended for indoor use as relocatable multiple outlet extensions of a single branch circuit to supply laboratory equipment, home workshops, home movie lighting controls, musical instrumentation, and to provide outlet receptacles for computers, audio and video equipment, and other equipment. They consist of one attachment plug and a single length of flexible cord terminated in a single enclosure in which one or more receptacles are mounted. They may, in addition, be provided with fuses or other supplementary overcurrent protection, switches, suppression components and/or indicator lights in any combination, or connections for cable, communications, telephone and/or antenna.
Relocatable power taps are intended to be directly connected to a permanently installed branch circuit receptacle. Relocatable power taps are not intended to be series connected (daisy chained) to other relocatable power taps or to extension cords.
Relocatable power taps are not intended for use at construction sites and similar locations.
Relocatable power taps are not intended to be permanently secured to building structures, tables, work benches or similar structures, nor are they intended to be used as a substitute for fixed wiring. The cords of relocatable power taps are not intended to be routed through walls, windows, ceilings, floors or similar openings.
Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, "National Electrical Code."