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Based on observation and interview, it was determined the facility failed to maintain exit signage according to NFPA standards. The deficiency had the potential to affect two (2) of the twenty two (22) smoke compartments, residents, staff and visitors. The facility is licensed for three hundred ninety six (396) beds and the census was two hundred seven (207) on the day of the survey.

The findings include:

Observation, on 03/21/12 at 1:14 PM, with the Maintenance Staff and the Administrator revealed the exits located in the laundry room and basement mechanical room, were not identified by approved, readily visible exit signage.

Interview, on 03/21/12 at 1:14 PM, with the Maintenance Staff and Administrator revealed they were not aware the doors did not have proper signage.


NFPA 101 (2000 Edition)

7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect two (2) of three (3) smoke compartments, residents, staff and visitors.


The findings include:

Observation, on 03/20/12 at 5:38 PM, with the Maintenance Staff revealed the smoke partitions extending above the ceiling located in the Administration Hall, Outpatient Registration Hall, and above the doors to ER, were noted to have penetrations by pipes and wires. The spaces around the penetrations were not filled with a material rated equal to the partition and could not resist the passage of smoke.

Interview, on 03/20/12 at 5:38 PM, with the Maintenance Staff revealed they were not aware of the penetrations.



Reference: NFPA 101 (2000 Edition).

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

Based on observation and interview, it was determined the facility failed to ensure cross -corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA Standards. The deficiency had the potential to affect two (2) of three (3) smoke compartments, residents, staff and visitors.

The findings include:

Observation, on 03/20/12 at 4:49 PM, at Jewish Hospital Bldg. 9, with the Maintenance Staff revealed the cross-corridor doors located between the ER and Medical Imaging would not close completely when tested.

Interview, on 03/20/12 at 4:49 PM, with the Maintenance Staff revealed they were unaware the doors would not close completely in the event of an emergency.


Reference: NFPA 101 (2000 edition)

8.3.4.1* Doors in smoke barriers shall close the opening leaving
only the minimum clearance necessary for proper operation
and shall be without undercuts, louvers, or grilles.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect one (1) of fourteen (14) smoke compartments, residents, staff and visitors.


The findings include:

Observation, on 03/20/12 at 2:30 PM, at Jewish Hospital Bldg. 5, with the Maintenance Staff revealed the door to the Soiled Utility Room next to CT, was broken and would not shut properly. The self closing device was not letting the door close and the door had been forced, splitting the door at the top hinge.

Interview, on 03/20/12 at 2:30 PM, with the Maintenance Staff revealed they were not aware the door had been damaged, stating the door was just inspected the day before, and shut properly.

Reference:

NFPA 101 (2000 Edition).

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

Based on observation and interview, it was determined the facility failed to ensure means of egress in accordance with NFPA standards. The deficiency had the potential to affect two (2) of twenty two (22) smoke compartments, residents, staff and visitors. The facility is licensed for three hundred ninety six (396) beds with a census of two hundred seven (207) on the day of the survey.


The findings include:

Observation, on 03/21/12 between 9:00 AM and 1:30 PM, with the Maintenance Staff and Administrator revealed the exit from the John Paul Building to the upper playground, and the Secure Recreation Exit, did not have a durable surface to a public way.

Interview, on 03/21/12 between 9:00 AM and 1:30 PM, with the Maintenance Staff and Administrator revealed they were not aware the exits needed a durable surface to a public way.


Exits must have a durable surface to the public way to support wheelchairs, beds, equipment, etc., in case of an emergency situation.

Based on observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect three (3) of twenty two (22) smoke compartments, residents, staff and visitors. The facility is licensed for three hundred ninety six (396) beds with a census of two hundred seven (207) on the day of the survey.

The findings include:

Observation, on 03/21/12 between 9:00 AM and 1:30 PM, with the Maintenance Director and Administrator revealed the exterior exits located at the John Paul Building to upper playground, the Outpatient external exit, and Administration exit were equipped with a single bulb for illuminating egress path to the public way from the exit.

Interview, on 03/21/12 between 9:00 AM and 1:30 PM, with the Maintenance Director and Administrator revealed they were unaware the lighting fixtures serving the exterior exits must include more than one bulb.


Reference: NFPA 101 (2000 edition)
7.8.1.4* Required illumination shall be arranged so that the
failure of any single lighting unit does not result in an illumination
level of less than 0.2 ft-candle (2 lux) in any designated
area.

Based on observation and interview, it was determined the facility failed to provide emergency lighting in accordance with NFPA standards. The deficiency had the potential to affect fourteen (14) of fourteen (14) smoke compartments, staff and all residents.

The findings include:

Observation, on 03/20/12 at 2:22 PM, at Jewish Hospital Bldg. 5, with the Maintenance Staff revealed an emergency battery light located inside each of the two (2) generator enclosures that did not function properly.

Interview, on 03/20/12 at 2:22 PM, with the Maintenance Staff revealed they tested the lights monthly and were not aware lights inside the generators were not working properly.



Reference: NFPA 101 (2000 edition)
7.9.2.1* Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6
lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

Based on Fire Drill record review and interview, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times, in accordance with NFPA standards. The deficiency had the potential to affect fourteen (14) of fourteen (14) smoke compartments, residents, staff, and visitors.

The findings include:

Fire Drill record review, on 03/20/12 at 2:11 PM, with the Maintenance Staff revealed the fire drills were not being conducted at unexpected times under varied conditions. The second shift fire drills were being conducted between 3:20 PM and 4:41 PM, Third shift fire drills were being conducted between 5:30 AM and 6:06 AM.


Interview, on 03/20/12 at 2:11 PM, with the Maintenance Staff revealed they were unaware the fire drills were not being conducted as required.



Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Based on observation and interview, it was determined the facility failed to ensure sprinkler heads were maintained in accordance with NFPA standards. The deficiency had the potential to affect one (1) of twenty two (22) smoke compartments, residents, staff, and visitors. The facility is licensed for three hundred ninety six (396) beds with a census of two hundred seven (207) on the day of the survey.

The findings include:

Observation, on 03/21/12 at 10:48 AM, with the Maintenance Staff and Administrator revealed the sprinkler heads located in 2 North Laundry, and the bathroom of Classroom A to have paint on the heads decreasing their ability to react as intended.

Interview, on 03/21/12 at 10:48 AM, with the Maintenance Staff and Administrator revealed they were not aware that the sprinklers heads had been painted.

Reference: NFPA 25 (1998 Edition).

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

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect two (2) of three (3) smoke compartments, residents, staff and visitors.

The findings include:

Observation, on 03/20/12 between 9:00 AM and 11:00 AM, with the Maintenance Staff revealed a portable space heater located in the Administration Office, ER Reception Desk, and the Outpatient Registration Desk.

Interview, on 03/20/12 between 9:00 AM and 11:00 AM, with the Maintenance Staff revealed they were not aware the heaters could not exceed 212°F in nonsleeping staff, and employee areas.


Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in nonsleeping staff and employee areas where the heating elements of
such devices do not exceed 212°F (100°C).

Based on observation and interview, it was determined the facility failed to maintain exit access in accordance with NFPA standards. The deficiency had the potential to affect one (1) of fourteen (14) smoke compartments, residents, staff, and visitors.

The findings include:

Observation, on 03/20/12 at 2:58 PM, at Jewish Hospital Bldg. 5, with the Maintenance Staff revealed hazardous materials, and surgical supply carts stored in the Non Sterile Supply Hall between Surgery, and PACU.

Interview, on 03/20/12 at 2:58 PM, with the Maintenance Staff revealed the facility routinely stored items, hazardous material, and surgical supply carts in this hall.

Reference: NFPA 101 (2000 Edition)
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 the facility failed to ensure oxygen cylinders were stored in accordance with NFPA standards. This deficiency had the potential to affect one (1) of three (3) smoke compartments, residents, staff, and visitors.


The findings include:

Observation, on 03/20/12 at 10:23 AM, with the Maintenance Staff revealed there was no signage indicating full or empty oxygen tanks in the Trash/Hazardous Hold Room. Further observation revealed no signage was present on the outside of the room indicating oxygen was being stored inside.

Interview, on 03/20/12 at 10:23 AM, with the Maintenance Staff revealed they were not aware the oxygen tanks needed signage indicating full or empty. Further interview revealed they were not aware the room needed signage indicating the tanks were inside.



Reference: NFPA 99 (1999 edition)
8-3.1.11.2
Storage for nonflammable gases greater than 8.5 m3 (300 ft3) but less than 85 m3 (3000 ft3)
(A) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(B) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(C) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) A minimum distance of 6.1 m (20 ft)
(2) A minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) An enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.


8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

Based on observation and interview, it was determined the facility failed to maintain doors within a required means of egress in accordance with NFPA standards. The deficiency had the potential to affect one (1) of the three (3) smoke compartments, residents, staff, and visitors.

The findings include:

Observation, on 03/20/12 at 4:59 PM, with the Maintenance Staff revealed an unapproved lock (slide bolt type) was installed on the egress side of the Fire Door at Radiology.

Interview, on 03/20/12 at 4:59 PM, with the Maintenance Staff revealed they were aware of the lock installed on the door; however, they were not aware that slide bolt locks were prohibited.


Reference: NFPA 101 (2000 Edition)

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Based on observation and interview, it was determined the facility failed to ensure emergency generators were maintained in accordance with NFPA standards. The deficiency had the potential to affect fourteen (14) of fourteen (14) smoke compartments, residents, staff, and visitors.

The findings include:

Observation, on 03/20/12 at 2:42 PM, at Jewish Hospital Bldg. 5, with the Maintenance Staff revealed the facility was equipped with an emergency generator. The generator was not equipped with an annunciation panel in an area that was readily observed to make staff aware of alarm conditions with the generators.

Interview, on 03/20/12 at 2:42 PM, with the Maintenance Staff revealed he was not aware the generator needed an annunciation panel to inform staff of alarm conditions of the emergency power source.




Reference: NFPA 99 (1999 Edition).

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

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect fifteen (15) of twenty two (22) smoke compartments, residents, staff, and visitors. The facility is licensed for three hundred ninety six (396) beds with a census of two hundred seven (207) on the day of the survey.

The findings include:

Observations, on 03/21/12 between 9:00 AM and 1:30 PM, at Our Lady of Peace Bldg. 4, with the Maintenance Staff and Administrator revealed:

1) A power strip plugged into another power strip, also a power strip plugged into a multi plug adaptor located in room #11.
2) A refrigerator was plugged into a power strip located in the Nurse Managers Office on 3 Lourdes.
3) Open electrical junction boxes located in the Mechanical Chase that runs the entire height of the building.
4) A refrigerator and microwave were plugged into a power strip located in the Social Worker Office on 2 South.
5) A refrigerator and microwave were plugged into a power strip that was plugged into an extension cord located in the Nurse Managers Office on 2 North.
6) A refrigerator and an air conditioning unit were plugged into a multi plug adaptor located in the Priest Dressing Room off of the Chapel.
7) A refrigerator and microwave were plugged into a power strip located in the Access Storage on 1 Lourdes Breezeway.
8) A computer printer was plugged into an extension cord that was plugged into a power strip that was plugged into another extension cord located in the Controller's Office on 1 North.
9) A refrigerator and microwave were plugged into a power strip that was plugged into an extension cord located in the Team Room on 1 South.
10) A microwave was plugged into a power strip located in the Food Nutrition Break Room.
11) A refrigerator was plugged into a power strip located in the Food Nutrition Directors Office.
12) An extension cord in use in the John Paul Utilization, and #26.
13) A refrigerator and microwave were plugged into a power strip located in John Paul #23.
14) An open electrical junction box located in the Administration Mechanical Closet.
15) A microwave and toaster were plugged into a power strip located in Human Resources.
16) A microwave was plugged into a power strip located in the Outpatient Breakroom.




Interview, on 03/21/12 between 9:00 AM and 1:30 PM, with the Maintenance Staff and Administrator revealed they were not aware the extension cords were only for temporary use, or the power strips were being misused. They were also not aware of the open junction boxes.





Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.



Reference: NFPA 70 (1999 edition)

370.28(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 Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.