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Based on observation and interview the facility failed to ensure walls were maintained without unsealed penetrations.

The deficiency had the potential of not providing the required fire-resistive construction level of protection

Findings:

1. On 9/11/18 at 12:20 p.m., the evaluator observed that the Outpatient Child Family room had a penetration through the concrete block wall around a copper water line that separated the fire panel room from Classroom B storage room.

During an interview at the same time as the observation the Facilities Manager acknowledged the penetration through the wall.

2. On 9/11/18 at 12:30 p.m., the evaluator observed that the Outpatient Child Family room had a penetration through the concrete block wall around a copper water line that separated Classroom C from the chase above the entrance to Classroom C.

During an interview at the same time as the observation the Facilities Manager acknowledged the penetration through the wall.

3. On 9/11/18 at 2:25 p.m., the evaluator observed that the Outpatient Child Family room had two penetrations through the concrete block wall that separated the medical records storage room and the elevator machine room.

During an interview at the same time as the observation the Facilities Manager acknowledged the penetrations through the wall.

NFPA 101 Life Safety Code 2012 Edition

7.1.10.1* General. 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.

7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof.

7.2.1.5.10.1 The releasing mechanism for any latch shall be located as follows:

(1) Not less than 34 in. (865 mm) above the finished floor for other than existing installations

(2) Not more than 48 in. (1220 mm) above the finished floor 7.2.1.5.10.2 The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6.

This Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure unobstructed full instant use of an exit doors.

The deficiency had the potential to delay or prevent the rapid evacuation of occupants.

Findings:

1. On 9/11/18 at 11:30 a.m., the evaluator observed that the the exit door by Outpatient Child Family Pediatric Playroom was obstructed from fully opening by a tumbling mat that obstructed the door from fully opening.

During an interview at the same time as the observation the Facilities Manager acknowledged that the exit door was obstructed from fully opening.

2. On 9/11/18 at 11:30 a.m., the evaluator observed that the the exit door by the Outpatient Child Family Pediatric Playroom had a slide bolt installed at a height greater than 48 inches (4 feet) above the finished floor at the exit door and may nor be reachable to others.

During an interview at the same time as the observation the Facilities Manager acknowledged that the slide bolt was installed at 5 1/2 feet (66 inches) above the finished floor.

3. On 9/11/18 at 12:20 p.m., the evaluator observed that the the rear exit door by Outpatient Child Family Classroom B, was obstructed by a children's chair and couch.

During an interview at the same time as the observation the Facilities Manager acknowledged that the exit door was obstructed.

4. On 9/12/18 at 11 a.m., the evaluator observed that the office exit door by the Outpatient Hip and Pelvis Institute, was obstructed from fully opening by a bookcase.

During an interview at the same time as the observation the Facilities Manager acknowledged that the exit door was obstructed from fully opening.

NFPA 10 Standard for Portable Fire Extinguishers 2010 Edition

7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.

7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for non-rechargeable extinguishers using push to-test pressure indicators

This Standard was not met as evidenced by:

Based on observation and interview, the facility failed to ensure that fire extinguishers were inspected at 30-day intervals.

Portable fire extinguishers are intended as a first line of defense to cope with fires of limited size. For fire extinguisher to do their job they must be readily available, fully charged and in working condition. The deficient practice did not ensure that the fire extinguishers were in their designated locations, fully charged and in good condition.

Findings:

1. On 9/11/18 between 11:40 a.m. and 2:25 p.m., the evaluator observed that 17 of 17 fire extinguishers in the Outpatient Child Family unit, did not have the monthly check for August 2018. Closer observation revealed the annual service was done on 6/4/18.

The fire extinguishers missing the August 2018 monthly check included;

Fire extinguisher across from room 110.
Fire extinguisher in the kitchen.
Fire extinguishers in 3 fire hose cabinets.
Fire extinguisher in break room.
Fire extinguisher near viewing room of classroom B.
Fire extinguisher in classroom B.
Fire extinguisher in classroom C.
Fire extinguisher in classroom E.
Fire extinguisher in classroom F.
Fire extinguisher in the basement communication room.
Fire extinguisher in the basement cage.
4 fire extinguishers in the basement medical records storage room.

During an interview at the same time as the observation, the Facility Manager acknowledged the missing August 2018 checks of the fire extinguishers and stated that it looked like rounds were not made for August 2018.

2. On 9/12/18 at 11:05 a.m., the evaluator observed that a fire extinguisher that did not have eight monthly checks, including January, February, March, April, May, June, July, and August for 2018, in the Outpatient Laboratory. Closer observation revealed the annual service was done on 1/4/18.

During an interview at the same time as the observation, the Facility Manager acknowledged the 8 missing checks.

3. On 9/13/18 at 9:05 a.m., the evaluator observed that a fire extinguisher located on the 2nd floor ICU CCU (Intensive Care Unit Critical Care Unit), did not have the monthly check for August-2018. Closer observation revealed the annual service was done on 6/4/18.

During an interview at the same time as the observation, the Facility Manager acknowledged the missing checks for August of 2018 check.

Based on observation and interview, the hospital failed to ensure that a corridor doors could resist the passage of smoke and that there were no impediments to the latching of corridor doors.

The deficiency had the potential to impede and delay the rapid closing of the doors in the event of a fire, and create a condition conducive to the spread of fire, smoke, and heat.

Findings:

1. On 9/11/18 at 2:07 p.m., the evaluator observed that the Outpatient Child Family that office room 211's corridor door had a plastic toy on the floor in front of the door that held the door fully open and obstructing it from closing.

During an interview at the same time as the observation the Facilities Manager acknowledged the obstruction to closing the corridor door.


2. On 9/12/18 at 1:10 p.m., the evaluator observed that the the corridor door of patient room 2416 on the 4th floor of the Oncology unit had a folded pillow case over the top of the door that obstructed he door from closing.

During an interview at the same time as the observations the Facilities Manager acknowledged the obstruction to the door closing and stated that he would remove the pillow case from the door.

3. On 9/12/18 between 2 p.m. and 2:33 p.m., the evaluator observed that the corridor doors of patient rooms 2312, 2336, 2342 and 2374 on the the 3rd floor Ortho unit, failed to hold in the closed position when shut.

During an interview at the same time as the observations the Facilities Manager acknowledged the four corridor doors not holding closed.

4. On 9/13/18 between 1 p.m. and 2:33 p.m., the evaluator observed that the corridor doors of patient rooms 2112 and 2174 at the 1st Floor Med Surge unit failed to hold and close when shut.

During an interview at the same time as the observation the Facilities Manager acknowledged the two corridor doors not holding closed.

NFPA 82 Standard on Incinerators and Waste and Linen Handling Systems
and Equipment 2009 Edition

5.2.4.1.1 Waste and linen chutes shall terminate or discharge directly into a room having a minimum fire resistance rating not less than that specified for the chute.

10.2.1 Chute loading and discharge doors shall be maintained clear and unobstructed at all times.

This Standard was not met as evidenced by:

Based on observation and interview the Hospital failed to ensure that a chute loading door was unobstructed from closing. Two of two chute discharge doors were unobstructed from closing, and the corridor door of a chute room was also observed unobstructed from closing.

In the event of a fire, the conditions that existed in the chute room and discharge rooms had the potential for preventing the chute's loading and discharge doors, and chute discharge room door from closing thereby, creating a chimney effect, a condition conducive to the spread of fire and smoke vertically to the floors above and to the corridor.

Findings:

1. On 9/13/18 at 9:52 a.m., the evaluator noted that a trash chute access door was propped open by overflowing bags of trash in the 1st floor Med Surge unit Biohazard Room.

During a interviews at the same time as the observation the Facility Manager and the Environmental Services Director acknowledged propped open chute door.

2. On 9/13/18 at 11 a.m., the evaluator noted that the Keck basement trash chute room the trash chute's discharge door was obstructed from closing by a bin over filled with bags of trash directly under and abutting the open chute door with bags of trash backed up into the chute.

During a interviews at the same time as the observation the Facility Manager and the Environmental Services Director acknowledged obstructed chute door and identified the chute as the chute serving the Keck building.

3. On 9/13/18 at 11:45 a.m., the evaluator noted that the trash chute's discharge door was obstructed from closing by a bin over filled with bags of trash directly under and abutting the open chute door and bags of trash the Med Surge unit.

During a interviews at the same time as the observation the Facility Manager and the Environmental Services Director acknowledged obstructed chute door and identified the chute as the chute serving the 1st floor Med Surge unit where earlier that morning a trash chute access door was observed to be propped open by overflowing trash bags.

4. On 9/13/18 at 11:50 a.m., the evaluator noted that the soiled linen chute room's self-closing 1 1/2 hour fire rated corridor door was held fully open by a linen bin and was obstructed from closing by bags of soiled linen on the floor in the path of swing of the door the basement soiled linen chute room across from Pharmacy.

During an interviews at the same time as the observation the Environmental Services Director acknowledged the obstructed corridor door and stated that the doors should be unobstructed to self-close.

NFPA 70 National Electrical Code 2011 Edition

400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:

(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage

400.9 Splices. Flexible cord shall be used only in continuous lengths without splice or tap where initially installed in applications permitted by 400.7(A). The repair of hard-service cord and junior hard-service cord (see Trade Name column in Table 400.4) 14 AWG and larger shall be permitted if conductors are spliced in accordance with 110.14(B) and the completed splice retains the insulation, outer sheath properties, and usage characteristics of the cord being spliced.

This Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70 by using extension cords as permanent wiring.

To meet power supply needs in buildings with an inadequate supply of readily available electrical receptacles, extension cords and/or power strips are often interconnected ("daisy chained") to provide more receptacles and/or reach greater distances. Interconnecting these devices can cause them to become overloaded, leading to their failure and a possible fire. Because electrical resistance increases with increased power cord length, interconnecting cords increases the total resistance and resultant heat generation. This creates an additional risk of equipment failure and fire.

Findings:

1. On 9/11/18 at 11:40 a.m., the evaluator observed that the the light to a fish tank was connected to a two prong household tap type extension cord that was connected to a wall receptacle at Outpatient Child Family lobby area.

During an interview at the same time as the observation the Facilities Manager stated that when he came to the facility six years ago the extension cord had already been in use connecting the light to the electrical receptacle.

2. On 9/11/18 at 12:20 a.m., the evaluator observed that there was an extension cord connected to to an electrical receptacle behind a wall anchored book case in the Outpatient Child Family unit.

During an interview at the same time as the observation the Facilities Manager acknowledged the extension cords were used as permanent wiring, and stated that the extension cord was connected at an angle to the wall receptacle.

3. On 9/11/18 at 1:55 p.m., the evaluator observed that there was a power strip connected to an extension cord that in was in turn, connected to a wall receptacle in the Outpatient Child Family Psychology Intern Room 213.

During an interview at the same time as the observation the Facilities Manager acknowledged the daisy-chaining of the power strip and extension cord.

NFPA 99 Health Care Facilities Code 2012 Edition

11.6.2.3 Cylinders shall be protected from damage by means
of the following specific procedures:

(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
(3) Cylinders shall be protected from tampering by unauthorized individuals.
(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5) Safety relief devices in valves or cylinders shall not be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
(7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

This Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure that an oxygen cylinder was secure.

The deficiency had the potential of the oxygen cylinder falling. If the valve of the cylinder were knocked off the high potential energy inside the cylinder could make the cylinder a missile that could penetrate a concrete wall.

Findings:

1. On 9/13/18 at 10:10 a.m., the evaluator observed a full e-cylinder oxygen tank that was stored and unsecured on the floor of 1st Floor Cardio Thoracic unit in front of room 8.

During an interview at the same time as the observation the Facilities Manager acknowledged the cylinder was full and unsecured.

2. On 9/13/18 at 10:55 a.m., the evaluator observed a standing and unsecured oxygen cylinder tank that was stored at the Central Plant in front of an eye wash station.

During an interview at the same time as the observation the Facilities Manager acknowledged the cylinder was unsecured.