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Based on observation, the facility failed to maintain the 2-hour building separation wall. This was evidenced by unsealed penetrations, and unfinished part of the seperation wall. This affected 2 of 5 Facility Buildings and had the potential to allow the spread of smoke and fire.

Findings:

During the facility tour with Staff 1 and 2 on November 17 and 18, 2010, the facility two hour separation barriers were observed.

1. At 9:27 a.m. on November 17, 2010, there was a two-inch circular unsealed penetration on the 5th floor In-Patient (IP) Tower side of the barrier at the entrance to the Diagnostic and Treatment Tower. Staff 1 confirmed there was a two inch circular penetration of the barrier that was not sealed.

2.. At 3:12 p.m. on November 18, 2010, at the first floor Clinic Tower and Diagnostic and Treatment Tower 2 hour separation barrier, only one side of the barrier was drywalled to the floor above. Staff 1 confirmed the non-dry-walled side of the barrier was filled in with fire rated caulking. Staff 1 stated he could not provide documentation that as built, the wall created a 2-hour barrier.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations through the ceilings and walls therefore compromising the containment of smoke and/or fire by the fire rated surface. This affected 5 of 5 facility buildings.

Findings:

During the facility tour with Engineering Staff 2 and 3 between November 15 and 16, 2010, the fire rated building walls were observed:

1. At 3:35 p.m. on November 15, 2010, in the 5P61 Clerk Station in OPD(Outpatient Department Bldg.), there was one approximately 1/2 inch penetration by the phone jack. Staff 2 confirmed there was a penetration by the phone jack.

2. At 3:45 p.m. on November 15, 2010, in the 4P21 Room E in OPD Bldg., there was one approximately 1 inch penetration in the center of the right wall. Staff 2 confirmed there was a penetration in the center of the right wall.

3. At 10:15 a.m. on November 16, 2010, in the Clinic Tower, there was one penetration measuring approximately 1-inch in diameter around the water pipe through the ceiling above the sprinkler test valve in the sprinkler room in the second floor. Staff 3 confirmed there was a penetration in the ceiling.

4. At 10:25 a.m. on November 16, 2010, in the Clinic Tower, there were two penetrations measuring approximately 1/2-inch each in diameter around the water pipes through the ceilings above the sprinkler test valve in the sprinkler room in the third floor. Staff 3 confirmed there were penetrations in the ceiling.

5. At 10:35 a.m. on November 16, 2010, in Cilic Tower, there were two penetrations measuring approximately ?-inch each in diameter around the water pipes through the ceilings above the sprinkler test valve in the sprinkler room in the fourth floor. Staff 3 confirmed there were penetrations in the ceiling.

6. At 2:00 p.m. on November 16, 2010, in OR 4, D&T Tower, there was an approximately 3 inch penetration behind the door in the center of the left wall. Staff 2 confirmed there was a penetration in the wall.

7. At 2:45 p.m. on November 16, 2010, in Radiation Room 4F130, D&T, there was an approximately 1/4 inch by 5 inch penetration in the bottom of the right wall along a metal plate. Staff 2 confirmed there was a penetration in the wall.

8.At 2:50 p.m. on November 16, 2010, in the IP Tower AGVS room 7L260 clean side, there was an approximately two inch by 36 inch damaged area of the wall. Staff 1 confirmed the wall was damaged and stated the damage was consistent with where the cart bumpers meet the wall.

9. At 3:25 p.m. on November 16, 2010, in the IP Tower clean utility room C7C109, there was an approximately two inch by twelve inch damaged area of the wall adjacent to electrical receptacle 7G-5. Staff 1 confirmed the wall was damaged and stated the damage was consistent with where the cart bumpers meet the wall.

10. At 4:15 p.m. on November 16, 2010, in the IP Tower Stairwell C4 on unit 6B, in the Fire Department Connection cabinet there was an approximately four inch circular cut out in the back of the box that was not sealed and an unsealed three-quarter inch gap around the pipe to the pressure gauge. Staff 1 confirmed there was a four inch cut out and a three-quarter inch gap around the pressure gauge pipe.

12. At 4:25 p.m. on November 16, 2010, in the IP Tower AGVS room 6C-2, there was an approximately two inch by twelve inch damaged area of the wall. Staff 1 confirmed the wall was damaged and stated the damage was consistent with where the cart bumpers met the wall.

13. At 8:47 a.m. on November 17, 2010, in the IP Tower clean utility room C6C109, there was an approximately two inch by twelve inch damaged area of the north wall. Staff 1 confirmed the wall was damaged and stated the damage was consistent with where the cart bumpers meet the wall.

14. At 10:47 a.m. on November 17, 2010, in the IP Tower room 5L281A, there was an approximately one inch around two conduits that penetrated the ceiling. Staff 1 confirmed there was an approximately one inch gap around two conduits that penetrated the ceiling.

15. At 11:20 a.m. on November 17, 2010, in the Gift Shop, D&T, there were two approximately 1/2 inch penetrations by the ceiling over the storage room. Staff 2 confirmed there was a penetration in the ceiling.

16. At 11:40 a.m. on November 17, 2010, in the IP Tower AGVS room 4L261A, there was an approximately two inch by sixty-four inch damaged area on 2 of 4 walls. Staff 1 confirmed the walls were damaged and stated the damage was consistent with where the cart bumpers meet the wall.

17. At 1:40 p.m. on November 17, 2010, in the IP Tower clean utility room 4H318, there was an approximately two inch by thirty-six inch damaged area of the north wall. Staff 1 confirmed the wall was damaged and stated the damage was consistent with where the cart bumpers meet the wall.

18. At 3:40 p.m. on November 17, 2010, in the IP Tower room 3P421, there were two approximately three-quarter inch circular holes in the wall adjacent to the time clock. Staff 1 confirmed there were two circular three-quarter inch holes in the wall adjacent to the time clock.

19. At 9:05 a.m. on November 18, 2010, there was one penetration measuring approximately 1/2-inch in diameter around the electric pipe through the ceiling in the interview room 2149 of Ward B in the second floor of the Augustus Hawkins Building (AHB).

20. At 9:15 a.m. on November 18, 2010, there was one penetration measuring approximately 1-inch in diameter around the base of sprinkler head through the ceiling in the dirty utility room of Ward B in the second floor of AHB.

21. At 9:55 a.m. on November 18, 2010, there was an approximately two inch circular unsealed penetration with a copper colored conduit that through the penetrating in the IP Tower Kitchen Ice Room 1H310B. Staff 1 confirmed the conduit penetration of the wall was not sealed.

22. At 9:55 a.m. on November 17, 2010, there was an approximately two-inch unsealed gap around three pipes that penetrated the east wall of the Kitchen Ice room 1H310B in the IP Tower. Staff 1 confirmed there was an approximately two-inch gap around three pipes that penetrated the east wall.

NFPA 80 (1999 Edition), 15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by corridor doors that were obstructed from closing, by corridor doors that failed to positive latch upon closure, by failure to provide documentation for the testing and maintenance of a roll-down door and by doors with tape over the latching mechanism. This could result in the spread of smoke and fire throughout the facility and increase the risk of injury to patients, visitors and staff. This affected 5 of 5 Facility Buildings.

Findings:

During the facility tour with Facility Engineering Staff 1, 2, 3 and 4 from November 15, 2010 through November 19, 2010, the corridor doors were observed.

1. At 3:55 p.m. on November 15, 2010, in Specialty Medicine 4P1, OPD(Outpatient Department), the exit door was blocked open with a broom. Staff 2 confirmed the door was blocked open with a broom.

2. At 10:00 a.m. on November 16, 2010, the Fire Door to the Infusion Clinic 3P1, OPD, the right leaf failed to fully close and positive latch. Staff 2 confirmed the door failed to fully close and latch.

3. At 10:08 a.m. on November 16, 2010, the door to resident room C8B106 in the IP Tower was obstructed from closing by a trash can. Staff 1 confirmed the trash can obstructed the door from closing.

4. At 10:12 a.m. on November 16, 2010, the door to the Nourishment Room C8B107 in the IP Tower failed to latch. Staff 1 confirmed the door failed to latch.

5. At 10:15 a.m. on November 16, 2010, the corridor self-closing door to room C8B101 in the IP Tower was prevented from closing by a door wedge. Staff 1 confirmed the door wedge prevented the door from closing.

6. At 10:30 a.m. on November 16, 2010, the Fire Door to UADC 2P52, OPD, the left leaf failed to fully close and positive latch.

7. At 10:40 a.m. on November 16, 2010, the corridor self-closing door to room C8A130 in the IP Tower was obstructed from closing by a trash can. Staff 1 confirmed the trash can obstructed the door from closing.

8. At 2:45 p.m. on November 16, 2010, in EVS(Environmental Services) Room 4D341, D&T Tower, the corridor door was covered with tape preventing the door from latching. Staff 2 confirmed the door was prevented from latching.

9. At 3:46 p.m. on November 16, 2010, the self-closing corridor door to EVS room 6H410 in the IP Tower was prevented from latching by a paper towel that was stuffed into the strike plate. Staff 1 confirmed there was a paper towel stuff into the strike plate and removed the paper towel.

10. At 8:44 a.m. on November 17, 2010, door 6R211 in Unit 6C in the IP Tower did not latch. Staff 1 confirmed the door failed to latch.

11. At 9:07 a.m. on November 17, 2010, the self-closing corridor door to the Ante room 6K419 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

12. At 11:15 a.m. on November 17, 2010, the self-closing door to Room 2C412 in the D&T Tower was jammed with paper preventing the door from latching. Staff 2 confirmed the door was obstructed from latching.

13. At 11:25 a.m. on November 17, 2010, the door to the Gift Shop Storage Room in the D&T Tower was prevented from closing by a door wedge. Staff 2 confirmed the door was obstructed from closing by a wedge.

14. At 11:30 a.m. on November 17, 2010, the self-closing corridor door to room 4R126 in the IP Tower was prevented from latching by a tongue depressor taped over the strike plate. Staff 1 confirmed the door was obstructed from latching.

15. At 11:31 a.m. on November 17, 2010, the corridor self-closing door to waiting room C4C100 in the IP Tower was obstructed from closing by a trash can. Staff 1 confirmed the trash can obstructed the door from closing and moved the trash can.

16. At 5:30 p.m. on November 17, 2010, the facility failed to provide documentation for the inspection and maintenance of the roll down door in the OPD generator room. Staff 1 stated there were no records available for review.

17. At 9:45 a.m. on November 18, 2010, the resident room door 2171 of Ward A in second floor of August Hawkins Building (AHB) failed to latch.

18. At 9:55 a.m. on November 18, 2010, the resident room door 2022 of Ward D in the second floor of AHB failed to latch.

19. At 9:55 a.m. on November 18, 2010, the corridor self-closing door to the kitchen pallet storage room in the IP Tower was obstructed from closing by the floor. The door stuck to the floor. Staff 1 confirmed the floor obstructed the door from closing.

20. At 10:05 a.m. on November 18, 2010, the resident room door 2078 of Ward F in the second floor of AHB failed to latch.

21 At 10:12 a.m. on November 18, 2010, the self-closing corridor door to room C2M180 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

22. At 11:18 a.m. on November 18, 2010, at the entrance door to Utilization Review next to Room 7B22, Clinic Tower, the corridor door was covered with tape preventing the door from latching.

23. At 1:40 p.m. on November 18, 2010, the self-closing corridor door to room CIL280 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

Based on observation, the facility failed to maintain access to exits. This was evidenced by the failure to provide visible exit signs and an exit sign that pointed in the wrong direction. This affected 1 of 5 Facility Buildings and had the potential for occupants not to readily reach an exit.

Findings:

During the facility tour with Engineering Staff 1 on November 17, 2010, access to the exits were observed.

2. At 9:25 a.m., there was no exit sign on the In-Patient (IP) Tower side of the 5th floor smoke barrier at the Diagnostic and Treatment (D & T) Tower entrance. Staff 1 confirmed there was not exit sign at the barrier.

3. At 9:41 a.m., there was no exit sign on the Burn Unit In-Patient (IP) Tower side of the 5th floor smoke barrier at the Diagnostic and Treatment (D & T) Tower entrance. Staff 1 confirmed there was not exit sign at the barrier.

4. At 9:44 a.m., the exit sign at the east end of the 5th floor corridor outside the burn unit was obstructed by a directional sign. Staff 1 confirmed the exit sign at the east end of the corridor outside the burn unit was obstructed by a directional sign.

5. At 11:05 a.m., the exit sign on the In-Patient (IP) Tower side of the 4th floor smoke barrier at the Diagnostic and Treatment (D & T) Tower entrance pointed in the opposite direction of the stairwell exit. Staff 1 confirmed the exit pointed in the opposite direction of the stairwell exit.

Based on observation, the facility failed to ensure the integrity and maintenance of 1 of 6 smoke barrier wall located in the attic space over cross-corridor fire doors in order to provide at least a one-half hour fire resistance rating. In the event of fire and/or smoke, the smoke barrier integrity compromised by a penetration, would not be able to provide at least a one-half hour fire resistance and would allow smoke and/or fire to pass from one smoke compartment to another smoke compartments, thereby affecting all residents in the facility. This affected 1 of 5 Facility Buildings.

Findings:

During the facility tour with Engineering Staff 4 on November 18, 2010, the facility smoke barriers were observed.

1. At 2:00 p.m. on November 17, 2010, there was an approximately 24 inch by 24 inch square penetration in the smoke barrier adjacent to the entrance to Unit 4B in the In Patient Tower. The penetration was above an access panel and was below the duct access panel to a smoke damper. Staff 1 confirmed there was penetration in the smoke barrier and stated there was a missing rated access door that had not been installed over the penetration.

2. At 10:55 a.m. on November 18, 2010, there was one penetration measuring approximately 1-inch in diameter around the electric pipe through the smoke barrier wall located in the attic space over cross-corridor fire doors next to the resident room 208 of Ward F in the second floor of the August Hawkins Building.

3. At 11:00 a.m. on November 18, 2010, there was an approximately 12 inch by 12 inch square unsealed penetration in the first floor smoke barrier that separated the In Patient Tower and the Diagnostic and Treatment Tower. There was a single blue wire through the penetration. Staff 1 confirmed there was penetration in the smoke barrier.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by the cross-corridor smoke barrier doors that failed to latch and/or had a gap between a set of smoke barrier doors. This affected 2 of 5 Facility Buildings and had the potential for the spread of smoke during a fire.

Findings:

During the facility tour and testing of the fire alarm system with Engineering Staff 1, 2 and 3 between November 16 and 18, 2010, the smoke barrier doors were observed:

1. At 10:05 a.m. on November 16, 2010, the cross-corridor smoke barrier doors in the first floor of the Clinic Tower did not latch and had a 1/2-inch gap between a set of the doors. Staff 3 confirmed the doors failed to latch and that there was a gap between the doors.

2. At 10:20 a.m. on November 16, 2010, the cross-corridor smoke barrier door between the Clinic Tower and Diagnostic and Treatment Building (D&T) in the third floor failed to latch and had 1-inch gap between the set of the doors. Staff 3 confirmed the doors failed to latch and that there was a gap between the doors.

3. At 10:30 a.m. on November 16, 2010, the cross-corridor smoke barrier door between the Clinic Tower and Diagnostic and Treatment Building (D&T) in the fourth floor had 1-inch gap between a set of the doors. Staff 3 confirmed there was a gap between the doors.

4. At 10:40 a.m. on November 16, 2010, the cross-corridor smoke barrier door between the Clinic Tower and Diagnostic and Treatment Building (D&T) in the fifth floor failed to latch and had 1-inch gap between a set of the doors. Staff 3 confirmed the doors failed to latch and that there was a gap between the doors.

5. At 10:50 a.m. on November 16, 2010, the cross corridor smoke barrier door in front the electric room in the fifth floor had a 1/2-inch gap between a set of the doors. Staff 3 confirmed there was a gap between the doors.

6. At 10:25 a.m. on November 17, 2010, in the common wall at the entrance to the D & T tower from the Clinic, the right leaf on the smoke barrier double dour failed to fully close and positive latch. Staff 2 confirmed the right leaf failed to fully close and latch.

Based on observation, the facility failed to protect their hazardous areas. This was evidenced by hazardous areas that failed to have self-closures on the doors, storage areas that were open to the corridor and unrated areas with hazardous supplies. This could potentially allow the spread of smoke and fire from hazardous areas to other areas, in the event of a fire and increase the risk of injury to patients, visitors and staff. This affected 5 of 5 Facility Buildings.

Findings:

During a tour of the facility with the Engineering Staff 1 and 2 on November 15 through November 19, 2010, the hazardous areas were observed.

1. At 3:40 p.m. on November 15, 2010, in Primary Care 5P61, OPD, the door to Room 16 was open. The room contained 5 gallon paint containers and paint supplies. Staff 2 confirmed the room contained the paint and supplies.

2. At 3:45 p.m. on November 15, 2010, the janitor storage area adjacent to room 1P-46 in the OPD building was open to the corridor. There were approximately 15 cardboard boxes of supplies in the area.

3. At 3:50 p.m. on November 15, 2010, the janitor storage area adjacent to Stairwell 3 on the first floor in the OPD building was open to the corridor. There were approximately 15 cardboard boxes of supplies in the area.

4. At 3:20 p.m. on November 16, 2010, the self-closing corridor door to soiled utility room C7C107 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

5. At 1:40 p.m. on November 17, 2010, the Information Systems Conference Room, D&T. The unrated room measured over 50 square feet and had an abundant amount of combustible materials including 40 boxes of cables, IT supplies, paper materials and miscellaneous supplies. Staff 2 confirmed the room was used for storage.

6. At 2:41 p.m. on November 17, 2010, the self-closing corridor door to soiled utility room C310 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

7. At 3:01 p.m. on November 17, 2010, the self-closing corridor door to soiled utility room 3P422 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

8. At 1:40 p.m. on November 18, 2010, the door to Med Clinic Storage 5B120, Clinic Tower was not self or auto-closing. The room measured over 50 square feet and had an abundant amount of combustible materials including paper supplies, plastics, and linen.

Based on observation, the faility failed to maintain stairways free from potential interference to egress. This was evidenced by 44 gallon containers and equipment left in the stairwell corridor affecting 1 of 5 buildings. This could result in delay in evacuation and cause injury to patients, staff and visitors.

Findings:

1. At 3:47 p.m. on November 16, 2010, there was a 44-gallon gray container stored in the exit stairwell corridor C2 inside door 6H251 in the IP Tower. Staff 1 confirmed there was a container stored in the exit stairwell.

2. At 10:41 a.m. on November 17, 2010, there was a 44-gallon gray container stored in the exit stairwell corridor C4 off unit 5B in the IP Tower. Staff 1 confirmed there was a container stored in the exit stairwell.
3. At 10:44 a.m. on November 17, 2010, there was a 44-gallon gray container and red 44-gallon gray container stored in the exit stairwell corridor C5 off unit 5A in the IP Tower. Staff 1 confirmed there was a container stored in the exit stairwell.
4. At 11:35 a.m. on November 17, 2010, there was a floor cleaning machine stored in the exit stairwell corridor C7 off unit 4C in the IP Tower. Staff 1 confirmed there was a floor cleaning machine stored in the exit stairwell.
5.. At 11:18 a.m. on November 18, 2010, there was a 44-gallon gray container stored in the exit stairwell corridor C8 adjacent to the locksmith office in the IP Tower. Staff 1 confirmed there was a container stored in the exit stairwell

Based on observation, the facility failed to maintain exit access. This was evidenced by doors that were not equipped with door releasing devices in the In Patient (IP) Tower and exit egress that was obstructed. This affected 2 of 5 Facility Buildings and had the potential for delaying egress in an emergency.
Findings:
During the facility tour with the Engineering Staff 1 and 2 on November 16, 2010, the facility exit corridors were observed.

1. At 11:10 .m. on November 16, 2010, 3 of 3 exit doors from the Child Life Playroom in the IP Tower were not equipped with panic hardware. When locked, the doors could not be opened without a key. Staff 1 confirmed the doors were not equipped with panic hardware.

2. At 2:40 p.m. November 16, 2010, at the OR Exit by Room 26 in the D&T Tower, there was a C-Arm blocking the right leaf of the double door exit. Staff 2 confirmed the door was obstructed.

3. At 2:45 p.m., November 17, 2010, at the ER Exit by 1E132 in the D&T Tower, there was a portable X-ray machine blocking the right leaf of the double door exit. Staff 2 confirmed the door was obstructed.

Based on observation, the facility failed to maintain exit access free from obstructions to quick egress. This was evidenced by obstructed exit corridors in the In Patient (IP) Tower. This affected 1 of 5 Facility Buildings and had the potential for delaying egress in an emergency.

Findings:

During the observation of the exit corridors with the Engineering Staff at 11:10 a.m. on November 18, 2010, there were four gurneys, a patient bed, a wheelchair and three housekeeping machines stored in the exit corridor from the IP Tower to the Emergency Room entrance. The corridor ran parallel to the Diagnostic and Treatment Tower wall. Staff 1 confirmed the items were stored in the exit corridor.

NFPA 99 (1999 Edition) 3-3.2.1.2 (5) (e) Wiring in Anesthetizing Locations. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Based on observation, the facility failed to maintain the emergency lighting as evidenced by the failure to provide one or more battery-powered emergency lighting units in 2 of 2 delivery suites. This had the potential for lack of lighting during a power failure causing confusion during emergency egress.

Findings:

During the facility tour with the Engineering Staff 1 on November 17, 2010, the emergency lighting in the corridors were observed.

At 3:10 p.m. on November 17, 2010, the facility failed to provide battery-powered emergency lighting units in 2 of 2 delivery suites. Staff 1 confirmed there were no battery-powered emergency lighting units in the delivery suites.

Based on record review and interview, the facility failed to conduct fire drills at least quarterly for all shifts, failed to follow-up on drills per the facilities policy and procedure and failed to hold fire drills at varying times. This was evidenced by the facility failure to provide records for 1 of 12 fire drills for the D&T tower, provide follow-up on fire drills where staff performed poorly, and failed to conduct fire drills at varying times. This could result in any one member of the staff failing to accomplish all of the tasks required of him of her in the event of a fire and the increased risk of injury to the patients, visitors and staff due to smoke and fire and affected 1 of 5 facility buildings.

Findings:

During record review and interview with the facility staff on November 15, 2010 through November 19, 2010, fire drill records were reviewed and staff interviewed.

1. At 1:25 p.m. on November 15, 2010, there was no record of fire drill conducted for the D&T Tower for the PM shift, first quarter of 2010 and the AM shift for the second quarter 2010. Staff 2 confirmed the drills were not available.

2. At 1:30 p.m. on November 15, 2010, in the D&T bldg., the facility conducted 3 of 4 AM fire drills at 10:00 a.m., 3 of 4 PM fire drills at 4:00 p.m.and 4 of 4 NOC fire drills at 6:00 a.m. Staff 2 confirmed the drills were held at the same time on each shift.

3. At 1:40 p.m. on November 15, 2010, D&T, the facility conducted fire drills for August 13, 2010 and July 20, 2010 in which some of the staff performed poorly. On November 17, 2010, at 1:20 p.m., Facility Staff 2 stated that there was no follow-up training on these drills.

4. At 9:00 a.m. on November 16, 2010, the facility fire drills for the previous 12 months conducted in the IP Tower showed 4 of 4 AM shift drills were conducted at 10:00 a.m., 4 of 4 drills for the PM shift being conducted at 4:00 p.m., and 4 of 4 drills for the NOC shift being conducted between 6:00 a.m. and 6:15 a.m. Staff 2 confirmed the drills were held at approximately the same time during each shift.

NFPA 72 (1999 Edition) 2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

NFPA 101 (2000 Edition) 9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by a manual pull box that failed when tested, a trouble light on in the fire alarm panel, obstructed access to a manual pull box and a fire alarm panel that read the incorrect time. This affected 3 of 5 Facility Buildings and had the potential to delay fire department response or alarm system failure.

Findings:

During the facility tour with Engineering Staff 1, 2 and 3, between November 16 and 18, 2010, the fire alarm system was observed and tested.

1. At 11:55 a.m. on November 16, 2010, the manual fire alarm pull box in front the room 5B170 in the fifth floor of the Clinic Tower failed to sound the alarm when activated. Staff 3 confirmed the manual pull box failed when tested.

2. At 8:32 a.m. on November 17, 2010, in the Radiation Break Room 3D 325 in the D&T Tower, the Pre-Action System Fire Alarm Control Panel, displayed a trouble signal. Staff 2 confirmed that the information was correct.

3. At 8:50 a.m. on November 17, 2010, in the Radiation Break Room 3D 325, D&T, the Fire Alarm Control Panel displayed the time as 10:06 a.m. instead of 8:50 a.m., Staff 2 confirmed the panel read the incorrect time.

4. At 9:15 a.m. on November 17, 2010, Central Plant, staff at Central Plant was interviewed. Trouble signal showed at 5:06 a.m. Engineer reported trouble signal on Device M3-210 to vendor at 7:30 a.m. Staff 1 and Staff 2 set-up fire watch and interim life safety measures.

5. At 11:40 a.m. on November 17, 2010, access to the manual fire alarm box in the 4th floor AVGS room 4L261B was obstructed by a biohazard container. Staff 1 confirmed access to the manual fire alarm box was obstructed by a biohazard container.

6. At 1:44 p.m. on November 17, 2010, in the Information Systems Pre-Action Sapphire System Room inside the Conference Room 2F110, the Fire Alarm Control Panel displayed the time as 2:44 p.m. Staff 2 confirmed the panel read the incorrect time.

7. At 2:40 p.m. on November 17, 2010, the Pull Station M7L2103, in ER North in the D&T Tower, was blocked by a linen cart. Staff 2 confirmed the pull station access was blocked.

8. At 3:00 p.m. on November 17, 2010, the Pull Station M7L2126, in the ER Waiting Room in the D&T Tower, was blocked by a rolling table. Staff 2 confirmed the pull station access was blocked

9. At 3:05 p.m. on November 17, 2010, the Pull Station M7L114, in the Ped ER in the D&T Tower, was blocked by a step ladder. Staff 2 confirmed the pull station access was blocked

10. At 3:12 p.m. on November 17, 2010, the Pull Station M7L207, in ER East in the D&T Tower, was blocked by equipment. Staff 2 confirmed the pull station access was blocked

11. At 3:15 p.m. on November 17, 2010, the Pull Station M2L413, in the Ambulance Entrance in the D&T Tower, was blocked by a gurney. Staff 2 confirmed the pull station access was blocked

13. At 11:20 a.m. on November 18, 2010, the 7th Floor Pull Station, in Anatomic Pathology A7A, Clinic Tower, was blocked by two carts. Staff 2 confirmed the pull station access was blocked.

NFPA 101 (2000 Edition) 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 (1999 Edition) 7-7.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

NFPA 72 (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.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.

Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Based on interview and document review, the facility failed to maintain the smoke detectors in the OPD Building. This was evidenced by the failure to test the smoke detectors for sensitivity. This affected 1 of 5 Facility Buildings and had the potential for detector failure.

Findings:

During the document review on November 15, 2010, the inspection and test record for the fire alarm systems was reviewed with the Engineering Staff.

At 4:40 p.m., the facility provided documentation for the testing and maintenance of the fire alarm system in the OPD Building dated 2-4-10. The fire alarm inspection report did not include records for sensitivity testing of the smoke detectors. Staff 1 stated there were no other documents available for review.

NFPA 13 (1999 Edition) 3-8.3* Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.

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, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Based on observation, the facility failed to maintain their automatic sprinkler system in the Clinic Tower. This was evidenced by missing escutcheon rings, sprinkler heads with foreign materials, and faded valve identification signs. This affected 4 of 5 Facility Buildings and had the potential for sprinkler failure.

Findings:

During the facility tour with the Engineering Staff 1, 2, 3 and 4, between November 15 and 18, 2010, the sprinkler system was observed.

1. At 3:15 p.m. on November 15, 2010, in the 5th Floor Health Services Room 2, OPD, 1 of 1 sprinkler heads was missing the escutcheon ring. Staff 2 confirmed the escutcheon ring was missing.

2. At 10:07 a.m. on November 16, 2010, in the 3rd Floor VIP Pediatric 3P61 Reception, OPD, there was 1 of 2 sprinklers missing an escutcheon ring. Staff 2 confirmed the escutcheon ring was missing.

3. At 10:35 a.m. on November 16, 2010, in the Clinic 2P52 Reception, OPD, there was a build-up of debris on 3 of 10 sprinkler heads. Staff 2 confirmed there was debris build-up on 3 of 10 sprinkler heads.

4. At 2:10 p.m. on November 16, 2010, the auxiliary drain for the sprinkler system in the EVS closet adjacent to room 7P128 in the IP Tower was not identified with a sign. Staff 1 confirmed there was no sign on the valve.

5. At 8:37 a.m. on November 17, 2010, the auxiliary drain for the sprinkler system in the Unit 6C EVS closet 6N116 in the IP Tower was not identified with a sign. Staff 1 confirmed there was no sign on the valve.

6. At 8:45 a.m. on November 17, 2010, the auxiliary drain for the sprinkler system in the Unit 6C EVS closet 6R115 in the IP Tower was not identified with a sign. Staff 1 confirmed there was no sign on the valve.

7. At 8:57 a.m. on November 17, 2010, the sprinkler head in the office supply closet on unit 6D was wrapped with masking tape. Staff 1 confirmed the sprinkler head was wrapped with masking tape.

8. At 11:05 a.m. on November 17, 2010, there was no sign for inspector test valve (ITV) of the sprinkler system in the sprinkler room in the basement of the OPD facility. Staff 3 confirmed there was no identification sign on the ITV.

9. At 11:21 a.m. on November 18, 2010, the auxiliary drain for the sprinkler system in the EVS closet IK415A in the IP Tower was not identified with a sign. Staff 1 confirmed there was no sign on the valve.


10. At 11:25 a.m. on November 18, 2010, in the August Hawkins Building, one sprinkler head located in the hallway in front the nurse station of Ward F in the second floor had a heavy accumulation of dust and lint.

11. At 1:50 p.m. on November 18, 2010, in the Ophthalmology Med Surg A4A, Clinic Tower, there was 1 of 2 sprinklers missing an escutcheon ring. Staff 2 confirmed the escutcheon was missing.

12. At 2:30 p.m. on November 18, 2010, the valve identification sign and the hydraulic name plate sign outside the elevator room for elevators 21, 22 and 23 on the roof of the Clinic Tower were faded and not legible. Staff 1 confirmed the signs were faded and not legible.

NFPA 10 (1998 Edition) 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.

NFPA 10 (1998 Edition), 4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.

NFPA 10 (1998 Edition) 4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

NFPA 10 (1998 Edition) 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

NFPA 10 (1998 Edition) 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

Based on observation, the facility failed to maintain the portable fire extinguishers. This was evidenced by fire extinguishers impeded from access, no documentation for the monthly inspection of the fire extinguishers and fire extinguishers mounted more than 60 inches above the floor. This could result in delayed response to a fire and increase the risk of injury to patients, visitors and staff. This affected 4 of 5 Facility Buildings.

Findings:

During the facility tour with Engineering Staff 1, 2, 3 and 4 November 15 through November 19, 2010, the fire extinguishers were observed.

1. At 3:58 p.m. on November 15, 2010, in Human Resources 4P42, OPD, the fire extinguisher was blocked by a table. Staff 2 confirmed access to the extinguisher was blocked by a table.

2. At 9:48 a.m. on November 16, 2010, in the elevator rooms for elevators 1-6, 7-10 and 11-12 in the In-Patient (IP) Tower, the facility failed to provide documentation for the monthly inspection of the fire extinguishers in the elevator rooms since the fire extinguishers were serviced on 6-29-10. Staff 1 confirmed the fire extinguishers had not been inspected since the extinguishers were serviced on 6-29-10.

3. At 9:50 a.m. on November 16, 2010, in the mechanical room AB on the roof of the In-Patient (IP) Tower, the facility failed to provide fire extinguishers at the locations identified by fire extinguisher brackets attached to the wall. Staff 1 confirmed the fire extinguishers had not been installed. Staff 1 stated the facility had identified the deficiency of the lack of extinguishers in the area and was installing the brackets to hang new extinguishers.

4. At 10:02 a.m. November 16, 2010, in the Infusion Clinic 43P1, OPD, the central fire extinguisher was blocked by a linen cart. Staff 2 confirmed access to the extinguisher was blocked by a linen cart.

5. At 10:15 a.m. November 16, 2010, in the VIP Conference Room 3P61, OPD, the fire extinguisher was installed approximately 72 inches from the top of the fire extinguisher to the floor. Staff 2 confirmed the top of the extinguisher was approximately 72 inches above the floor.

6. At 3:50 p.m. November 16, 2010, in 3rd Floor by B3B106 in the D&T Tower, the fire extinguisher was blocked from access. Staff 2 confirmed access to the extinguisher was blocked.

7. At 9:20 a.m. November 17, 2010, in Central Plant, the fire extinguisher by the FACP was laying sideways on the floor. Staff 2 confirmed the fire extinguisher was laying on the floor.

8. At 3:05 p.m. November 17, 2010, in Pediatric ER in the D&T Tower, by Pull Station M7L114, the fire extinguisher was blocked from access by a step ladder. Staff 2 confirmed access to the extinguisher was blocked by a step ladder.

9. At 3:20 p.m. November 17, 2010, in ER Overflow in the D&T Tower, the fire extinguisher was blocked from access by a patient bed. Staff 2 confirmed access to the extinguisher was blocked by a patient bed.

10. At 3:25 p.m. on November 17, 2010, the ABC fire extinguisher in the NICU adjacent to stairwell C2 was not hanging on a bracket designed for the extinguisher. Staff 1 confirmed the bracket was not designed for the extinguisher.

11. At 9:47 a.m. on November 18, 2010, in the kitchen elevator room in the In-Patient (IP) Tower, the facility failed to provide documentation for the monthly inspection of the fire extinguisher in the elevator room since the fire extinguisher was serviced on 6-29-10. Staff 1 confirmed the fire extinguisher had not been inspected since the extinguisher was serviced on 6-29-10.

12. At 1:35 p.m. on November 18, 2010, access to the fire extinguisher in the EVS office 1L213A in the IP Tower was obstructed by an end table, which required reaching over the end table to access the extinguisher. Staff 1 confirmed the end table obstructed access to the extinguisher and had the end table moved.

13. At 1:45 p.m. on November 18, 2010, access to the fire extinguisher in the Materials Management Receiving area in the IP Tower was obstructed by a copy machine, which required reaching over the copy machine to access the extinguisher. Staff 1 confirmed the copy machine obstructed access to the extinguisher.

14. At 2:10 p.m. on November 18, 2010, in Elevator Room 26/27, Clinic Tower, the fire extinguisher failed to have monthly checks for August 2010 through October 2010. Staff 2 confirmed the fire extinguisher was not checked from August through October.

15. At 2:15 p.m. on November 18, 2010, in Elevator Room 24/25, Clinic Tower, the fire extinguisher failed to have monthly checks for July 2010 through October 2010. Staff 2 confirmed the fire extinguisher was not checked from July through October.

16. At 2:25 p.m. on November 18, 2010, in Elevator Room 21/22/23, Clinic Tower, the fire extinguisher failed to have monthly checks for August 2010 through October 2010. Staff 2 confirmed the fire extinguisher was not checked from August through October.

Based on observation, the facility failed to maintain the smoking areas as evidenced by the failure to provide a self-closing container where ashtrays could be emptied. This affected 2 of 5 Facility Buildings and had the potential for a fire.

Findings:

During the facility tour with the Engineering Staff 1 and 4 on November 18, 2010, the smoking areas were observed.

1. At 10:30 a.m. on November 18, 2010, the ashtrays provided in the smoking area of the In-Patient Tower were of an open design with sand. There were no self-closing containers into where ashtrays could be emptied. Staff 1 confirmed there were no self-closing containers in the smoking area.

2. At 11:45 a.m. on November 18, 2010, there was one metal cigarette ashtray without self-closing cover device in the smoking area in the patio in the second floor of the Augustus Hawkins facility. A review of the smoking policy of the facility on 11/18/10, at 11:50 a.m., revealed that the policy did not include provision for metal container with self-closing cover device into which ashtray can be emptied in all areas where cigarette smoking was permitted

NFPA 90A (1999 Edition), 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

NFPA 90A (1999 Edition), 2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

NFPA 90A (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 close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on observation and interview, the facility failed to maintain the heating, ventilation and air conditioning systems. This was evidenced by the failure to provide documentation for the testing of the fire dampers and the failure to identify the service openings in the air duct. This affected 1 of 5 Facility Buildings and had the potential to fail to contain smoke.

Findings:

During the facility tour with the Engineering Staff 1 on November 16, 2010, the fire dampers and duct access panels were observed.

1. At 5:45 p.m., the air duct for the 3rd floor west air conditioning duct was observed. The air duct access panel was opened exposing a fire damper. The duct access panel was not labeled indicating the presence of the fire damper. Staff 1 acknowledged the access panel was not labeled stated that the unlabeled access panel was consistent with the other duct access panels in the OPD building system.

2. At 5:45 p.m., the fire damper in the 3rd floor west air conditioning duct was observed. Staff 1 stated there were no records available for review for the testing and maintenance of the dampers in the OPD building.

NFPA 99 (1999 Edition) Chapter 12 Hospital Requirements

12-1 Scope. This chapter addresses safety requirements of nursing homes.

NFPA 99 (1999 Edition) 12-3.8 Gas Equipment Requirements.
12-3.8.1 Patient. Equipment shall conform to requirements for patient equipment in Chapter 8.

NFPA 99 (1999 Edition) 8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).

(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.

NFPA 99 (1999 Edition) 8-3.1.11.2 (h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

NFPA 99 (1999 edition), 4-3.5.2.1(b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation, the facility failed to ensure that the compressed gas cylinders were secured. This was evidenced by unsecured compressed gas cylinders. This affected 8 of 44 smoke compartments and had the potential for damage to the cylinders and harm to patients.

Findings:

During the facility tour with the Engineering Staff 1 between November 16 and 18, 2010, the facility compressed gas cylinder storage areas were observed.

1. At 3:05 p.m. on November 16, 2010, there were 3 unsecured E oxygen cylinders in the Soiled Utility Room C7D119 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinders were not secured.

2. At 3:20 p.m. on November 16, 2010, there were 6 E oxygen cylinders and an E compressed gas cylinder laying unsecured on the floor in the Soiled Utility Room C7C107 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinders were not secured and laying on the floor.

3. At 3:35 p.m. on November 16, 2010, there was an unsecured E oxygen cylinder in room 6L210 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was not secured.

4. At 3:40 p.m. on November 16, 2010, there was a free-standing, unsecured oxygen cylinder in the Soiled Utility Room C6A117 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was free standing and not secured.

5. At 3:50 p.m. on November 16, 2010, there was an unsecured oxygen cylinder lying on the floor in the Soiled Utility Room C6A107 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was lying on the floor and was not secured.

6. At 4:03 p.m. on November 16, 2010, there was an unsecured oxygen cylinder lying on the floor adjacent to the crash cart in Unit 6B in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was lying on the floor and was not secured.

7. At 10:10 a.m. on November 17, 2010, there were two unsecured Nitric Oxide E cylinders lying on the floor and an unsecured Nitric Oxide E cylinder in a storage cart in room C5G111 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinders were not secured.

8. At 1:35 p.m. on November 17, 2010, there was an unsecured oxygen cylinder lying on the floor in the Soiled Utility Room C4B132 on unit 4B in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was lying on the floor and was not secured.

9. At 1:41 p.m. on November 17, 2010, there was an unsecured oxygen cylinder lying on the floor in the Soiled Utility Room 4H427 on unit 4A in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was lying on the floor and was not secured.

Based on observation, the facility failed to maintain the oxygen storage areas as evidenced by the failure to provide " NON SMOKING " signs at the front doors of the oxygen storage rooms. This affected 1 of 5 facility buildings.

Findings:

During the facility tour with Staff 4 on November 18, 2010, the oxygen storage areas were observed.

At 11:55 a.m. on November 18, 2010, there were no " NON-SMOKING " signs posted at the front doors of the medication rooms of Ward A, Ward C, Ward E in the second floor where the oxygen tanks were stored.

NFPA 110 (1999 Edition) 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Based on observation, the facility failed to maintain the battery powered emergency lighting in the generator area as evidenced by the failure of the emergency lighting when tested. This affected 1 of 5 Facility Buildings.

Findings:

During the facility tour with Staff 1 on November 17, 2010, the emergency lighting was observed.

At 5:30 p.m., the battery-powered emergency light in the generator room in the OPD Building failed when tested. Staff 1 confirmed the light failed when tested.

NFPA 70 (1999 Edition), article 110-12(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 70 (1999 Edition) 384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

NFPA 70 (1999 Edition), 400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:

(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)


Based on observation, the facility failed to maintain the electrical safety. This was as evidenced by the failure to identify the purpose or use of electrical breakers, damaged electrical receptacles, a refrigerator that was plugged into a surge protector instead of directly into an electrical receptacle and electrical boxes that were missing the cover or had a damaged cover. This affected 3 of 5 Facility Buildings and had the potential for a fire or electrical shock.


Findings:

During the facility tour with the Engineering Staff 1, 2, 3 and 4 between November 16 and 18, 2010, the facility electrical wiring and equipment were observed.

1. At 9:50 a.m. on November 16, 2010, the cover plate on data line 9M 170-02 in the electrical room in the IP Tower Roof Mechanical Room was missing. Staff 1 confirmed the cover plate was missing.

2. At 10:20 a.m. on November 16, 2010, on the west wall of IP Tower electrical room 8P470, the fire alarm junction box was missing the cover plate. Staff 1 confirmed the fire alarm junction box was missing the cover plate.

3. At 10:35 a.m. on November 16, 2010, in IP Tower electrical panel IP8HA, breakers 14-18 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

4. At 10:35 a.m. on November 16, 2010, in IP Tower electrical panel IP8LA, breakers 36-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

5. At 10:35 a.m. on November 16, 2010, in IP Tower electrical panel IP8CHA, breakers 23 and 24 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

6. At 10:45 a.m. on November 16, 2010, in IP Tower electrical panel IP8A, breakers 30-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

7. At 10:45 a.m. on November 16, 2010, in IP Tower electrical panel IP8CA, breakers 27 and 29-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

8. At 11:00 a.m. on November 16, 2010, in IP Tower electrical panel IP8LS, breakers 2, 3, 5, 7, 16, 18, 20, 26 and 27 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

9. At 11:15 a.m. on November 16, 2010, in IP Tower electrical panel IP8E, breakers 24, 26, 28, 30 and 32-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

10. At 11:15 a.m. on November 16, 2010, in IP Tower electrical panel IP8F, breakers 18-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

11. At 11:15 a.m. on November 16, 2010, in IP Tower electrical panel IP8CE, breakers 32 and 36-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

12. At 11:15 a.m. on November 16, 2010, in IP Tower electrical panel IP8CF, breakers 9, 10, 12 and 14-30 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

13. At 2:10 p.m. on November 16, 2010, in IP Tower electrical panel IP7CA, breaker 37 was in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breaker was not labeled.

14. At 2:58 p.m. on November 16, 2010, IP Tower electrical receptacle 7E-12 adjacent to room C7D18, was darkened. Staff 1 confirmed the receptacle was darkened and stated it appeared a piece of equipment had arched across the receptacle.

15. At 3:22 p.m. on November 16, 2010, in IP Tower electrical panel IP7CF, breakers 39 and 41 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

16. At 3:45 p.m. on November 16, 2010, the electrical panel in Radiology, Room 3E210 in the D&T Tower was blocked by a chair. Staff 2 confirmed that the panel was blocked.

17. At 4:25 p.m. on November 16, 2010, in IP Tower AGVS room 6C-2, the electrical receptacle cover plate was damaged. Staff 1 confirmed the cover plate was damaged.

18. At 9:30 a.m. on November 17, 2010, the cover plate for the roll down fire door motor on the 5th Floor Diagnostic and Treatment Tower side of the 2-hour building separation with the IP Tower was missing. Staff 1 confirmed the cover plate was missing on the motor for the roll down door.

19. At 9:31 a.m. on November 17, 2010, there was a refrigerator plugged into a surge protector instead of directly into an electrical receptacle in the Burn Administration Office. Staff 1 confirmed the refrigerator was plugged into a surge protector instead of directly into an electrical receptacle.

20. At 9:40 a.m. on November 17, 2010, in IP Tower electrical panel IP5HC, breakers 8, 10, 12 and 14-24 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

21. At 9:40 a.m. on November 17, 2010, in IP Tower electrical panel IP5CE, breakers 40-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

22. At 9:40 a.m. on November 17, 2010, in IP Tower electrical panel IP5CD, breakers 38, 40 and 42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

23. At 9:45 p.m. on November 17, 2010, IP Tower electrical receptacle 5E-5 in the corridor adjacent to the burn unit, was darkened. Staff 1 confirmed the receptacle was darkened and stated it appeared a piece of equipment had arched across the receptacle.

24. At 10:06 a.m. on November 17, 2010, in IP Tower electrical panel 5M181, breakers 2, 4, 6, 8, 10-24 and 26-30 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

25. At 10:30 a.m. on November 17, 2010, in IP Tower electrical panel IP5F, breakers 2, 4, 6, 8, 13, 16, 36 and 38-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

26. At 10:30 a.m. on November 17, 2010, in IP Tower electrical panel IP5G, breakers 19, 20 and 40-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

27. At 10:30 a.m. on November 17, 2010, in IP Tower electrical panel IP5I, breakers 7, 33 and 35 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

28. At 10:30 a.m. on November 17, 2010, in IP Tower electrical panel IP5CF, breakers 7, 19 and 21-30 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

29. At 10:30 a.m. on November 17, 2010, in IP Tower electrical panel IP5CG, breakers 32, 34, 35 and 37-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

30. At 11:10 a.m. on November 17, 2010, in D&T Tower, there was a refrigerator plugged into a surge protector instead of directly into an electrical receptacle in the center of the Core LAB. Staff 2 confirmed the refrigerator was plugged into a surge protector instead of directly into an electrical receptacle.

31. At 11:12 a.m. on November 17, 2010, there was an open junction box in the corridor in the IP Tower above the drop ceiling above door 4G151. Staff 1 confirmed the junction box was open and missing the cover.

32. At 1:48 p.m., on November 17, 2010, in D&T Tower, Electrical Room B2C370, electrical panel DT2B, breakers 15,17,18,20,34and 36, DT2A, breakers 22,24,27,28,29 and 31, DT2C8, breakers 2 and 4, DT2CA, breakers 29, 34 and 41, were in the on position and not labeled as to the area or use of the breaker. Staff 2 confirmed the breakers were not labeled.

33. At 1:54 p.m. on November 17, 2010, in IP Tower electrical panel IP4M, breakers 23, 25, 27, 29 and 31-36 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

34. At 2:05 p.m., on November 17, 2010, in D&T Tower, Electrical Room, B2D470, electrical panel DT2EHD, breakers 32-42 and 25 to 41 were in the on position and not labeled as to the area or use of the breaker. Staff 2 confirmed the breakers were not labeled.

35. At 2:10 a.m. on November 17, 2010, the cover plate for the roll down fire door motor on the 3rd Floor Diagnostic and Treatment Tower side of the 2-hour building separation with the IP Tower was missing. Staff 1 confirmed the cover plate was missing on the motor for the roll down door.

36. At 2:44 p.m. on November 17, 2010, in IP Tower electrical panel IP3CF, breakers 23 and 25-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

37. At 2:44 p.m. on November 17, 2010, in IP Tower electrical panel IP3CG, breakers 28, 30 and 32-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

38. At 2:44 p.m. on November 17, 2010, in IP Tower electrical panel IP3G, breakers 40-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

39. At 2:44 p.m. on November 17, 2010, in IP Tower electrical panel IP3H, breakers 35, 37, 39, 40 and 41 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

40. At 3:10 p.m., on November 17, 2010, in D&T Tower, Electrical Room, 1D480, electrical panel DT1LS, breakers 5,6 and 7 were in the on position and not labeled as to the area or use of the breaker. Staff 2 confirmed the breakers were not labeled.

41. At 9:45 a.m. on November 18, 2010, in the IP Tower electrical room 1H470 in the kitchen, there were two electrical junction boxes above the door with cover plate on the box not secured. Staff 1 confirmed the cover plates were not secured to the junction boxes.

42. At 10:10 a.m. on November 18, 2010, in IP Tower electrical panel IP2LS, breaker 26 was in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breaker was not labeled.

43. At 11:00 a.m., on November 18, 2010, in Clinic Tower, 2nd Floor Electrical Room, electrical panel P2CC, breakers 12, 14, 16 and 17 thru 24 were in the on position and not labeled as to the area or use of the breaker. Staff 2 confirmed the breakers were not labeled.

44. At 2:50 p.m. on November 18, 2010, in Clinic Tower electrical panel OP-1CA, breakers 26 and 35-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

45. At 2:50 p.m. on November 18, 2010, in Clinic Tower electrical panel OP-1A, breakers 40-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

Based on observation, the facility failed to maintain the 2-hour building separation wall. This was evidenced by unsealed penetrations, and unfinished part of the seperation wall. This affected 2 of 5 Facility Buildings and had the potential to allow the spread of smoke and fire.

Findings:

During the facility tour with Staff 1 and 2 on November 17 and 18, 2010, the facility two hour separation barriers were observed.

1. At 9:27 a.m. on November 17, 2010, there was a two-inch circular unsealed penetration on the 5th floor In-Patient (IP) Tower side of the barrier at the entrance to the Diagnostic and Treatment Tower. Staff 1 confirmed there was a two inch circular penetration of the barrier that was not sealed.

2.. At 3:12 p.m. on November 18, 2010, at the first floor Clinic Tower and Diagnostic and Treatment Tower 2 hour separation barrier, only one side of the barrier was drywalled to the floor above. Staff 1 confirmed the non-dry-walled side of the barrier was filled in with fire rated caulking. Staff 1 stated he could not provide documentation that as built, the wall created a 2-hour barrier.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations through the ceilings and walls therefore compromising the containment of smoke and/or fire by the fire rated surface. This affected 5 of 5 facility buildings.

Findings:

During the facility tour with Engineering Staff 2 and 3 between November 15 and 16, 2010, the fire rated building walls were observed:

1. At 3:35 p.m. on November 15, 2010, in the 5P61 Clerk Station in OPD(Outpatient Department Bldg.), there was one approximately 1/2 inch penetration by the phone jack. Staff 2 confirmed there was a penetration by the phone jack.

2. At 3:45 p.m. on November 15, 2010, in the 4P21 Room E in OPD Bldg., there was one approximately 1 inch penetration in the center of the right wall. Staff 2 confirmed there was a penetration in the center of the right wall.

3. At 10:15 a.m. on November 16, 2010, in the Clinic Tower, there was one penetration measuring approximately 1-inch in diameter around the water pipe through the ceiling above the sprinkler test valve in the sprinkler room in the second floor. Staff 3 confirmed there was a penetration in the ceiling.

4. At 10:25 a.m. on November 16, 2010, in the Clinic Tower, there were two penetrations measuring approximately 1/2-inch each in diameter around the water pipes through the ceilings above the sprinkler test valve in the sprinkler room in the third floor. Staff 3 confirmed there were penetrations in the ceiling.

5. At 10:35 a.m. on November 16, 2010, in Cilic Tower, there were two penetrations measuring approximately ?-inch each in diameter around the water pipes through the ceilings above the sprinkler test valve in the sprinkler room in the fourth floor. Staff 3 confirmed there were penetrations in the ceiling.

6. At 2:00 p.m. on November 16, 2010, in OR 4, D&T Tower, there was an approximately 3 inch penetration behind the door in the center of the left wall. Staff 2 confirmed there was a penetration in the wall.

7. At 2:45 p.m. on November 16, 2010, in Radiation Room 4F130, D&T, there was an approximately 1/4 inch by 5 inch penetration in the bottom of the right wall along a metal plate. Staff 2 confirmed there was a penetration in the wall.

8.At 2:50 p.m. on November 16, 2010, in the IP Tower AGVS room 7L260 clean side, there was an approximately two inch by 36 inch damaged area of the wall. Staff 1 confirmed the wall was damaged and stated the damage was consistent with where the cart bumpers meet the wall.

9. At 3:25 p.m. on November 16, 2010, in the IP Tower clean utility room C7C109, there was an approximately two inch by twelve inch damaged area of the wall adjacent to electrical receptacle 7G-5. Staff 1 confirmed the wall was damaged and stated the damage was consistent with where the cart bumpers meet the wall.

10. At 4:15 p.m. on November 16, 2010, in the IP Tower Stairwell C4 on unit 6B, in the Fire Department Connection cabinet there was an approximately four inch circular cut out in the back of the box that was not sealed and an unsealed three-quarter inch gap around the pipe to the pressure gauge. Staff 1 confirmed there was a four inch cut out and a three-quarter inch gap around the pressure gauge pipe.

12. At 4:25 p.m. on November 16, 2010, in the IP Tower AGVS room 6C-2, there was an approximately two inch by twelve inch damaged area of the wall. Staff 1 confirmed the wall was damaged and stated the damage was consistent with where the cart bumpers met the wall.

13. At 8:47 a.m. on November 17, 2010, in the IP Tower clean utility room C6C109, there was an approximately two inch by twelve inch damaged area of the north wall. Staff 1 confirmed the wall was damaged and stated the damage was consistent with where the cart bumpers meet the wall.

14. At 10:47 a.m. on November 17, 2010, in the IP Tower room 5L281A, there was an approximately one inch around two conduits that penetrated the ceiling. Staff 1 confirmed there was an approximately one inch gap around two conduits that penetrated the ceiling.

15. At 11:20 a.m. on November 17, 2010, in the Gift Shop, D&T, there were two approximately 1/2 inch penetrations by the ceiling over the storage room. Staff 2 confirmed there was a penetration in the ceiling.

16. At 11:40 a.m. on November 17, 2010, in the IP Tower AGVS room 4L261A, there was an approximately two inch by sixty-four inch damaged area on 2 of 4 walls. Staff 1 confirmed the walls were damaged and stated the damage was consistent with where the cart bumpers meet the wall.

17. At 1:40 p.m. on November 17, 2010, in the IP Tower clean utility room 4H318, there was an approximately two inch by thirty-six inch damaged area of the north wall. Staff 1 confirmed the wall was damaged and stated the damage was consistent with where the cart bumpers meet the wall.

18. At 3:40 p.m. on November 17, 2010, in the IP Tower room 3P421, there were two approximately three-quarter inch circular holes in the wall adjacent to the time clock. Staff 1 confirmed there were two circular three-quarter inch holes in the wall adjacent to the time clock.

19. At 9:05 a.m. on November 18, 2010, there was one penetration measuring approximately 1/2-inch in diameter around the electric pipe through the ceiling in the interview room 2149 of Ward B in the second floor of the Augustus Hawkins Building (AHB).

20. At 9:15 a.m. on November 18, 2010, there was one penetration measuring approximately 1-inch in diameter around the base of sprinkler head through the ceiling in the dirty utility room of Ward B in the second floor of AHB.

21. At 9:55 a.m. on November 18, 2010, there was an approximately two inch circular unsealed penetration with a copper colored conduit that through the penetrating in the IP Tower Kitchen Ice Room 1H310B. Staff 1 confirmed the conduit penetration of the wall was not sealed.

22. At 9:55 a.m. on November 17, 2010, there was an approximately two-inch unsealed gap around three pipes that penetrated the east wall of the Kitchen Ice room 1H310B in the IP Tower. Staff 1 confirmed there was an approximately two-inch gap around three pipes that penetrated the east wall.

NFPA 80 (1999 Edition), 15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by corridor doors that were obstructed from closing, by corridor doors that failed to positive latch upon closure, by failure to provide documentation for the testing and maintenance of a roll-down door and by doors with tape over the latching mechanism. This could result in the spread of smoke and fire throughout the facility and increase the risk of injury to patients, visitors and staff. This affected 5 of 5 Facility Buildings.

Findings:

During the facility tour with Facility Engineering Staff 1, 2, 3 and 4 from November 15, 2010 through November 19, 2010, the corridor doors were observed.

1. At 3:55 p.m. on November 15, 2010, in Specialty Medicine 4P1, OPD(Outpatient Department), the exit door was blocked open with a broom. Staff 2 confirmed the door was blocked open with a broom.

2. At 10:00 a.m. on November 16, 2010, the Fire Door to the Infusion Clinic 3P1, OPD, the right leaf failed to fully close and positive latch. Staff 2 confirmed the door failed to fully close and latch.

3. At 10:08 a.m. on November 16, 2010, the door to resident room C8B106 in the IP Tower was obstructed from closing by a trash can. Staff 1 confirmed the trash can obstructed the door from closing.

4. At 10:12 a.m. on November 16, 2010, the door to the Nourishment Room C8B107 in the IP Tower failed to latch. Staff 1 confirmed the door failed to latch.

5. At 10:15 a.m. on November 16, 2010, the corridor self-closing door to room C8B101 in the IP Tower was prevented from closing by a door wedge. Staff 1 confirmed the door wedge prevented the door from closing.

6. At 10:30 a.m. on November 16, 2010, the Fire Door to UADC 2P52, OPD, the left leaf failed to fully close and positive latch.

7. At 10:40 a.m. on November 16, 2010, the corridor self-closing door to room C8A130 in the IP Tower was obstructed from closing by a trash can. Staff 1 confirmed the trash can obstructed the door from closing.

8. At 2:45 p.m. on November 16, 2010, in EVS(Environmental Services) Room 4D341, D&T Tower, the corridor door was covered with tape preventing the door from latching. Staff 2 confirmed the door was prevented from latching.

9. At 3:46 p.m. on November 16, 2010, the self-closing corridor door to EVS room 6H410 in the IP Tower was prevented from latching by a paper towel that was stuffed into the strike plate. Staff 1 confirmed there was a paper towel stuff into the strike plate and removed the paper towel.

10. At 8:44 a.m. on November 17, 2010, door 6R211 in Unit 6C in the IP Tower did not latch. Staff 1 confirmed the door failed to latch.

11. At 9:07 a.m. on November 17, 2010, the self-closing corridor door to the Ante room 6K419 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

12. At 11:15 a.m. on November 17, 2010, the self-closing door to Room 2C412 in the D&T Tower was jammed with paper preventing the door from latching. Staff 2 confirmed the door was obstructed from latching.

13. At 11:25 a.m. on November 17, 2010, the door to the Gift Shop Storage Room in the D&T Tower was prevented from closing by a door wedge. Staff 2 confirmed the door was obstructed from closing by a wedge.

14. At 11:30 a.m. on November 17, 2010, the self-closing corridor door to room 4R126 in the IP Tower was prevented from latching by a tongue depressor taped over the strike plate. Staff 1 confirmed the door was obstructed from latching.

15. At 11:31 a.m. on November 17, 2010, the corridor self-closing door to waiting room C4C100 in the IP Tower was obstructed from closing by a trash can. Staff 1 confirmed the trash can obstructed the door from closing and moved the trash can.

16. At 5:30 p.m. on November 17, 2010, the facility failed to provide documentation for the inspection and maintenance of the roll down door in the OPD generator room. Staff 1 stated there were no records available for review.

17. At 9:45 a.m. on November 18, 2010, the resident room door 2171 of Ward A in second floor of August Hawkins Building (AHB) failed to latch.

18. At 9:55 a.m. on November 18, 2010, the resident room door 2022 of Ward D in the second floor of AHB failed to latch.

19. At 9:55 a.m. on November 18, 2010, the corridor self-closing door to the kitchen pallet storage room in the IP Tower was obstructed from closing by the floor. The door stuck to the floor. Staff 1 confirmed the floor obstructed the door from closing.

20. At 10:05 a.m. on November 18, 2010, the resident room door 2078 of Ward F in the second floor of AHB failed to latch.

21 At 10:12 a.m. on November 18, 2010, the self-closing corridor door to room C2M180 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

22. At 11:18 a.m. on November 18, 2010, at the entrance door to Utilization Review next to Room 7B22, Clinic Tower, the corridor door was covered with tape preventing the door from latching.

23. At 1:40 p.m. on November 18, 2010, the self-closing corridor door to room CIL280 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

Based on observation, the facility failed to maintain access to exits. This was evidenced by the failure to provide visible exit signs and an exit sign that pointed in the wrong direction. This affected 1 of 5 Facility Buildings and had the potential for occupants not to readily reach an exit.

Findings:

During the facility tour with Engineering Staff 1 on November 17, 2010, access to the exits were observed.

2. At 9:25 a.m., there was no exit sign on the In-Patient (IP) Tower side of the 5th floor smoke barrier at the Diagnostic and Treatment (D & T) Tower entrance. Staff 1 confirmed there was not exit sign at the barrier.

3. At 9:41 a.m., there was no exit sign on the Burn Unit In-Patient (IP) Tower side of the 5th floor smoke barrier at the Diagnostic and Treatment (D & T) Tower entrance. Staff 1 confirmed there was not exit sign at the barrier.

4. At 9:44 a.m., the exit sign at the east end of the 5th floor corridor outside the burn unit was obstructed by a directional sign. Staff 1 confirmed the exit sign at the east end of the corridor outside the burn unit was obstructed by a directional sign.

5. At 11:05 a.m., the exit sign on the In-Patient (IP) Tower side of the 4th floor smoke barrier at the Diagnostic and Treatment (D & T) Tower entrance pointed in the opposite direction of the stairwell exit. Staff 1 confirmed the exit pointed in the opposite direction of the stairwell exit.

Based on observation, the facility failed to ensure the integrity and maintenance of 1 of 6 smoke barrier wall located in the attic space over cross-corridor fire doors in order to provide at least a one-half hour fire resistance rating. In the event of fire and/or smoke, the smoke barrier integrity compromised by a penetration, would not be able to provide at least a one-half hour fire resistance and would allow smoke and/or fire to pass from one smoke compartment to another smoke compartments, thereby affecting all residents in the facility. This affected 1 of 5 Facility Buildings.

Findings:

During the facility tour with Engineering Staff 4 on November 18, 2010, the facility smoke barriers were observed.

1. At 2:00 p.m. on November 17, 2010, there was an approximately 24 inch by 24 inch square penetration in the smoke barrier adjacent to the entrance to Unit 4B in the In Patient Tower. The penetration was above an access panel and was below the duct access panel to a smoke damper. Staff 1 confirmed there was penetration in the smoke barrier and stated there was a missing rated access door that had not been installed over the penetration.

2. At 10:55 a.m. on November 18, 2010, there was one penetration measuring approximately 1-inch in diameter around the electric pipe through the smoke barrier wall located in the attic space over cross-corridor fire doors next to the resident room 208 of Ward F in the second floor of the August Hawkins Building.

3. At 11:00 a.m. on November 18, 2010, there was an approximately 12 inch by 12 inch square unsealed penetration in the first floor smoke barrier that separated the In Patient Tower and the Diagnostic and Treatment Tower. There was a single blue wire through the penetration. Staff 1 confirmed there was penetration in the smoke barrier.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by the cross-corridor smoke barrier doors that failed to latch and/or had a gap between a set of smoke barrier doors. This affected 2 of 5 Facility Buildings and had the potential for the spread of smoke during a fire.

Findings:

During the facility tour and testing of the fire alarm system with Engineering Staff 1, 2 and 3 between November 16 and 18, 2010, the smoke barrier doors were observed:

1. At 10:05 a.m. on November 16, 2010, the cross-corridor smoke barrier doors in the first floor of the Clinic Tower did not latch and had a 1/2-inch gap between a set of the doors. Staff 3 confirmed the doors failed to latch and that there was a gap between the doors.

2. At 10:20 a.m. on November 16, 2010, the cross-corridor smoke barrier door between the Clinic Tower and Diagnostic and Treatment Building (D&T) in the third floor failed to latch and had 1-inch gap between the set of the doors. Staff 3 confirmed the doors failed to latch and that there was a gap between the doors.

3. At 10:30 a.m. on November 16, 2010, the cross-corridor smoke barrier door between the Clinic Tower and Diagnostic and Treatment Building (D&T) in the fourth floor had 1-inch gap between a set of the doors. Staff 3 confirmed there was a gap between the doors.

4. At 10:40 a.m. on November 16, 2010, the cross-corridor smoke barrier door between the Clinic Tower and Diagnostic and Treatment Building (D&T) in the fifth floor failed to latch and had 1-inch gap between a set of the doors. Staff 3 confirmed the doors failed to latch and that there was a gap between the doors.

5. At 10:50 a.m. on November 16, 2010, the cross corridor smoke barrier door in front the electric room in the fifth floor had a 1/2-inch gap between a set of the doors. Staff 3 confirmed there was a gap between the doors.

6. At 10:25 a.m. on November 17, 2010, in the common wall at the entrance to the D & T tower from the Clinic, the right leaf on the smoke barrier double dour failed to fully close and positive latch. Staff 2 confirmed the right leaf failed to fully close and latch.

Based on observation, the facility failed to protect their hazardous areas. This was evidenced by hazardous areas that failed to have self-closures on the doors, storage areas that were open to the corridor and unrated areas with hazardous supplies. This could potentially allow the spread of smoke and fire from hazardous areas to other areas, in the event of a fire and increase the risk of injury to patients, visitors and staff. This affected 5 of 5 Facility Buildings.

Findings:

During a tour of the facility with the Engineering Staff 1 and 2 on November 15 through November 19, 2010, the hazardous areas were observed.

1. At 3:40 p.m. on November 15, 2010, in Primary Care 5P61, OPD, the door to Room 16 was open. The room contained 5 gallon paint containers and paint supplies. Staff 2 confirmed the room contained the paint and supplies.

2. At 3:45 p.m. on November 15, 2010, the janitor storage area adjacent to room 1P-46 in the OPD building was open to the corridor. There were approximately 15 cardboard boxes of supplies in the area.

3. At 3:50 p.m. on November 15, 2010, the janitor storage area adjacent to Stairwell 3 on the first floor in the OPD building was open to the corridor. There were approximately 15 cardboard boxes of supplies in the area.

4. At 3:20 p.m. on November 16, 2010, the self-closing corridor door to soiled utility room C7C107 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

5. At 1:40 p.m. on November 17, 2010, the Information Systems Conference Room, D&T. The unrated room measured over 50 square feet and had an abundant amount of combustible materials including 40 boxes of cables, IT supplies, paper materials and miscellaneous supplies. Staff 2 confirmed the room was used for storage.

6. At 2:41 p.m. on November 17, 2010, the self-closing corridor door to soiled utility room C310 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

7. At 3:01 p.m. on November 17, 2010, the self-closing corridor door to soiled utility room 3P422 in the IP Tower did not fully close and latch without assistance. Staff 1 confirmed the door did not fully close and latch without assistance.

8. At 1:40 p.m. on November 18, 2010, the door to Med Clinic Storage 5B120, Clinic Tower was not self or auto-closing. The room measured over 50 square feet and had an abundant amount of combustible materials including paper supplies, plastics, and linen.

Based on observation, the faility failed to maintain stairways free from potential interference to egress. This was evidenced by 44 gallon containers and equipment left in the stairwell corridor affecting 1 of 5 buildings. This could result in delay in evacuation and cause injury to patients, staff and visitors.

Findings:

1. At 3:47 p.m. on November 16, 2010, there was a 44-gallon gray container stored in the exit stairwell corridor C2 inside door 6H251 in the IP Tower. Staff 1 confirmed there was a container stored in the exit stairwell.

2. At 10:41 a.m. on November 17, 2010, there was a 44-gallon gray container stored in the exit stairwell corridor C4 off unit 5B in the IP Tower. Staff 1 confirmed there was a container stored in the exit stairwell.
3. At 10:44 a.m. on November 17, 2010, there was a 44-gallon gray container and red 44-gallon gray container stored in the exit stairwell corridor C5 off unit 5A in the IP Tower. Staff 1 confirmed there was a container stored in the exit stairwell.
4. At 11:35 a.m. on November 17, 2010, there was a floor cleaning machine stored in the exit stairwell corridor C7 off unit 4C in the IP Tower. Staff 1 confirmed there was a floor cleaning machine stored in the exit stairwell.
5.. At 11:18 a.m. on November 18, 2010, there was a 44-gallon gray container stored in the exit stairwell corridor C8 adjacent to the locksmith office in the IP Tower. Staff 1 confirmed there was a container stored in the exit stairwell

Based on observation, the facility failed to maintain exit access. This was evidenced by doors that were not equipped with door releasing devices in the In Patient (IP) Tower and exit egress that was obstructed. This affected 2 of 5 Facility Buildings and had the potential for delaying egress in an emergency.
Findings:
During the facility tour with the Engineering Staff 1 and 2 on November 16, 2010, the facility exit corridors were observed.

1. At 11:10 .m. on November 16, 2010, 3 of 3 exit doors from the Child Life Playroom in the IP Tower were not equipped with panic hardware. When locked, the doors could not be opened without a key. Staff 1 confirmed the doors were not equipped with panic hardware.

2. At 2:40 p.m. November 16, 2010, at the OR Exit by Room 26 in the D&T Tower, there was a C-Arm blocking the right leaf of the double door exit. Staff 2 confirmed the door was obstructed.

3. At 2:45 p.m., November 17, 2010, at the ER Exit by 1E132 in the D&T Tower, there was a portable X-ray machine blocking the right leaf of the double door exit. Staff 2 confirmed the door was obstructed.

Based on observation, the facility failed to maintain exit access free from obstructions to quick egress. This was evidenced by obstructed exit corridors in the In Patient (IP) Tower. This affected 1 of 5 Facility Buildings and had the potential for delaying egress in an emergency.

Findings:

During the observation of the exit corridors with the Engineering Staff at 11:10 a.m. on November 18, 2010, there were four gurneys, a patient bed, a wheelchair and three housekeeping machines stored in the exit corridor from the IP Tower to the Emergency Room entrance. The corridor ran parallel to the Diagnostic and Treatment Tower wall. Staff 1 confirmed the items were stored in the exit corridor.

NFPA 99 (1999 Edition) 3-3.2.1.2 (5) (e) Wiring in Anesthetizing Locations. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Based on observation, the facility failed to maintain the emergency lighting as evidenced by the failure to provide one or more battery-powered emergency lighting units in 2 of 2 delivery suites. This had the potential for lack of lighting during a power failure causing confusion during emergency egress.

Findings:

During the facility tour with the Engineering Staff 1 on November 17, 2010, the emergency lighting in the corridors were observed.

At 3:10 p.m. on November 17, 2010, the facility failed to provide battery-powered emergency lighting units in 2 of 2 delivery suites. Staff 1 confirmed there were no battery-powered emergency lighting units in the delivery suites.

Based on record review and interview, the facility failed to conduct fire drills at least quarterly for all shifts, failed to follow-up on drills per the facilities policy and procedure and failed to hold fire drills at varying times. This was evidenced by the facility failure to provide records for 1 of 12 fire drills for the D&T tower, provide follow-up on fire drills where staff performed poorly, and failed to conduct fire drills at varying times. This could result in any one member of the staff failing to accomplish all of the tasks required of him of her in the event of a fire and the increased risk of injury to the patients, visitors and staff due to smoke and fire and affected 1 of 5 facility buildings.

Findings:

During record review and interview with the facility staff on November 15, 2010 through November 19, 2010, fire drill records were reviewed and staff interviewed.

1. At 1:25 p.m. on November 15, 2010, there was no record of fire drill conducted for the D&T Tower for the PM shift, first quarter of 2010 and the AM shift for the second quarter 2010. Staff 2 confirmed the drills were not available.

2. At 1:30 p.m. on November 15, 2010, in the D&T bldg., the facility conducted 3 of 4 AM fire drills at 10:00 a.m., 3 of 4 PM fire drills at 4:00 p.m.and 4 of 4 NOC fire drills at 6:00 a.m. Staff 2 confirmed the drills were held at the same time on each shift.

3. At 1:40 p.m. on November 15, 2010, D&T, the facility conducted fire drills for August 13, 2010 and July 20, 2010 in which some of the staff performed poorly. On November 17, 2010, at 1:20 p.m., Facility Staff 2 stated that there was no follow-up training on these drills.

4. At 9:00 a.m. on November 16, 2010, the facility fire drills for the previous 12 months conducted in the IP Tower showed 4 of 4 AM shift drills were conducted at 10:00 a.m., 4 of 4 drills for the PM shift being conducted at 4:00 p.m., and 4 of 4 drills for the NOC shift being conducted between 6:00 a.m. and 6:15 a.m. Staff 2 confirmed the drills were held at approximately the same time during each shift.

NFPA 72 (1999 Edition) 2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

NFPA 101 (2000 Edition) 9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by a manual pull box that failed when tested, a trouble light on in the fire alarm panel, obstructed access to a manual pull box and a fire alarm panel that read the incorrect time. This affected 3 of 5 Facility Buildings and had the potential to delay fire department response or alarm system failure.

Findings:

During the facility tour with Engineering Staff 1, 2 and 3, between November 16 and 18, 2010, the fire alarm system was observed and tested.

1. At 11:55 a.m. on November 16, 2010, the manual fire alarm pull box in front the room 5B170 in the fifth floor of the Clinic Tower failed to sound the alarm when activated. Staff 3 confirmed the manual pull box failed when tested.

2. At 8:32 a.m. on November 17, 2010, in the Radiation Break Room 3D 325 in the D&T Tower, the Pre-Action System Fire Alarm Control Panel, displayed a trouble signal. Staff 2 confirmed that the information was correct.

3. At 8:50 a.m. on November 17, 2010, in the Radiation Break Room 3D 325, D&T, the Fire Alarm Control Panel displayed the time as 10:06 a.m. instead of 8:50 a.m., Staff 2 confirmed the panel read the incorrect time.

4. At 9:15 a.m. on November 17, 2010, Central Plant, staff at Central Plant was interviewed. Trouble signal showed at 5:06 a.m. Engineer reported trouble signal on Device M3-210 to vendor at 7:30 a.m. Staff 1 and Staff 2 set-up fire watch and interim life safety measures.

5. At 11:40 a.m. on November 17, 2010, access to the manual fire alarm box in the 4th floor AVGS room 4L261B was obstructed by a biohazard container. Staff 1 confirmed access to the manual fire alarm box was obstructed by a biohazard container.

6. At 1:44 p.m. on November 17, 2010, in the Information Systems Pre-Action Sapphire System Room inside the Conference Room 2F110, the Fire Alarm Control Panel displayed the time as 2:44 p.m. Staff 2 confirmed the panel read the incorrect time.

7. At 2:40 p.m. on November 17, 2010, the Pull Station M7L2103, in ER North in the D&T Tower, was blocked by a linen cart. Staff 2 confirmed the pull station access was blocked.

8. At 3:00 p.m. on November 17, 2010, the Pull Station M7L2126, in the ER Waiting Room in the D&T Tower, was blocked by a rolling table. Staff 2 confirmed the pull station access was blocked

9. At 3:05 p.m. on November 17, 2010, the Pull Station M7L114, in the Ped ER in the D&T Tower, was blocked by a step ladder. Staff 2 confirmed the pull station access was blocked

10. At 3:12 p.m. on November 17, 2010, the Pull Station M7L207, in ER East in the D&T Tower, was blocked by equipment. Staff 2 confirmed the pull station access was blocked

11. At 3:15 p.m. on November 17, 2010, the Pull Station M2L413, in the Ambulance Entrance in the D&T Tower, was blocked by a gurney. Staff 2 confirmed the pull station access was blocked

13. At 11:20 a.m. on November 18, 2010, the 7th Floor Pull Station, in Anatomic Pathology A7A, Clinic Tower, was blocked by two carts. Staff 2 confirmed the pull station access was blocked.

NFPA 101 (2000 Edition) 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 (1999 Edition) 7-7.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

NFPA 72 (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.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.

Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Based on interview and document review, the facility failed to maintain the smoke detectors in the OPD Building. This was evidenced by the failure to test the smoke detectors for sensitivity. This affected 1 of 5 Facility Buildings and had the potential for detector failure.

Findings:

During the document review on November 15, 2010, the inspection and test record for the fire alarm systems was reviewed with the Engineering Staff.

At 4:40 p.m., the facility provided documentation for the testing and maintenance of the fire alarm system in the OPD Building dated 2-4-10. The fire alarm inspection report did not include records for sensitivity testing of the smoke detectors. Staff 1 stated there were no other documents available for review.

NFPA 13 (1999 Edition) 3-8.3* Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.

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, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Based on observation, the facility failed to maintain their automatic sprinkler system in the Clinic Tower. This was evidenced by missing escutcheon rings, sprinkler heads with foreign materials, and faded valve identification signs. This affected 4 of 5 Facility Buildings and had the potential for sprinkler failure.

Findings:

During the facility tour with the Engineering Staff 1, 2, 3 and 4, between November 15 and 18, 2010, the sprinkler system was observed.

1. At 3:15 p.m. on November 15, 2010, in the 5th Floor Health Services Room 2, OPD, 1 of 1 sprinkler heads was missing the escutcheon ring. Staff 2 confirmed the escutcheon ring was missing.

2. At 10:07 a.m. on November 16, 2010, in the 3rd Floor VIP Pediatric 3P61 Reception, OPD, there was 1 of 2 sprinklers missing an escutcheon ring. Staff 2 confirmed the escutcheon ring was missing.

3. At 10:35 a.m. on November 16, 2010, in the Clinic 2P52 Reception, OPD, there was a build-up of debris on 3 of 10 sprinkler heads. Staff 2 confirmed there was debris build-up on 3 of 10 sprinkler heads.

4. At 2:10 p.m. on November 16, 2010, the auxiliary drain for the sprinkler system in the EVS closet adjacent to room 7P128 in the IP Tower was not identified with a sign. Staff 1 confirmed there was no sign on the valve.

5. At 8:37 a.m. on November 17, 2010, the auxiliary drain for the sprinkler system in the Unit 6C EVS closet 6N116 in the IP Tower was not identified with a sign. Staff 1 confirmed there was no sign on the valve.

6. At 8:45 a.m. on November 17, 2010, the auxiliary drain for the sprinkler system in the Unit 6C EVS closet 6R115 in the IP Tower was not identified with a sign. Staff 1 confirmed there was no sign on the valve.

7. At 8:57 a.m. on November 17, 2010, the sprinkler head in the office supply closet on unit 6D was wrapped with masking tape. Staff 1 confirmed the sprinkler head was wrapped with masking tape.

8. At 11:05 a.m. on November 17, 2010, there was no sign for inspector test valve (ITV) of the sprinkler system in the sprinkler room in the basement of the OPD facility. Staff 3 confirmed there was no identification sign on the ITV.

9. At 11:21 a.m. on November 18, 2010, the auxiliary drain for the sprinkler system in the EVS closet IK415A in the IP Tower was not identified with a sign. Staff 1 confirmed there was no sign on the valve.


10. At 11:25 a.m. on November 18, 2010, in the August Hawkins Building, one sprinkler head located in the hallway in front the nurse station of Ward F in the second floor had a heavy accumulation of dust and lint.

11. At 1:50 p.m. on November 18, 2010, in the Ophthalmology Med Surg A4A, Clinic Tower, there was 1 of 2 sprinklers missing an escutcheon ring. Staff 2 confirmed the escutcheon was missing.

12. At 2:30 p.m. on November 18, 2010, the valve identification sign and the hydraulic name plate sign outside the elevator room for elevators 21, 22 and 23 on the roof of the Clinic Tower were faded and not legible. Staff 1 confirmed the signs were faded and not legible.

NFPA 10 (1998 Edition) 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.

NFPA 10 (1998 Edition), 4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.

NFPA 10 (1998 Edition) 4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

NFPA 10 (1998 Edition) 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

NFPA 10 (1998 Edition) 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

Based on observation, the facility failed to maintain the portable fire extinguishers. This was evidenced by fire extinguishers impeded from access, no documentation for the monthly inspection of the fire extinguishers and fire extinguishers mounted more than 60 inches above the floor. This could result in delayed response to a fire and increase the risk of injury to patients, visitors and staff. This affected 4 of 5 Facility Buildings.

Findings:

During the facility tour with Engineering Staff 1, 2, 3 and 4 November 15 through November 19, 2010, the fire extinguishers were observed.

1. At 3:58 p.m. on November 15, 2010, in Human Resources 4P42, OPD, the fire extinguisher was blocked by a table. Staff 2 confirmed access to the extinguisher was blocked by a table.

2. At 9:48 a.m. on November 16, 2010, in the elevator rooms for elevators 1-6, 7-10 and 11-12 in the In-Patient (IP) Tower, the facility failed to provide documentation for the monthly inspection of the fire extinguishers in the elevator rooms since the fire extinguishers were serviced on 6-29-10. Staff 1 confirmed the fire extinguishers had not been inspected since the extinguishers were serviced on 6-29-10.

3. At 9:50 a.m. on November 16, 2010, in the mechanical room AB on the roof of the In-Patient (IP) Tower, the facility failed to provide fire extinguishers at the locations identified by fire extinguisher brackets attached to the wall. Staff 1 confirmed the fire extinguishers had not been installed. Staff 1 stated the facility had identified the deficiency of the lack of extinguishers in the area and was installing the brackets to hang new extinguishers.

4. At 10:02 a.m. November 16, 2010, in the Infusion Clinic 43P1, OPD, the central fire extinguisher was blocked by a linen cart. Staff 2 confirmed access to the extinguisher was blocked by a linen cart.

5. At 10:15 a.m. November 16, 2010, in the VIP Conference Room 3P61, OPD, the fire extinguisher was installed approximately 72 inches from the top of the fire extinguisher to the floor. Staff 2 confirmed the top of the extinguisher was approximately 72 inches above the floor.

6. At 3:50 p.m. November 16, 2010, in 3rd Floor by B3B106 in the D&T Tower, the fire extinguisher was blocked from access. Staff 2 confirmed access to the extinguisher was blocked.

7. At 9:20 a.m. November 17, 2010, in Central Plant, the fire extinguisher by the FACP was laying sideways on the floor. Staff 2 confirmed the fire extinguisher was laying on the floor.

8. At 3:05 p.m. November 17, 2010, in Pediatric ER in the D&T Tower, by Pull Station M7L114, the fire extinguisher was blocked from access by a step ladder. Staff 2 confirmed access to the extinguisher was blocked by a step ladder.

9. At 3:20 p.m. November 17, 2010, in ER Overflow in the D&T Tower, the fire extinguisher was blocked from access by a patient bed. Staff 2 confirmed access to the extinguisher was blocked by a patient bed.

10. At 3:25 p.m. on November 17, 2010, the ABC fire extinguisher in the NICU adjacent to stairwell C2 was not hanging on a bracket designed for the extinguisher. Staff 1 confirmed the bracket was not designed for the extinguisher.

11. At 9:47 a.m. on November 18, 2010, in the kitchen elevator room in the In-Patient (IP) Tower, the facility failed to provide documentation for the monthly inspection of the fire extinguisher in the elevator room since the fire extinguisher was serviced on 6-29-10. Staff 1 confirmed the fire extinguisher had not been inspected since the extinguisher was serviced on 6-29-10.

12. At 1:35 p.m. on November 18, 2010, access to the fire extinguisher in the EVS office 1L213A in the IP Tower was obstructed by an end table, which required reaching over the end table to access the extinguisher. Staff 1 confirmed the end table obstructed access to the extinguisher and had the end table moved.

13. At 1:45 p.m. on November 18, 2010, access to the fire extinguisher in the Materials Management Receiving area in the IP Tower was obstructed by a copy machine, which required reaching over the copy machine to access the extinguisher. Staff 1 confirmed the copy machine obstructed access to the extinguisher.

14. At 2:10 p.m. on November 18, 2010, in Elevator Room 26/27, Clinic Tower, the fire extinguisher failed to have monthly checks for August 2010 through October 2010. Staff 2 confirmed the fire extinguisher was not checked from August through October.

15. At 2:15 p.m. on November 18, 2010, in Elevator Room 24/25, Clinic Tower, the fire extinguisher failed to have monthly checks for July 2010 through October 2010. Staff 2 confirmed the fire extinguisher was not checked from July through October.

16. At 2:25 p.m. on November 18, 2010, in Elevator Room 21/22/23, Clinic Tower, the fire extinguisher failed to have monthly checks for August 2010 through October 2010. Staff 2 confirmed the fire extinguisher was not checked from August through October.

Based on observation, the facility failed to maintain the smoking areas as evidenced by the failure to provide a self-closing container where ashtrays could be emptied. This affected 2 of 5 Facility Buildings and had the potential for a fire.

Findings:

During the facility tour with the Engineering Staff 1 and 4 on November 18, 2010, the smoking areas were observed.

1. At 10:30 a.m. on November 18, 2010, the ashtrays provided in the smoking area of the In-Patient Tower were of an open design with sand. There were no self-closing containers into where ashtrays could be emptied. Staff 1 confirmed there were no self-closing containers in the smoking area.

2. At 11:45 a.m. on November 18, 2010, there was one metal cigarette ashtray without self-closing cover device in the smoking area in the patio in the second floor of the Augustus Hawkins facility. A review of the smoking policy of the facility on 11/18/10, at 11:50 a.m., revealed that the policy did not include provision for metal container with self-closing cover device into which ashtray can be emptied in all areas where cigarette smoking was permitted

NFPA 90A (1999 Edition), 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

NFPA 90A (1999 Edition), 2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

NFPA 90A (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 close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on observation and interview, the facility failed to maintain the heating, ventilation and air conditioning systems. This was evidenced by the failure to provide documentation for the testing of the fire dampers and the failure to identify the service openings in the air duct. This affected 1 of 5 Facility Buildings and had the potential to fail to contain smoke.

Findings:

During the facility tour with the Engineering Staff 1 on November 16, 2010, the fire dampers and duct access panels were observed.

1. At 5:45 p.m., the air duct for the 3rd floor west air conditioning duct was observed. The air duct access panel was opened exposing a fire damper. The duct access panel was not labeled indicating the presence of the fire damper. Staff 1 acknowledged the access panel was not labeled stated that the unlabeled access panel was consistent with the other duct access panels in the OPD building system.

2. At 5:45 p.m., the fire damper in the 3rd floor west air conditioning duct was observed. Staff 1 stated there were no records available for review for the testing and maintenance of the dampers in the OPD building.

NFPA 99 (1999 Edition) Chapter 12 Hospital Requirements

12-1 Scope. This chapter addresses safety requirements of nursing homes.

NFPA 99 (1999 Edition) 12-3.8 Gas Equipment Requirements.
12-3.8.1 Patient. Equipment shall conform to requirements for patient equipment in Chapter 8.

NFPA 99 (1999 Edition) 8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).

(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.

NFPA 99 (1999 Edition) 8-3.1.11.2 (h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

NFPA 99 (1999 edition), 4-3.5.2.1(b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation, the facility failed to ensure that the compressed gas cylinders were secured. This was evidenced by unsecured compressed gas cylinders. This affected 8 of 44 smoke compartments and had the potential for damage to the cylinders and harm to patients.

Findings:

During the facility tour with the Engineering Staff 1 between November 16 and 18, 2010, the facility compressed gas cylinder storage areas were observed.

1. At 3:05 p.m. on November 16, 2010, there were 3 unsecured E oxygen cylinders in the Soiled Utility Room C7D119 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinders were not secured.

2. At 3:20 p.m. on November 16, 2010, there were 6 E oxygen cylinders and an E compressed gas cylinder laying unsecured on the floor in the Soiled Utility Room C7C107 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinders were not secured and laying on the floor.

3. At 3:35 p.m. on November 16, 2010, there was an unsecured E oxygen cylinder in room 6L210 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was not secured.

4. At 3:40 p.m. on November 16, 2010, there was a free-standing, unsecured oxygen cylinder in the Soiled Utility Room C6A117 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was free standing and not secured.

5. At 3:50 p.m. on November 16, 2010, there was an unsecured oxygen cylinder lying on the floor in the Soiled Utility Room C6A107 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was lying on the floor and was not secured.

6. At 4:03 p.m. on November 16, 2010, there was an unsecured oxygen cylinder lying on the floor adjacent to the crash cart in Unit 6B in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was lying on the floor and was not secured.

7. At 10:10 a.m. on November 17, 2010, there were two unsecured Nitric Oxide E cylinders lying on the floor and an unsecured Nitric Oxide E cylinder in a storage cart in room C5G111 in the In-Patient (IP) Tower. Staff 1 confirmed the cylinders were not secured.

8. At 1:35 p.m. on November 17, 2010, there was an unsecured oxygen cylinder lying on the floor in the Soiled Utility Room C4B132 on unit 4B in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was lying on the floor and was not secured.

9. At 1:41 p.m. on November 17, 2010, there was an unsecured oxygen cylinder lying on the floor in the Soiled Utility Room 4H427 on unit 4A in the In-Patient (IP) Tower. Staff 1 confirmed the cylinder was lying on the floor and was not secured.

Based on observation, the facility failed to maintain the oxygen storage areas as evidenced by the failure to provide " NON SMOKING " signs at the front doors of the oxygen storage rooms. This affected 1 of 5 facility buildings.

Findings:

During the facility tour with Staff 4 on November 18, 2010, the oxygen storage areas were observed.

At 11:55 a.m. on November 18, 2010, there were no " NON-SMOKING " signs posted at the front doors of the medication rooms of Ward A, Ward C, Ward E in the second floor where the oxygen tanks were stored.

NFPA 110 (1999 Edition) 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Based on observation, the facility failed to maintain the battery powered emergency lighting in the generator area as evidenced by the failure of the emergency lighting when tested. This affected 1 of 5 Facility Buildings.

Findings:

During the facility tour with Staff 1 on November 17, 2010, the emergency lighting was observed.

At 5:30 p.m., the battery-powered emergency light in the generator room in the OPD Building failed when tested. Staff 1 confirmed the light failed when tested.

NFPA 70 (1999 Edition), article 110-12(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 70 (1999 Edition) 384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

NFPA 70 (1999 Edition), 400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:

(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)


Based on observation, the facility failed to maintain the electrical safety. This was as evidenced by the failure to identify the purpose or use of electrical breakers, damaged electrical receptacles, a refrigerator that was plugged into a surge protector instead of directly into an electrical receptacle and electrical boxes that were missing the cover or had a damaged cover. This affected 3 of 5 Facility Buildings and had the potential for a fire or electrical shock.


Findings:

During the facility tour with the Engineering Staff 1, 2, 3 and 4 between November 16 and 18, 2010, the facility electrical wiring and equipment were observed.

1. At 9:50 a.m. on November 16, 2010, the cover plate on data line 9M 170-02 in the electrical room in the IP Tower Roof Mechanical Room was missing. Staff 1 confirmed the cover plate was missing.

2. At 10:20 a.m. on November 16, 2010, on the west wall of IP Tower electrical room 8P470, the fire alarm junction box was missing the cover plate. Staff 1 confirmed the fire alarm junction box was missing the cover plate.

3. At 10:35 a.m. on November 16, 2010, in IP Tower electrical panel IP8HA, breakers 14-18 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

4. At 10:35 a.m. on November 16, 2010, in IP Tower electrical panel IP8LA, breakers 36-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

5. At 10:35 a.m. on November 16, 2010, in IP Tower electrical panel IP8CHA, breakers 23 and 24 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

6. At 10:45 a.m. on November 16, 2010, in IP Tower electrical panel IP8A, breakers 30-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

7. At 10:45 a.m. on November 16, 2010, in IP Tower electrical panel IP8CA, breakers 27 and 29-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

8. At 11:00 a.m. on November 16, 2010, in IP Tower electrical panel IP8LS, breakers 2, 3, 5, 7, 16, 18, 20, 26 and 27 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

9. At 11:15 a.m. on November 16, 2010, in IP Tower electrical panel IP8E, breakers 24, 26, 28, 30 and 32-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

10. At 11:15 a.m. on November 16, 2010, in IP Tower electrical panel IP8F, breakers 18-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

11. At 11:15 a.m. on November 16, 2010, in IP Tower electrical panel IP8CE, breakers 32 and 36-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

12. At 11:15 a.m. on November 16, 2010, in IP Tower electrical panel IP8CF, breakers 9, 10, 12 and 14-30 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

13. At 2:10 p.m. on November 16, 2010, in IP Tower electrical panel IP7CA, breaker 37 was in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breaker was not labeled.

14. At 2:58 p.m. on November 16, 2010, IP Tower electrical receptacle 7E-12 adjacent to room C7D18, was darkened. Staff 1 confirmed the receptacle was darkened and stated it appeared a piece of equipment had arched across the receptacle.

15. At 3:22 p.m. on November 16, 2010, in IP Tower electrical panel IP7CF, breakers 39 and 41 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

16. At 3:45 p.m. on November 16, 2010, the electrical panel in Radiology, Room 3E210 in the D&T Tower was blocked by a chair. Staff 2 confirmed that the panel was blocked.

17. At 4:25 p.m. on November 16, 2010, in IP Tower AGVS room 6C-2, the electrical receptacle cover plate was damaged. Staff 1 confirmed the cover plate was damaged.

18. At 9:30 a.m. on November 17, 2010, the cover plate for the roll down fire door motor on the 5th Floor Diagnostic and Treatment Tower side of the 2-hour building separation with the IP Tower was missing. Staff 1 confirmed the cover plate was missing on the motor for the roll down door.

19. At 9:31 a.m. on November 17, 2010, there was a refrigerator plugged into a surge protector instead of directly into an electrical receptacle in the Burn Administration Office. Staff 1 confirmed the refrigerator was plugged into a surge protector instead of directly into an electrical receptacle.

20. At 9:40 a.m. on November 17, 2010, in IP Tower electrical panel IP5HC, breakers 8, 10, 12 and 14-24 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

21. At 9:40 a.m. on November 17, 2010, in IP Tower electrical panel IP5CE, breakers 40-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

22. At 9:40 a.m. on November 17, 2010, in IP Tower electrical panel IP5CD, breakers 38, 40 and 42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

23. At 9:45 p.m. on November 17, 2010, IP Tower electrical receptacle 5E-5 in the corridor adjacent to the burn unit, was darkened. Staff 1 confirmed the receptacle was darkened and stated it appeared a piece of equipment had arched across the receptacle.

24. At 10:06 a.m. on November 17, 2010, in IP Tower electrical panel 5M181, breakers 2, 4, 6, 8, 10-24 and 26-30 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

25. At 10:30 a.m. on November 17, 2010, in IP Tower electrical panel IP5F, breakers 2, 4, 6, 8, 13, 16, 36 and 38-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

26. At 10:30 a.m. on November 17, 2010, in IP Tower electrical panel IP5G, breakers 19, 20 and 40-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

27. At 10:30 a.m. on November 17, 2010, in IP Tower electrical panel IP5I, breakers 7, 33 and 35 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

28. At 10:30 a.m. on November 17, 2010, in IP Tower electrical panel IP5CF, breakers 7, 19 and 21-30 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

29. At 10:30 a.m. on November 17, 2010, in IP Tower electrical panel IP5CG, breakers 32, 34, 35 and 37-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

30. At 11:10 a.m. on November 17, 2010, in D&T Tower, there was a refrigerator plugged into a surge protector instead of directly into an electrical receptacle in the center of the Core LAB. Staff 2 confirmed the refrigerator was plugged into a surge protector instead of directly into an electrical receptacle.

31. At 11:12 a.m. on November 17, 2010, there was an open junction box in the corridor in the IP Tower above the drop ceiling above door 4G151. Staff 1 confirmed the junction box was open and missing the cover.

32. At 1:48 p.m., on November 17, 2010, in D&T Tower, Electrical Room B2C370, electrical panel DT2B, breakers 15,17,18,20,34and 36, DT2A, breakers 22,24,27,28,29 and 31, DT2C8, breakers 2 and 4, DT2CA, breakers 29, 34 and 41, were in the on position and not labeled as to the area or use of the breaker. Staff 2 confirmed the breakers were not labeled.

33. At 1:54 p.m. on November 17, 2010, in IP Tower electrical panel IP4M, breakers 23, 25, 27, 29 and 31-36 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

34. At 2:05 p.m., on November 17, 2010, in D&T Tower, Electrical Room, B2D470, electrical panel DT2EHD, breakers 32-42 and 25 to 41 were in the on position and not labeled as to the area or use of the breaker. Staff 2 confirmed the breakers were not labeled.

35. At 2:10 a.m. on November 17, 2010, the cover plate for the roll down fire door motor on the 3rd Floor Diagnostic and Treatment Tower side of the 2-hour building separation with the IP Tower was missing. Staff 1 confirmed the cover plate was missing on the motor for the roll down door.

36. At 2:44 p.m. on November 17, 2010, in IP Tower electrical panel IP3CF, breakers 23 and 25-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

37. At 2:44 p.m. on November 17, 2010, in IP Tower electrical panel IP3CG, breakers 28, 30 and 32-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

38. At 2:44 p.m. on November 17, 2010, in IP Tower electrical panel IP3G, breakers 40-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

39. At 2:44 p.m. on November 17, 2010, in IP Tower electrical panel IP3H, breakers 35, 37, 39, 40 and 41 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

40. At 3:10 p.m., on November 17, 2010, in D&T Tower, Electrical Room, 1D480, electrical panel DT1LS, breakers 5,6 and 7 were in the on position and not labeled as to the area or use of the breaker. Staff 2 confirmed the breakers were not labeled.

41. At 9:45 a.m. on November 18, 2010, in the IP Tower electrical room 1H470 in the kitchen, there were two electrical junction boxes above the door with cover plate on the box not secured. Staff 1 confirmed the cover plates were not secured to the junction boxes.

42. At 10:10 a.m. on November 18, 2010, in IP Tower electrical panel IP2LS, breaker 26 was in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breaker was not labeled.

43. At 11:00 a.m., on November 18, 2010, in Clinic Tower, 2nd Floor Electrical Room, electrical panel P2CC, breakers 12, 14, 16 and 17 thru 24 were in the on position and not labeled as to the area or use of the breaker. Staff 2 confirmed the breakers were not labeled.

44. At 2:50 p.m. on November 18, 2010, in Clinic Tower electrical panel OP-1CA, breakers 26 and 35-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.

45. At 2:50 p.m. on November 18, 2010, in Clinic Tower electrical panel OP-1A, breakers 40-42 were in the on position and not labeled as to the area or use of the breaker. Staff 1 confirmed the breakers were not labeled.