HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected two of five floors and the basement of the main hospital and one of four floors of the 101 Building. This could result in the faster spread of fire and smoke, increasing the risk of injury to patients, visitors, and staff.

NFPA 101, Life Safety Code, 2000 Edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)

19.1.6.3 All interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.

8.2.3.1.1 Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the walls and ceilings were observed.

MAIN HOSPITAL
BASEMENT

1. At 3:09 p.m., on 3/7/16, the panels of the two attic access hatches, in the ceiling of the room behind the old sterilizer in Sterile Processing, were open and the attic was exposed. There was an approximately 2 foot by 2 foot zigzag-shaped cut-out in the ceiling where the attic was exposed. There was an approximately 10 inch hole in the ceiling that was surrounded by mold and had water leaking through it from a steam line (refer to K67).

During an interview at 3:10 p.m., the Manager of Facilities Services (MFS1) stated that the packing on the shut-off valve for the old steam line was leaking and caused water damage to the ceiling.


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MAIN HOSPITAL
FIRST FLOOR

2. At 3:05 p.m., on 3/7/16, there were five approximately 1/2 inch penetrations in the west wall of Operating Room 5. The penetrations were covered with blue tape.

101 BUILDING
FIRST FLOOR

3. At 2:08 p.m., 3/9/16, there was an approximately 2 foot by 4 foot cut-out in the rated ceiling, and an approximately 1 foot by 18 inch cut-out, in the ceiling of the fire alarm panel room.

During an interview at 2:09 p.m., Plant Operations Engineer (POE1) stated the cut-out of the rated ceiling was possibly due to construction that was done in the room.

4. At 2:09 p.m., on 3/9/16, there was an approximately 3 inch penetration around pipes, and an approximately 2 inch circular penetration, in the ceiling of the fire alarm panel room.

5. At 2:12 p.m., on 3/9/16, the 1 foot by 1 foot attic access door in the ceiling of the sprinkler riser room was left open.

MAIN HOSPITAL
FOURTH FLOOR

6. At 10:24 a.m., on 3/10/16, there were penetrations around wall screws that anchor the oxygen cylinder rack to the dividing wall of the clean utility room. The screws were loose from the wall.

Based on observation, the facility failed to maintain their doors. This was evidenced by doors held open by unapproved methods and by doors with broken hardware. This had the potential to allow the migration of smoke and result in injury to patients. This affected two of five floors in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous
areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the doors were observed.

MAIN HOSPITAL
FIRST FLOOR

1. At 3:05 p.m., on 3/8/16, the housekeeping closet in the Radiology Department had a broken self-closing device.

2. At 3:15 p.m., on 3/8/16, the self-closing corridor door into the Ultrasound Department was obstructed from closing by a biohazard receptacle.

3. At 4:16 p.m., on 3/8/16, the self-closing door to the Pediatric Treatment Room 15 - 18 in the Emergency Care Center (ECC) was obstructed from closing by a soiled linen receptacle.


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MAIN HOSPITAL
THIRD FLOOR
4. At 10:10 a.m., on 3/10/16, the door to the Nurses Chart Room was obstructed from closing by a trash can.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls. This was evidenced by penetrations in the smoke barrier walls. This failure affected one of five floors of the main hospital and one of four floors of the 101 Building. This could result in the faster spread of smoke and fire between smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

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

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the smoke barrier walls were inspected.

MAIN HOSPITAL
THIRD FLOOR

1. At 11:51 a.m., on 3/8/16, there was an approximately 1 inch penetration around a 2-inch wide conduit in the fire wall near Room 305.

101 BUILDING

2. At 2:15 p.m., on 3/9/16, there was an approximately 6 inch by 4 inch penetration in the fire wall above the entrance into Suite 106. There were multiple conduits going through the penetration. There were approximately 1 inch penetrations around two 2-inch wide conduits, and an approximately 1 inch penetration, in the center of the fire wall.

Based on observation, the facility failed to maintain their fire doors. This was evidenced by smoke barrier doors that failed to positive latch and by one smoke barrier door with broken latching hardware. This could result in the faster spread of smoke and fire between smoke compartments. This affected one of five floors in the main hospital and one of four floors in the 101 Building.

NFPA 101, Life Safety Code, 2000 Edition
19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition.
2-5.2 Manufacturers' Instructions. All components shall be installed in accordance with the manufacturers' installation instructions and shall be adjusted to function as described in the listing.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the smoke barrier doors were observed.

MAIN HOSPITAL
FIRST FLOOR

1. At 3:10 p.m., on 3/8/16, the fire door outside the Control Room released from its magnetic holding device during fire alarm testing. The fire door was equipped with latching hardware but failed to latch.

101 BUILDING

2. At 2:19 p.m., on 3/9/16, the 90-minute fire-rated door into Suite 104 was equipped with latching hardware but failed to latch.


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MAIN HOSPITAL
FIRST FLOOR

3. At 10:05 a.m., on 3/10/16, Smoke Barrier Door F-38 had broken latching hardware. One end of the handle was loose from the door leaf.

Based on observation, record review, and interview, the facility failed to maintain their battery-powered emergency lights. This was evidenced by battery-powered emergency lights that failed to illuminate when tested and by no records of testing the lights in February 2016. This affected five of five floors of the main hospital, four of four floors in the 101 Building, and the Wound Care Clinic. This could result in a lack of illumination, in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During document review with staff from 5/4/15 to 5/8/15, records of maintenance of the emergency lights were requested.

MAIN HOSPITAL
BASEMENT

1. At 2:25 p.m., on 3/7/16, the battery-powered emergency lighting unit in the corridor, outside the education room, failed to illuminate when tested.

TOWER

2. At 9:30 a.m., on 3/8/16, the battery-powered emergency light in Stairwell 2, between Levels 2 and 3 failed to illuminate when tested.

FIRST FLOOR

3. At 3:22 p.m., on 3/8/16, the battery-powered emergency lighting unit in Room 8, in the catheterization lab (Cath Lab), failed to illuminate when tested.

MAIN HOSPITAL, WOUND CARE CLINIC, 101 BUILDING

4. At 1:00 p.m., on 3/10/16, records showed that the last 90-minute annual testing of the battery-powered emergency lights was conducted in February 2015. The testing records for February 2016 were not provided.

During an interview at 1:34 p.m., the Manager of Facilities Services (MFS1) stated that the staff who tested these lights has been out for approximately one month and the February 2016 records could not be retrieved. He stated that the Facilities Department had been short-staffed.


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MAIN HOSPITAL
FIRST FLOOR

5. At 3:02 p.m., on 3/7/16, the battery-powered emergency lights in Operating Room 4 failed to illuminated when tested.

Based on observation, record review, and interview, the facility failed to maintain their exit signs. This was evidenced by one exit sign equipped with battery-operated emergency illumination that failed when tested. This was also evidenced by no records of testing the exit signs in February 2016. This affected four of four floors of the 101 Building and the Wound Care Clinic. This could result in a delay in evacuation during a power outage.

NFPA 101, Life Safety Code, 2000 Edition.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

7.10.4 Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11
through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.

7.10.5.1 General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the exit signs were observed and maintenance records were requested.

WOUND CARE CLINIC (HYPERBARIC CENTER)

1. At 10:36 a.m., on 3/9/16, the exit sign above the door, leading into the lobby between the clinic and the hyperbaric holding area, was equipped with battery-powered emergency power. The exit sign failed to illuminate when tested.

101 BUILDING, WOUND CARE CLINIC

2. At 1:00 p.m., on 3/10/16, records showed that the last 90-minute annual testing of the exit signs, equipped with battery-powered emergency power, was conducted in February 2015. The testing records for February 2016 were not provided.

During an interview at 1:34 p.m., the Manager of Facilities Services (MFS1) stated that the staff who tested these exit signs has been out for approximately one month and the February 2016 records could not be retrieved. He stated he did not know if the annual testing was conducted last month. He stated that the Facilities Department had been short-staffed.

Based on observation and interview, the facility failed to ensure that all staff are familiar with their duties pertaining to fire alarm response. This was evidenced by Public Board Exchange (PBX) operators that failed to respond to a fire alarm, by staff that did not know the fire response procedures, and by evacuation equipment that was not accessible to staff. This affected the main hospital and could result in a delay in staff and emergency services response, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as out lined in the fire safety plan.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, staff were interviewed about the fire response procedures. R.A.C.E. (Rescue, Alarm, Confine, Extinguish/Evacuate) instructions were posted in some areas of the hospital.

MAIN HOSPITAL

1. At 11:32 a.m., on 3/7/16, the pull station in the hallway outside the FACP Room was tested by POE1. PBX operators were not informed that this was a test. Only local alarms at the fire alarm panels were activated.
During an interview at 11:33 a.m., the Manager of Facilities Services (MFS1) stated that when PBX operators hear the local signal at their fire alarm subpanel, they dispatch facilities staff and plant operations engineers.
No PBX dispatch could be heard from POE1, POE2, and MFS1's radios.

During an interview at 11:40 a.m., PBX Operator1 and PBX Operator2 both stated that the fire alarm panel exhibited an audible signal. They stated that they were not informed that the fire alarm system was being tested and they did not know if the signal was from an actual fire incident. PBX Operator2 stated that he silenced the fire panel after the signal was received because they were busy with calls.

The fire alarm system was placed on test on 3/7/16 and signal transmission to the monitoring company was disabled. The fire alarm subpanel in the PBX office is the only fire alarm panel located at a continuously manned location. PBX did not follow the Code Red response plan that stated that operators were to check the fire alarm panel for the location of the fire alarm origin and overhead page "Code Red" and the location.

2. During an interview at 2:20 p.m., on 3/7/16, dietary staff were asked how they would respond to a grease fire. Cook1, who has worked at the facility for eight years, stated that she would turn off the stove and throw flour on the fire. She did not know how to activate the fire suppression system. She stated that she would use the ABC-Class fire extinguisher instead of the K-Class fire extinguisher for a grease fire.


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3. At 2:27 p.m., on 3/8/16, Housekeeper1, who has worked at the facility for six years, was asked what actions she would take if she discovered a fire. She stated she would help the patients in close vicinity but was not familiar with any other fire response procedures.

4. At 9:45 a.m., on 3/10/16, Housekeeper2, who has worked at the facility for 24 years, was asked what actions she would take if she discovered a fire. She stated she would close doors and make sure things are on one side of the egress corridor.

5. At 11:13 a.m., on 3/10/16, Security Guard1, who has worked at the facility for 18 months, was asked what actions he would take if he discovered a fire. He stated that he would close the doors and use the fire extinguisher but stated he could not remember what else to do.

There were no signatures of housekeeping, dietary, and security staff on the fire drill participation list. (Refer to K50)

6. During an interview at 1:59 p.m., on 3/9/16, staff on the fifth floor were asked about evacuation of patients in the event of a fire. The Charge Nurse stated that each floor is equipped with sliders (sleds) for evacuation of non-ambulatory patients down the stairs. She stated that the sliders are locked in the Rehabilitation Room and nursing staff do not have access to a key that unlocks the door. Staff would have to rely on the availability of the rehab staff for access to the sliders.

7. During an interview at 2:01 p.m., on 3/9/16, Nursing Assistant1 on the fifth floor did not know the location of the sliders required for evacuation.

Based on record review and interview, the facility failed to ensure that fire drills are conducted in accordance with NFPA 101 and that all staff participate in the fire drills. This was evidenced by no records of overnight shift fire drills for 2015, by fire drills that were not conducted under varying conditions, and by the failure of all staff to participate in the drills. The failure to conduct fire drills quarterly on each shift, and under varying times, could result in a delay in staff response during a fire on the night shift, during shift change, during meal times, and other conditions. This affected the entire main hospital and could result in the increased risk of injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
19.7.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During record review with staff from 3/7/16 to 3/10/16, the fire drill records were provided.

MAIN HOSPITAL

1. At 1:18 p.m., on 3/7/16, the facility failed to provide documents to show that overnight shift fire drills were conducted in the last 12 months. There were no overnight drills for four of four quarters of 2015.

2. At 1:19 p.m., on 3/7/16, records indicated that the morning shift fire drills were not conducted under varying conditions. Four of four morning shift drills conducted in 2015 were held between 6:31 a.m. and 6:45 a.m.

During an interview at 9:18 a.m., on 3/8/16, the Nursing Supervisor stated that the nurses overnight shift was from 7 p.m. to 7 a.m.

3. At 9:19 a.m., on 3/8/16, the facility's fire drill records did not include any housekeeping staff signatures to show participation in the drills. There were no security staff signatures and no dietary staff signatures on the fire drills.

During an interview At 9:20 a.m., the Director of Facilities Services (DFS1) stated that overnight housekeeping staff worked from 10:30 p.m., to 7 a.m. He stated employee signatures are meant to show which staff have participated in the fire drills.

During an interview at 9:37 a.m., the security manager (SM1) stated overnight security staff worked from 10 p.m. to 6:30 a.m., and employee signatures were meant to show which staff have participated in the fire drills.

Housekeeping, dietary, and security staff did not know the fire response procedures during interviews cited under K48.

Based on observation, record review, and interview, the facility failed to maintain their fire alarm system. This was evidenced by hospital-wide disabling of the fire alarm devices, by the connection of exterior parking lot access readers to the fire alarm panel, by the addition of a panel to the system without approval, and by a failed fire alarm system at one offsite clinic. This affected five of five stories of the main hospital and the Wound Care Clinic/Hyperbaric Center. These deficiencies could result in a delay in notification of a fire, a delay in emergency response, and the increased risk of injury to patients, visitors, and staff.

NFPA 101, Life Safety Code, 2000 Edition.
4.1.1 Fire and Similar Emergency. The goal of this Code is to provide an environment for the occupants that is reasonably safe from fire and similar emergencies by the following means:
(1) Protection of occupants not intimate with the initial fire development
(2) Improvement of the survivability of occupants intimate with the initial fire development.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

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.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.1.3 System Design. Fire alarm system plans and specifications shall be developed in accordance with this code by persons who are experienced in the proper design, application, installation, and testing of fire alarm systems. The system designer shall be identified on the system design documents. Evidence of qualifications shall be provided when requested by the authority having jurisdiction.

1-5.5.2.1 All systems shall be installed in accordance with the specifications and standards approved by the authority having jurisdiction.

1-5.7.1.1 The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. All required annunciation means shall be readily accessible to responding personnel and shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.

1-6.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. At its request, complete information regarding the system or system alterations, including specifications, wiring diagrams, battery calculation, and floor plans shall be submitted for approval.

1-6.1.2 Before requesting final approval of the installation, if required by the authority having jurisdiction, the installing contractor shall furnish a written statement stating that the system has been installed in accordance with approved plans and tested in accordance with the manufacturer's specifications and the appropriate NFPA requirements.

7-1.6.2.1 Reacceptance testing shall be performed after any of the following:
(1) Added or deleted system components
(2) Any modification, repair, or adjustment to system hardware or wiring
(3) Any change to site-specific software.
All components, circuits, systems operations, or site-specific software functions known to be affected by the change or identified by a means that indicates the system operational changes shall be 100 percent tested. In addition, 10 percent of initiating devices that are not directly affected by the change, up to a maximum of 50 devices, also shall be tested, and correct system operation shall be verified. A revised record of completion in accordance with 1-6.2.1 shall be prepared to reflect any changes.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the fire alarm systems were observed.

MAIN HOSPITAL

1. At 11:10 a.m., on 3/7/16, the fire alarm subpanel at the Central Plant exhibited over 30 trouble signals. The trouble signals indicated that fire dampers, smoke detectors, fire doors, and notification devices were "disabled."

During an interview at 11:15 a.m., Plant Operations Engineer 1 (POE1) confirmed that all the devices were disabled and if the fire alarm were tested, no notification devices would activate. He stated that the fire alarm system was usually disabled Monday through Friday from approximately 5:00 a.m. to 4:30 p.m. because of construction going on in the building.

The Manager of Facilities Services (MFS1) and the Project Manager for Construction (PMC1) stated that they were unaware that the fire alarm system was disabled and they thought the system was only being placed on test. They thought the fire alarm would activate but only the signal transmission to the monitoring company was disabled.

PMC1 pointed out on the facility floor plan that construction was conducted in five small areas of the first floor (approximately 5 percent of the total square footage), a small portion of the corridor in the basement, in both stairways of the Tower, and in two elevator lobbies in the Tower. She stated that the facility was only conducting Fire Watch rounds in the two stairwells and in the basement flooring area.

The Plant Log, where Plant Operations Engineers log their activities, was reviewed. An entry at 5:15 a.m., on 3/7/16, indicated "Posted fire system till 1630."

During an interview at 11:25 a.m., POE2 stated that "posted" means disabled. He confirmed that strobes, horns, fire dampers, and fire doors are bypassed during the weekdays when construction occurs at the facility.
The Plant Logs dating back to the date of 2/9/16 indicated that the fire alarm system was "posted" on most weekdays from approximately 5:00 a.m. to 4:30 p.m. Plant Logs before that date were not provided.

During an interview at 11:26 a.m., POE1 and POE2 stated that the fire alarm system has been disabled for construction for years. PMC1 stated that this probably started when the VSI Project (seismic retrofit) began in 2014.

The construction permit for the VSI Project HL111174-0 was approved by the Office of Statewide Health Planning and Development (OSHPD) on 10/25/13.

At 11:30 a.m., the main fire alarm control panel (FACP) on the first floor exhibited the same troubles as the subpanel in Central Plant. The smoke detector outside the FACP Room was sprayed with aerosol smoke three times by POE1. The smoke detector failed to activate any fire alarm devices or a signal at the FACP. The smoke detector was not located in close proximity to any construction areas. The smoke detector was in a hallway near the main lobby and in a central hallway close to patient care areas.

At 11:32 a.m., the pull station in the hallway outside the FACP Room was tested by POE1. A local signal at the FACP was heard. All notification devices in the facility failed to activate and all the fire doors failed to close.
During an interview at 11:33 a.m., MFS1 stated that when Public Board Exchange (PBX) operators hear the local signal at their fire alarm subpanel, they dispatch facility staff and plant operations engineers.

No fire alarm dispatch could be heard from POE1, POE2, and MFS1's radios.

During an interview at 11:38 a.m., after MFS1 came back from the PBX Office, he stated that the operators heard the signal but failed to dispatch facilities and plant operations engineers.

During an interview at 11:40 a.m., PBX Operator1 and PBX Operator2 both stated that the fire alarm panel exhibited an audible signal. They stated that they were not informed that the fire alarm system was being tested and they did not know if the signal was from an actual fire incident. PBX Operator2 stated that he silenced the fire panel after the signal was received because they were busy with calls.

During an interview at 2:45 p.m., on 3/7/16, the Operating Room Director (DOR1) stated that she was not told that the fire alarm system was regularly disabled.

The facility disabled the fire alarm system in the entire hospital regularly without implementing a fire watch in accordance with their Interim Life Safety Measures (ILSM) policy.

An Immediate Jeopardy (IJ) was called at 12:45 a.m. in the presence of PMC1, the Chief Operating Officer (COO), and the Chief Executive Officer (CEO).

The IJ was abated at 6:04 p.m., in the presence of the COO and CEO, after the fire alarm devices were enabled and an acceptable Plan of Correction (POC) was received.

2. At 1:48 p.m., on 3/7/16, after the fire alarm troubles related to disabled devices were cleared, there was a "Reader Fault" trouble exhibited at the FACP. This trouble signal persisted throughout the survey.

During an interview at 1:49 p.m., MFS1 stated that the trouble was from the doctors parking lot entrance card reader. He stated that it was damaged during the rain. He stated that all the parking lot card readers were connected to the fire alarm system.

During a telephone interview at 8:18 a.m., on 3/9/16, the Office of Statewide Health Planning and Development (OSHPD) Fire Life Safety Officer (FLSO) stated that the parking lot card readers should not be hooked up to the fire panel.

At 8:25 a.m., on 3/10/16, the card reader trouble was still exhibited by the FACP.

At 9:04 a.m., on 3/10/16, two fire alarm system blue prints were provided by the Director of Facilities Services (DFS1), one approved by OSHPD on 9/28/04 and the other on 6/6/00. Both plans did not indicate that the parking lot card readers were connected to the system.

During an interview at 9:05 a.m., DFS1 stated that these were the most recent fire alarm blue prints. He stated he did not know if there were plans showing that the connection of the parking lot card readers to the fire alarm system was approved.

WOUND CARE CLINIC (HYPERBARIC CENTER)

3. At 10:39 a.m., on 3/9/16, the main FACP was in the lobby directly outside the hyperbaric holding area. There were no indicators lit on the panel and the screen on the panel was not functioning. When the panel box was open, there were scorch marks on the power board.

During a telephone interview at 10:40 a.m., a representative from the remote monitoring station stated that the last signal received from the facility's panel was a trouble signal on 3/6/15 at 11:29 a.m. He stated that the monitoring station conducted daily tests to ensure communication with the facility's panel.

At 10:45 a.m., the pull station near the FACP was tested by POE1 while the monitoring station representative was on the phone. No alarms were activated in the facility and the monitoring station representative did not receive any signal from the facility after more than two minutes.

At 3:06 p.m., the Detailed Activity Report from the monitoring company indicated that the monitoring station conducted a daily "Periodic test with system trouble" at 11:29 a.m. to establish a connection with the facility's panel. The report showed that on 3/7/16 at 12:41 p.m., and on 3/8/16 at 1:53 p.m., a test signal was not received and a notification email was sent to a representative from the fire alarm vendor

During an interview at 3:41 p.m., MFS1 stated that he spoke to the fire alarm vendor representative who was emailed about the test signal not being received. MFS1 was told that the incident happened midnight on Sunday (3/6/16) and the representative was planning to call the facility yesterday (3/8/16).

There were nine patients in the facility at the time, one of them in a hyperbaric chamber when the fire alarm panel failure was discovered. An IJ was called at 12:21 p.m. and abated at 5:55 p.m. after the facility provided an approved POC.

MAIN HOSPITAL

4. At 8:40 a.m., on 3/10/16, the activity report from the fire alarm testing conducted the day before (3/9/16) indicated that only one signal was received by the monitoring station.

During an interview at 8:41 a.m., MFS1 stated that the staff were only resetting the main FACP and not both the FACP and the new "Focus" panel. He stated that if both were reset, the monitoring station would have received all the signals. He said that the Focus panel was connected to the FACP approximately one year ago when their monitoring company changed.

There were no records of AHJ approval of the Focus panel installation.

During a telephone interview at 8:45 a.m., the OSHPD FLSO stated that a permit would have been required to install an additional fire alarm component that altered the transmission of signals to the monitoring station.

Based on observation and record review, the facility failed to maintain their fire alarm system. This was evidenced by no records of testing the fire alarm system at one offsite location and by a sealed-lead acid battery in a fire alarm panel that was more than nine years old. This affected four of four floors at the 101 Building and could result in the increased risk of failure of the fire alarm system.

NFPA 101, Life Safety Code, 2000 Edition.
39.3.4.1 General. A fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Table 7-3.2 Testing Frequencies, requires annual testing of:
1. Control Equipment - Building Systems Connected to Supervising Station
a. Functions
b. Fuses
c. Interfaced Equipment
d. Lamps and LEDs
e. Primary (Main) Power Supply
f. Transponders
6. Batteries - Fire Alarm Systems
d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years.)
2. Discharge Test (30 minutes)
9. Control Unit Trouble Signals
14. Remote Annunciators
15. Initiating Devices
19. Alarm Notification Appliances

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the fire alarm systems were observed and maintenance records were requested. Records of annual testing of the fire alarm systems was requested on 3/7/16 at 9:30 a.m.

101 BUILDING

1. At 2:06 p.m., on 3/9/16, the battery in the fire alarm dialer panel, next to the main fire alarm control panel, was dated 2/13/07. The facility failed to replace the battery in 2011.

2. At 4:40 p.m., on 3/10/16, during the exit conference, records of an annual testing of the 101 Building's fire alarm system had not yet been provided. The Director of Facilities Services (DFS1) stated that he would email the documents the following day (3/11/16). No documents were sent as of 3/16/16.

Based on observation, record review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by no records of smoke detector sensitivity and by no records of testing single station smoke detectors in accordance with manufacturer's specifications. This was also evidenced by one smoke detector in the nonsprinklered Women's Care Center that was removed. This affected five of five floors of the main hospital, four of four floors of the 101 Building, the Wound Care Clinic, and the Women's Care Center. This could result in a delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.5.1 Detection systems, where required, shall be in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-6.3 Records. A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

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

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the smoke detectors were observed and maintenance records were requested. The facility was provided with a list, on 3/7/16 at 9:30 a.m. requesting the smoke detector sensitivity testing records.

MAIN HOSPITAL, 101 BUILDING, WOUND CARE CLINIC

1. At 11:20 a.m., on 3/8/16, the sensitivity testing records were requested again from the Director of Facilities Services (DFS1).

During an interview at 3:25 p.m., DFS1 stated that he believed the last smoke detector sensitivity test was conducted at the main hospital more than two years ago in 2013. He stated that he could not provide the documents.

At 2:02 p.m., on 3/10/16, facility failed to provide smoke detector sensitivity testing records for the Main Hospital, Wound Care Clinic, and the 101 Building.



29665

.
WOMEN'S CARE CENTER

2. At 9:53 a.m., on 3/9/16, the facility was equipped with single station smoke detector's throughout. The manufacturer's testing requirements were etched on the test buttons of the detectors and they stated "Push to Test Weekly." No records of testing the smoke detectors were provided.
During an interview at 9:54 a.m., the Plant Operations Engineer (POE1) stated that the detectors were tested on a monthly basis during the fire extinguisher inspections.

3. At 9:55 a.m., on 3/9/16, the base of a smoke detector was observed in the ceiling, near the rear exit door adjacent to the biohazard storage room, but there was no detector.

During an interview at 9:56 a.m., the Director of Business Management (DBM1) stated that there was a smoke detector at that location but it was recently removed when facilities came to change the batteries.

Based on record review and interview, the facility failed to maintain their automatic extinguishing systems. This was evidenced by halon and preaction systems that were not supervised by the hospital's main fire alarm panel in accordance with NFPA 101. This affected the basement of the main hospital and could result in a delay in notification of a fire to the building occupants and emergency forces.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

8.4.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the
building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

9.7.3.2 If the extinguishing system is installed in lieu of a required, supervised automatic sprinkler system, the action of the extinguishing system shall activate the building fire alarm system, where provided. The actuation of an extinguishing system that is not installed in lieu of a required supervised automatic sprinkler system shall be indicated at the building fire alarm system, where provided.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the automatic extinguishing systems were observed.

MAIN HOSPITAL
BASEMENT

1. At 2:35 p.m., on 3/7/16, there was a halon suppression system in the Communications Room. The halon system was connected to a local panel and a bell inside the room.

During an interview at 2:36 p.m., the plant operations engineer (POE1) and the Manager of Facilities Services (MFS1) stated that the halon system was not connected to the hospital's main fire alarm panel.

2. At 2:46 p.m., on 3/7/16, there was a preaction suppression system in the IT Room. The system was connected to a local panel and a bell in the office outside of the room.

During an interview at 2:47 p.m., POE1 stated that the preaction system was not connected to the hospital's main fire alarm panel.

At 3:58 p.m., records of an inspection of the IT Room's preaction system, dated 3/10/15, were reviewed. Under the Deficiencies and Comments section, the vendor stated that the preaction system "does not transmit any fire, trouble, or supervisory signal to the Main Fire Control Panel."

During a telephone interview at 8:18 a.m., on 3/9/16, the Office of Statewide Health Planning and Development (OSHPD) Fire Life Safety Officer (FLSO) stated that preaction and halon suppression systems are required to be connected to the hospital's main fire alarm panel.

Based on observation, interview, and record review, the facility failed to maintain their automatic fire sprinkler system is supervised by an approved method. This was evidenced by the failure of the remote monitoring station to receive supervisory signals from closure of the control valves. This could result in a delayed notification, in the event of tampered sprinkler control valves, and a delay in extinguishing a fire. This deficiency affected the entire main hospital and increased the potential for harm to patients, visitors, and staff.

NFPA 101 Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

19.3.5.3 Where this Code permits exceptions for fully sprinklered buildings or smoke compartments and specifically reference this paragraph, the sprinkler system shall meet the following criteria:
(1) It shall be installed throughout the building in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
(4) It shall be equipped with listed quick-response or listed residential sprinklers throughout all smoke compartments containing patient sleeping rooms.
Exception No. 1: Standard response sprinklers shall be permitted to be continued to be used in existing approved sprinkler systems where quick-response and residential sprinklers were not listed for use in such locations at the time of installation.
Exception No. 2: Standard response sprinklers shall be permitted for use in hazardous areas protected accordance with 19.3.2.1

9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler system are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. 1998 Edition
1.4 Qualified. Having adequate knowledge of the installation, construction, or operations of apparatus and the hazards involved.
Supervision. A means of monitoring system status and indicating abnormal conditions.

NFPA 72 National Fire Alarm Code, 1999 Edition
1-4 Central Station. A supervising station that is listed for central station service.

1-5.4.3.2.2 Visible and audible supervisory signals and visible indication of their restoration to normal shall be indicated within 90 seconds at the following locations:
(1) Control unit (central equipment)for local fire alarm systems
(2) Building fire command center for emergency voice/alarm communication service
(3) Supervising station location for systems installed in compliance with Chapter 5.

5-2.5.1 The central station shall have sufficient personnel, but not less than two persons, on duty at the central station at all times to ensure disposition of signals in accordance with the requirements of 5-2.6.1.

5-2.5.2 Operation and supervision shall be the primary functions of the operators, and no other interest or activity shall take precedence over the protective service.

5-2.6.1.3 Upon receipt of a supervisory signal from a sprinkler system, other fire suppression system(s), or other equipment, the central station shall perform the following actions:
(1) Communicate immediately with the person(s) designated by the subscriber
(2) Dispatch a runner or maintenance person to arrive within 1 hour to investigate
Exception: Where the supervisory signal is cleared in accordance with a scheduled procedure determined by 5-2.6.1.3(1).
(3) Notify the fire department or law enforcement agency, or both, if required
(4) Notify the authority having jurisdiction when sprinkler systems or other fire suppression systems or equipment
has been wholly or partially out of service for 8 hours
(5) When service has been restored, provide notice, if required, to the subscriber or the authority having jurisdiction,
or both, as to the nature of the signal, the time of occurrence, and the restoration of service when equipment has been out of service for 8 hours or more
Exception: If the supervisory signal results from a prearranged test, the actions specified by 5-2.6.1.3 (1), (3), and (5) shall not be required.

Findings:

During record review and facility tour with staff from 3/7/16 to 3/10/16, the sprinkler control valves were tested and documents were reviewed.

MAIN HOSPITAL

1. At 10:37 a.m., on 3/10/16, during the fire alarm testing, the tamper switch on the post indicator valve (PIV) labeled "73 Building" was activated and a supervisory signal was sent to the fire panel.

At 10:40 a.m., the tamper switch on the PIV labeled "MRI Building" was activated and a supervisory signal was sent to the fire panel.

At 10:49 a.m., during the fire alarm testing, the tamper switch on the outside screw and yoke (OS&Y) valve located at the West Wing parking lot was activated and a supervisory signal was sent to the fire panel.

At 2:15 p.m., the monitoring report, dated 3/10/16, showed that the remote monitoring facility failed to receive the supervisory signals activated by closure of the sprinkler control valves.

During an interview with the Public Board Exchange (PBX) operators at 2:17 p.m., PBX Operator1 stated they were not trained on what the alarms of the sprinkler system meant and they were trained just to notify facilities and plant operations. PBX Operator2 confirmed that they were not trained on the sprinkler alarms. PBX Operator1 stated that there are two PBX operators during the day and one during the night.

On 3/7/16, at 11:40 a.m., PBX operators silenced the fire alarm panel and failed to respond upon receipt of a fire alarm signal because they were busy with calls (refer to the interview in Finding 1 of K51).

The facility failed to ensure that the supervisory and trouble alarms of the automatic sprinkler system were monitored by qualified, trained, and designated individuals and a supervising station that is listed for central station service.

Based on observation, record review, and interview, the facility failed to maintain their extinguishing systems. This was evidenced by no records of the required maintenance inspections, by no records of repairing deficiencies noted during vendor inspections, by leaking and obstructed valves, by missing fire department connection (FDC) caps, by sprinkler heads that were not free from obstructions, and by sprinkler heads that were corroded. This affected five of five floors of the main hospital, four of four floors in the 101 Building, and the Wound Care Clinic. These deficiencies could result in a delay in extinguishing a fire and an increased risk of injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

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

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Table 3-1 Summary of Standpipe and Hose System Inspection, Testing, and Maintenance.
Control Valves: Weekly/Monthly Inspection
Pressure Regulating Devices: Quarterly Inspection
Piping: Quarterly Inspection
Hose Connections: Quarterly Inspection
Alarm Device: Quarterly Test
Hose: 5 Year/3 Year Test
Hydrostatic Test: 5 Year Test
Flow Test: 5 Year Test

Table 5-1.1 Summary of Fire Pump Inspection, Testing, and Maintenance
Pump house, heating ventilating louvers: Weekly Inspection
Fire pump system: Weekly Inspection
Pump Operation
No-Flow condition: Weekly Test
Flow condition: Annual Test
Hydraulic: Annual Maintenance
Mechanical transmission: Annual Maintenance
Electrically system: Maintenance Varies
Controller, various components: Maintenance Varies
Motor: Annual Maintenance
Diesel Engine System: Maintenance Varies

5-1.2 A fire pump assembly provides water-flow and pressure for private fire protection. The assembly includes the water supply suction and discharge piping and valving; pump; electrical, diesel, or steam turbine driver and control; and the auxiliary equipment appurtenant thereto.

5.3.2 Weekly Test. Qualified operating personnel shall be in attendance during the weekly pump operation.

5-3.2.1 A weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.
Exception: A valve installed to open as safety feature shall be permitted to discharge water.

Table 9-1 Summary of Valves, Valve Components, and Trim Inspection, Testing and Maintenance
Control Valves
Sealed: Weekly Inspection
Locked: Monthly Inspection
Tamper switches: Monthly Inspection
Alarm Valves
Exterior: Monthly Inspection
Preaction/Deluge Valves
Exterior: Monthly Inspection
Pressure Reducing and Relief Valves
Sprinkler systems: Quarterly Inspection
Hose Connection: Quarterly Inspection
Hose Racks: Quarterly Inspection
Fire Pumps
Casing relief valves: Weekly Inspection
Pressure relief valves: Weekly Inspection
Waterflow Alarms: Quarterly Test
Control Valves
Supervisory: Semiannual Test
Preaction/Deluge Valves
Priming water: Quarterly Test
Low air pressure alarms: Quarterly Tests
Dry Pipe Valves/Quick-Opening Devices
Priming Water: Quarterly Test
Low air pressures alarm: Quarterly Test
Quick-opening devices: Quarterly Test

9.7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a)The fire department connections are visible and accessible.
(b)Couplings or swivels are not damaged and rotate smoothly.
(c)Plugs or caps are in place and undamaged
(d)Gaskets are in place and in good condition
(e)Identification signs are in place.
(f)The check valve is not leaking.
(g)The automatic drain valve is in place and operating properly.

9.7.2 If the fire department connection plugs or caps are not in place, the interior of the connection shall be inspected for obstructions, and it shall be verified that the valve clapper is operational over its full range.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the extinguishing systems were observed and maintenance records were requested. The facility was equipped with an automatic sprinkler system, two preaction systems, a fire pump, and a standpipe system.

MAIN HOSPITAL
BASEMENT

1. At 10:30 a.m., on 3/7/16, there were five corroded sprinklers heads at the loading dock.

2. At 1:15 p.m., on 3/7/16, the deficiencies from a 3/10/15 inspection of the IT Room's preaction system were listed from the vendor as:
a. the dry pipe trip test failed
b. the system gauge needs to be replaced
c. the manual test valve was heavily corroded.

There were no records of repairing these deficiencies.

FIFTH FLOOR

3. At 2:28 p.m., on 3/8/16, there was a corroded sprinkler head in the stairwell landing.

FOURTH FLOOR

4. At 2:29 p.m., on 3/8/16, there was a corroded sprinkler head in the stairwell landing.

FIRST FLOOR

5. At 3:45 p.m., on 3/8/16, the water pump located on the first floor had a leaking valve.

101 BUILDING
FIRST FLOOR

6. At 2:07 p.m., on 3/9/16, the sprinkler head in the electrical room had a build-up of debris.

7. At 2:21 p.m., on 3/9/16, there was paint on the sprinkler deflector in the manager's office bathroom of Suite 104.

MAIN HOSPITAL
FIRST FLOOR

8. At 9:15 a.m., on 3/10/16, access to the Inspector's Test Valve (ITV) and riser pipes, in the storage room of Labor and Delivery, was blocked by a cabinet that stored corrosive hazardous materials.

9. At 10:52 a.m., on 3/10/16, there were eight corroded sprinkler heads in the overhang of the patio near the doctor's parking lot.

MAIN HOSPITAL, 101 BUILDING, WOUND CARE CLINIC
MAINTENANCE RECORDS

10. During an interview at 1:10 p.m., on 3/10/16, the Director of Facilities Services (DFS1) stated that the facility conducts only annual inspections and tests of the automatic sprinkler systems, fire pump, pre-action systems, and standpipes.

The facility failed to provide documents to show quarterly testing and inspection of the automatic sprinkler systems in the main hospital, Wound Care Clinic, and the 101 Building.

The facility failed to provide documents to show weekly, monthly and quarterly inspections and testing of the fire pump system.

The facility failed to provide documents for the 5 year and 3 year inspections of the standpipe system.

The facility failed to provide documents to show weekly, monthly, and quarterly inspections of the preaction extinguishing systems.

11. At 1:11 p.m., on 3/10/16, the vendor's annual inspection reports conducted in February were reviewed. Deficiencies were listed as:
a. On 2/9/16, the vendor reported that a 2 1/2 inch Outside Screw and Yoke (OS&Y) valve on the fire pump is leaking and needed to be replaced because the packing glands could not be adjusted. (See Finding 5)
b. On 2/9/16, the vendor reported that the ITV in Building A was obstructed by a "refrigerator." (See Finding 8)
c. On 2/9/16, the vendor reported that a 5-star 155 degree SSP escutcheon was missing in Sterile Processing. (See Finding 17)
d. On 2/9/16, the vendor reported that the preaction system "upstairs" had a leak and the compressor activates every 30 seconds for a few seconds.
e. On 2/17/16, the vendor indicated that the panel for the preaction system exhibited a trouble for batteries.

No records of repairing the deficiencies were provided.

During an interview at 1:12 p.m., DFS1 confirmed that the facility has not corrected the deficiencies from the vendor's reports.


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MAIN HOSPITAL
BASEMENT

12. At 2:01 p.m., on 3/7/16, the sprinkler head in the women's locker room was missing an escutcheon ring.

13. At 2:06 p.m., on 3/7/16, the sprinkler head in one of two walk-in refrigerators, in the kitchen, had a misaligned escutcheon ring. The escutcheon ring was not flush to the ceiling of the refrigerator and a penetration was exposed around the sprinkler pipe.

14. At 2:29 p.m., on 3/7/16, the sprinkler head in the corridor, across from the environmental services office, was missing an escutcheon ring.

15. At 2:30 p.m., on 3/7/16, one of two sprinkler heads in the linen closet, across from the pharmacy, had an escutcheon ring that was not flush to the ceiling.

16. At 3:24 p.m., on 3/7/16, there were pieces of blue-colored plastic on the sprinkler head in the trash room.

17. At 8:52 a.m., on 3/8/16, the sprinkler head in the room behind the old sterilizer in Sterile Processing was missing an escutcheon ring and was completely corroded.

FIFTH FLOOR

18. At 10:24 a.m., on 3/8/16, the two sprinkler heads near the back elevators were corroded.

FIRST FLOOR EXTERIOR

19. At 3:35 p.m., on 3/8/16, one of two FDCs outside the Emergency Care Center (ECC) was missing a cover.

20. At 3:41 p.m., on 3/8/16, one of four FDCs for the Magnetic Resonance Imaging (MRI) Building was missing a cover.

101 BUILDING

21. At 2:22 p.m., the Inspector's Test Valve (ITV) on the roof was opened for testing by facility staff. The valve leaked at the turn wheel.

Based on observation, the facility failed to maintain their fire extinguishers. This was evidenced by fire extinguishers that were obstructed, one fire extinguisher that was mounted too high, and one fire extinguisher with an out-of-range pressure reading. This could result in a delay in extinguishing a fire. This affected the basement and one of five floors of the main hospital, and one of four floors of the 101 Building.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1.6.10 Fire extinguishers having a gross weight not exceeding 40 lbs (18.4 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 of more than 40 lb (18.4 kg) (except wheel type) shall be so installed that the top of the fire extinguisher is not more than 3.5 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in (10.2 cm).

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

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the fire extinguishers were observed.

MAIN HOSPITAL
BASEMENT

1. At 2:12 p.m., on 3/7/16, access to the K-Class extinguisher next to the fryer was blocked by a trash can, in the kitchen.

2. At 3:22 p.m., on 3/7/16, access to the fire extinguisher in the decontamination room was obstructed by equipment.


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101 BUILDING
SUITE 104 (FAMILY CARE CENTER)

3. At 2:23 p.m., on 3/9/16, the top of the fire extinguisher, in the hallway near the office, was mounted on the wall approximately 5 feet 8 inches from the floor.

MAIN HOSPITAL
FIRST FLOOR

4. At 9:05 a.m., on 3/10/16, the gauge of the fire extinguisher, located near the clean utility room in the Labor and Delivery Unit, had a pressure indicator that was outside the operable range. The extinguisher was "Overcharged."

Based on observation and interview, the facility failed to implement smoking provisions and precautions. This was evidenced by one hazardous area, where combustible gases and flammable liquids were used and stored, that was provided with a precautionary "No Smoking" sign. This was also evidenced by cigarette butts in close proximity to the hazardous area. This affected the main hospital and could increase the risk of a fire.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the Magnetic Resonance Imaging (MRI) Building's diesel generator location was observed.

1. At 4:06 p.m., on 3/8/16, there was no precautionary sign for "NO SMOKING" posted on the exterior fence of the generator enclosure. Several cigarette butts were observed on the ground around the diesel generator enclosure.

During an interview at 4:07 p.m., the Director of Facilities Services (DFS1) stated that it is hard to control the smoking public.

Based on observation, record review, and interview, the facility failed to maintain their heating, ventilating, and air conditioning (HVAC) systems. This was a evidenced a boiler pump that required a battery change, by a leak in a hot water pipe, by a leak in a steam line, a water heater vent that was obstructed by combustible materials, and by a portable air conditioner (AC) that was vented into the attic. This was also evidenced by no records of repairing fire dampers that failed inspection. This affected the main hospital and the Women's Care Center. This could result in the increased risk of a fire, the faster spread of smoke and fire through the HVAC system, and the increased risk of injury to patients.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
Exception: As modified in 19.5.2.2.

19.5.2.2 Any heating device other than a central heating plant shall be designed and installed so that combustible material will not be ignited by the device or its appurtenances. If fuel-fired, such heating devices shall be chimney connected or vent connected, shall take air for combustion directly from the outside, and shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area. Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure.
Exception No. 1: Approved, suspended unit heaters shall be permitted in locations other than means of egress and patient sleeping areas, provided that such heaters are located high enough to be out of the reach of persons using the area and are equipped with the safety features required by 19.5.2.2.
Exception No. 2: Fireplaces shall be permitted and used only in areas other than patient sleeping areas, provided that such areas are separated from patient sleeping spaces by construction having not less than a 1-hour fire resistance rating and that such fireplaces comply with the provisions of 9.2.2. In addition, the fireplace shall be equipped with a fireplace enclosure guaranteed against breakage up to a temperature of 650°F (343°C) and constructed of heat-tempered glass or other approved material. If, in the opinion of the authority having jurisdiction, special hazards are present, a lock on the enclosure and other safety precautions shall be permitted to be required.

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

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.1 Equipment shall be arranged to afford access for inspection, maintenance, and repair.

2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.

2-1.3 Equipment shall be guarded for personnel protection and against the intake of foreign matter into the system.

2-2.4.1 Installation. Heating and cooling equipment shall be installed in accordance with the applicable NFPA standards and the manufacturer's instructions. The equipment shall be approved for the specific installation.

2-2.4.3 Mechanical Cooling. Mechanical refrigeration used with air duct systems shall be installed in accordance with recognized safety practices. Installations conforming to ANSI/ASHRAE 15, Safety Code for Mechanical Refrigeration, shall be considered in compliance with these requirements.

2-3.1.2 Air ducts shall be permitted to be rigid or flexible and shall be constructed of materials that are reinforced and sealed to satisfy the requirements for the use of the air duct system, such as the supply air system, the return or exhaust air system, and the variable volume/pressure air system.

2-3.7 Air Inlets -- Return or Exhaust or Return and Exhaust
2-3.7.1 General. Air shall not be recirculated from any space in which flammable vapors, flyings, or dust is present in quantities and concentrations that would introduce a hazardous condition into the return air system.

3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct system.

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.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the HVAC systems were observed and maintenance records were reviewed.

MAIN HOSPITAL
CENTRAL PLANT

1. At 10:46 a.m., on 3/7/16, a panel on one boiler in the boiler room was exhibiting an "Error. Change Battery" trouble signal.

During an interview at 10:47 a.m., Plant Operations Engineer 1 (POE1) stated that the battery for the boiler blowdown pump needed to be replaced.

2. At 10:52 a.m., on 3/7/16, there was an approximately 1/4 inch leak in a pipe of the hot water heat exchanger in the boiler room. There was a bucket placed under the leak to catch the water and a hose leading the leaked water from the bucket into a drain.

During an interview at 10:53 a.m., POE1 stated that the pipe had been leaking for three weeks. He stated that repair of the pipe has not yet been scheduled.

3. At 3:09 p.m., on 3/7/16, there was an approximately 10 inch hole in the ceiling of the room behind the old sterilizer, in Sterile Processing, that was surrounded by mold and had water leaking through it.

During an interview at 3:10 p.m., the Manager of Facilities Services (MFS1) stated that the packing on the shut-off valve for the old steam line was leaking.

THIRD FLOOR

4. At 11:45 a.m., on 3/8/16, there was a portable air conditioner (AC) in use inside the storage/data room. The plastic air outlet exhaust pipe penetrated the ceiling.

During an interview at 11:46 a.m., MFS1 stated that the AC was needed because the room gets too hot. He stated that the hot air from the air outlet was vented directly into the attic.

WOMEN'S CARE CENTER

5. At 9:58 a.m., on 3/9/16, there were three cardboard boxes labeled Biohazard and a plastic biohazard receptacle stored directly adjacent to the vent in the metallic door of the water heater enclosure.


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MAIN HOSPITAL

6. At 11:35 a.m., on 3/8/16, a damper testing document from February 2013 reported the following failures:
a. Damper #112 was closed and the motor could not be accessed for testing.
b. Shut off power to the Damper #300 motor and there was no response
c. Shut off power to the Damper #303 motor and there was no response. Access to the motor was blocked by a duct.
d. Shut off power to the Damper #177 motor and there was no response.
e. Shut off power to the Damper #363 motor and there was no response.
f. Shut of power to the Damper #509 motor and there was no response. Could not repair because of congestion.
g. Shut off power to the Damper #460 motor and there was no response. Could not repair because of congestion.

The repair documents were requested from DFS1 but were not provided.

During an interview at 1:05 p.m., on 3/10/16, DFS1 stated that he could not provide repair documents because the inspection was in 2013.

Based on observation, record review, and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by grease-laden deposits on the kitchen hoods and by no records indicating that the hoods were cleaned at frequencies in accordance with NFPA 96. This affected the basement of the main hospital and could result in the increased risk of a grease fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

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

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tightfitting and firmly held in place.

8.3.1 Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking
Systems serving solid fuel cooking operations shall be inspected monthly.
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking shall be inspected quarterly.
Systems serving moderate-volume cooking operations shall be inspected semi-annually.
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers, shall be inspected annually.

8-3.1.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

8-3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also include areas no cleaned.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the kitchen was observed.

MAIN HOSPITAL
BASEMENT

1. At 2:11 p.m., on 3/7/16, the sticker on the kitchen hood indicated that it was last cleaned by a vendor on 7/10/15. The sticker stated that the next service was due in November 2015.

During an interview at 2:12 p.m., the Manager of Facilities Services (MFS1) stated that the hood had not been cleaned since because they were in the process of changing vendors.

2. At 2:15 p.m., on 3/7/16, the plant operations engineer (POE1) removed the filters above the fryer, griddle, and stove inside the main kitchen. The kitchen hood was heavily contaminated with grease-laden deposits.

At 2:17 p.m., on 3/7/16, POE1 removed the filters above the fryer, griddle, and stove in the cafeteria. There were grease-laden deposits dripping from the hood.

3. At 12:41 p.m., on 3/8/16, an invoice showed that the hoods were cleaned on 7/9/15. There were no other records of cleaning the kitchen hoods in 2015.

Based on observation and interview, the facility failed to maintain their means of egress. This was evidenced by egress corridors that were not free of obstructions and by one exit door that was locked from the egress side. This affected one of five floors at the main hospital and the Women's Care Center. This could result in a delay in evacuation and could result in the increased risk of injury to patients, visitors, and staff.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.

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

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

7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:
THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED
(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

Findings:

During tour of the facility with staff from 3/7/16 to 3/10/16, the means of egress were observed.

MAIN HOSPITAL
FIRST FLOOR

1. At 2:40 p.m., on 3/7/16, there was an employee work station, approximately 3 feet in length, that included a desk, a cabinet with drawers, two chairs, computers, a telephone, an industrial sized copy machine, and a trash can, that was stored in the corridor by the exit door of the surgery suite. The employee work station, the copy machine, and the trash can obstructed the path of egress from the operating room (OR) suite.

2. At 3:20 p.m., on 3/7/16, there were OR supplies supplies stored on approximately 6-foot tall carts, storage bins, and two H-sized nitrogen cylinders placed in the egress corridor by the ORs. Identification labels for the supplies and the nitrogen gas cylinders were mounted on the wall of the egress corridor.

During an interview at 3:21 p.m., interview with the OR Director (DOR1), stated all the supplies for operating rooms were stored in the corridor because the facility is not equipped with a storage room for the ORs. She stated that staff would have to go to the basement for their supplies. DOR1 also stated that the employee work station has been in the corridor for years because there is no space for a work station elsewhere.

The OR Suite was located in a nonsprinklered part of the building.

3. At 9:00 a.m., on 3/10/16, in Labor and Delivery, there was a public status monitoring board (television) mounted on the egress corridor wall across from the nurses station. The board projected approximately 8 inches measured at the smallest angle from the corridor wall. It protruded more than six inches into the corridor in violation of the requirements of S&C-10-18-LSC, a memorandum issued by CMS on 5/14/10. The board blocked access to the hand rail along the corridor wall.

During an interview at 9:01 a.m., the Director of Facilities Services (DFS1) stated the monitoring board was hung in the corridor without approval from authority having jurisdictions.

During an interview with the Office of Statewide Health Planning and Development Regional Compliance Officer, he stated that a permit is required to hang monitors on the wall for seismic safety and reduce the risk of harm.


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4. At 4:14 p.m., on 3/8/16, there was a gurney and a chair in the hallway outside Pediatric Treatment Room 15 - 18 in the Emergency Care Center (ECC). The gurney was in front of a sign that stated "Keep Hallways Clear." At 4:17 p.m., ECC staff parked another gurney in front of the first one.

5. At 4:19 p.m., on 3/8/16, there were four chairs and one receptacle for shredded paper in the egress hallway, across from Stations 8 and 9, in the ECC.

During an interview at 4:20 p.m., the Manager of Facilities Services (MFS1) stated that this is sometimes used as an extra waiting area.

6. At 4:22 p.m., on 3/8/16, there was a mail organizing system mounted on the wall across from the nurses station in the ECC. The mail board was approximately 5 feet wide by 4 feet tall and had 40 slots for mail. The mail slots projected more than 7 inches into the egress hallway. They protruded more than six inches into the corridor in violation of the requirements of S&C-10-18-LSC, a memorandum issued by the Centers for Medicaid and Medicare Services (CMS) on 5/14/10.

7. At 4:23 p.m., on 3/8/16, next to the mail board in the ECC was an approximately 40 inch public status monitoring board (television) mounted on the wall. The board projected approximately 12 inches into the hallway at its furthest point. It protruded more than six inches into the corridor in violation of the requirements of S&C-10-18-LSC, a memorandum issued by CMS on 5/14/10.

The ECC was located in a nonsprinklered part of the building.


WOMEN'S CARE CENTER

8. At 10:06 a.m., on 3/9/16, the rear exit door adjacent to the Classroom failed to open when the door handle was operated and the door was pushed. The exit door had a deadbolt above the door handle that was in the lock position. There were patients at the facility during time of the observation.

During an interview at 10:07 a.m., the Director of Business Management (DBM1) stated that the deadbolts on the exit doors are normally unlocked during business hours.

Based on observation and interview, the facility failed to maintain their medical gas storage areas. This was evidenced by medical gas cylinders that were not fully secured, by combustible materials stored in close proximity to the medical gas, by the failure to segregate full and empty cylinders, and by oxygen cylinders stored near an electrical outlet. This affected two of five floors in the main hospital and the exterior medical gas storage areas. This could result in the increased risk of hazardous conditions.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.


Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.
12-3.8.1 Patient. Equipment shall conform to the patient equipment requirements in Chapter 8, "Gas Equipment."
12-3.8.2 Nonpatient. Equipment shall conform to the non-patient equipment requirements in Chapter 8, "Gas Equipment."

Chapter 8 Gas Equipment
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.

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

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
11. Construction and Arrangement of Supply System Locations.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers-Level 1.
(b) Special Precautions-Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

4-3.5.2.2 Storage of Cylinders and Containers-Level 1.
(b) Nonflammable Gases.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the medical gas cylinders were observed.

MAIN HOSPITAL
FIRST FLOOR

1. At 3:21 p.m., on 3/8/16, there were eight oxygen E-cylinders stored in Room 8 of the catheterization lab (Cath Lab). Two of those eight cylinders were lying on the ground unsecured.


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THIRD FLOOR
2. At 10:11 a.m., on 3/10/16, there were four E-sized oxygen cylinders in a six-slot cart stored in the equipment room. The oxygen storage cart with oxygen cylinders was adjacent to an electrical outlet that had an electrocardiogram machine plugged into it.

During an interview at 10:12 a.m., the Quality Coordinator (QC1) acknowledged that the oxygen cart should not be stored next to the electric outlet.

EXTERIOR MEDICAL GAS STORAGE
NEXT TO RESPIRATORY DEPARTMENT

3. At 10:59 a.m., on 3/10/16, there were 8 H-sized medical gas cylinders that were chained around their bases in the exterior medical gas storage enclosure. The cylinders could be moved and were not fully secured against falling over.

A piece of plastic covered the H-sized cylinders and the empty cylinders were not segregated from the full cylinders.

EXTERIOR SOUTH WING STORAGE ROOM

4. At 11:09 a.m., on 3/10/16, the medical gas cylinders were stored with combustible storage including cartoned storage. The empty medical gas cylinders were not segregated from the full cylinders. There was approximately 1896 cubic feet of oxygen stored in the room.

During an interview at 11:10 a.m., respiratory staff stated this was a temporary storage location for the medical gas cylinders because the roof is leaking at the main medical gas storage location.

Based on observation, record review, and interview, the facility failed to ensure that equipment is installed in accordance with manufacturer's specifications and approved by the authority having jurisdiction (AHJ). This was evidenced by pharmacy hoods that were not permanently installed and by one pharmacy hood that was not vented correctly. This was also evidenced by medication dispensers that were not seismically anchored. This affected the basement and one of five floors of the main hospital. This could result in the increased risk of injury and could result in the increased risk of hazardous contamination.

NFPA 101, Life Safety Code, 2000 Edition.
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
Chapter 5 Environmental Systems
5-1 Scope. This chapter covers the performance, maintenance, and testing of the environmental systems used within health care facilities.

5-4.3.3 Fume hoods intended for use with radioactive isotopes
shall be constructed of stainless steel or other material suitable for the particular exposure.

5-4.3.5 Fume hoods shall be so designed that the face velocity ventilation is adequate to prevent the backflow of contaminants into the room, especially in the presence of cross drafts or the rapid movements of an operator working at the face of the hood.

Chapter 9 Manufacturer Requirements
9-1 Scope. This chapter covers the performance, maintenance, and testing, with regard to safety, required of manufacturers of equipment used within health care facilities.

9-2.1.1.2 Mechanical Stability. The appliance shall be mechanically stable in the position of normal use. If the appliance is intended for use in an anesthetizing location, 12-4.1 applies.

9-2.1.6.3 Chemical Agents. Electric appliances containing hazardous chemicals shall be designed to facilitate the replenishment of these chemicals without spillage to protect the patient, the operating personnel, and the safety features of the appliance from such chemicals.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the pharmacy hoods and medication dispensers were observed.

MAIN HOSPITAL
BASEMENT

1. At 1:30 p.m., on 3/7/16, the chemotherapy preparation (chemo prep) hood in the pharmacy's biohazard room was not permanently installed. It was equipped with wheels and was portable. The chemo prep hood had a six inch flexible exhaust duct penetrating the ceiling.

During an interview at 1:31 p.m., the Pharmacy Services Directors (DPS1) stated that both of the pharmacy's hoods are on wheels and they have been in use for three to four years.

During an interview at 1:36 p.m., the Manager of Facilities Services (MFS1) stated that the hospitals facilities department installed the exhaust. He stated that they exhausted the hood into a regular exhaust vent which they modified to seal around the duct.

2. At 1:34 p.m., on 3/7/16, the IV hood in the sterile area of the pharmacy was equipped on wheels and was portable.

Both hoods were not seismically anchored for earthquake safety and the installation and ventilation for the hoods was not approved by the AHJ.

FIRST FLOOR

3. At 4:06 p.m., on 3/8/16, there were two medication dispensers in the Emergency Care Center (ECC) Overflow that were plugged in but not anchored. The medication dispensers were approximately 6 feet tall.

At 4:22 p.m., on 3/8/16, the manufacturer's specifications and the Seismic Restraint Installation Guide for these dispensers was reviewed. The documents stated that the brackets are used to secure the cabinets in case of an earthquake and that "these restraints help minimize injury to hospital personnel and damage to equipment by eliminating cabinet movement."

4. At 4:25 p.m., on 3/8/16, there were two medication dispensers in the ECC that were plugged in but not anchored. The medication dispensers were approximately 6 feet tall.

During an interview at 9:20 a.m., on 3/9/16, the Director of Facilities Services (DFS1) stated that the medication dispensers throughout the hospital were not anchored and that were just pushed into place.

During a telephone interview at 10:18 a.m., on 3/9/16, the Office of Statewide Health Planning and Development Compliance Officer (OSHPD CO) stated that pharmacy hoods should not be vented into a regular exhaust. He also stated that the medication dispensers are required to be anchored per state regulations in case of a seismic event.


29566

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MAIN HOSPITAL
FIRST FLOOR

5. At 9:08 a.m., on 3/10/16, there were four medication dispenser units, approximately 6 feet in height, positioned against the wall of the central supply storage room in the Labor and Delivery Department. The dispensers were not secured against seismic activity.

Based on observation, facility failed to maintain their medical gas storage areas. This was evidenced by the absence of required precautionary signage for rooms that stored oxygen cylinders. This could increase the potential for a hazard condition and increase the risk of injury to staff and patients. This affected three of five floors in the main hospital.

NFPA 99, 1999 Edition
8-6.4.2 Signs. Precautionary signs, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed wherever supplemental oxygen is in use, and in aisles and walkways leading to that area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the oxygen cylinder storage locations were observed.


29665

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MAIN HOSPITAL
FIFTH FLOOR

1. At 10:11 a.m., on 3/8/16, there were four oxygen E-cylinders stored in the clean utility room. There was no precautionary signage on the door.

FOURTH FLOOR

2. At 10:52 a.m., on 3/8/16, there were five oxygen E-cylinders stored in the clean utility room. There was no precautionary signage on the door.

FIRST FLOOR

3. At 3:20 p.m., on 3/8/16, there were eight oxygen E-cylinders stored in Room 8 in the catheterization lab (Cath Lab). There was no precautionary signage on the door.

4. At 3:52 p.m., on 3/8/16, the room labeled "Film Processing Room" in the Magnetic Resonance Imaging (MRI) Building housed 20 oxygen E-cylinders. There was no precautionary signage on the door.

Based on observation, record review, and interview, the facility failed to maintain the safety of their hyperbaric facility. This was evidenced by a defective piped-in oxygen alarm panel and by an inoperable fire alarm system. This affected patients at the Wound Care Clinic. This could result in a delay in notification of a hazardous condition and an increased risk of injury to patients.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
Chapter 19 Hyperbaric Facilities
19-1.4.1 General. Chambers shall be classified according to occupancy in order to establish appropriate minimum essentials in construction and operation.

19-1.4.2 Occupancy.
(a) Class A-Human, multiple occupancy
(b) Class B-Human, single occupancy
(c) Class C-Animal, no human occupancy

19-1.5.1 This chapter for the use of hyperbaric facilities is intended to provide protection against fire, explosion, and other hazards without unduly limiting the activities of professional personnel involved in patient (in the case of hospitals) or other care. This principle, without minimizing the hazards, recognizes that professional personnel shall be guided by all of the hazards to life that are inherent in and around hyperbaric treatment procedures.

19-2.8.5.1 Oxygen levels shall be continuously monitored in any chamber in which nitrogen or other diluent gas is added to the chamber to reduce the volumetric concentration of oxygen in the atmosphere (saturation operations). Audible and visual alarms shall indicate unsafe low oxygen partial pressure in the chamber.

19-2.8.5.2 Oxygen levels shall be continuously monitored in Class A chambers when breathing mixtures containing in excess of 21 percent oxygen by volume are being breathed by patients or attendants and/or any flammable agents are present in the chamber. Audible and visual alarms shall indicate volumetric oxygen concentrations in excess of 23.5 percent.

19-3.1.3.1 Personnel having responsibility for the hyperbaric facility, and those responsible for licensing, accrediting, or approving institutions or other facilities in which hyperbaric installations are employed, shall establish and enforce appropriate programs to fulfill the provisions of this chapter.

19-3.1.4.3 All personnel, including those involved in maintenance and repair of the facility, shall become familiar with emergency equipment-its purposes, applications, operation, and limitations.

19-3.4.1.4 The requirements set forth in Section 4-3 of Chapter 4 concerning the storage, location, and special precautions required for compressed gases shall be followed.

19-3.6.4 Fire Protection Equipment. Electrical switches, valves, and electrical monitoring equipment associated with fire detection and extinguishment shall be visually inspected before each chamber pressurization. Fire detection equipment shall be tested each week and full testing, including discharge of extinguishing media, conducted annually. Testing shall include activation of trouble circuits and signals.

4-3.1.2.2 Gas Warning Systems.
(c) Area Alarms.
2. Area alarm panels shall be located at the nurses ' station or other location that will provide for responsible surveillance.

Findings:

During a facility tour with staff from 3/7/16 to 3/10/16, the hyperbaric facilities were observed.

WOUND CARE CLINIC (HYPERBARIC CENTER)

1. At 10:48 a.m., on 3/9/16, the facility was equipped with a piped-in oxygen system feeding the two hyperbaric chambers. The medical gas master alarm, located in the hyperbaric holding area, exhibited a "Low" oxygen pressure trouble light.

During an interview at 10:49 a.m., the Director of Wound Care (WCD) stated that the panel has been that way since he started working at the facility two weeks ago. He stated that staff are manually checking the pressure once a day. The Director of Facilities Services (DFS1) stated that the parts to repair the panel were on order. He stated that the panel's audible alarm was silenced.

During an interview at 11:07 a.m., the hyperbaric technician overseeing the patient in the chamber stated that he did not know that the master alarm panel for the piped-in oxygen system was broken and the pressure reading on the panel was not accurate. The hyperbaric technician stated that he checks the oxygen master alarm panel, the dials on the hyperbaric chamber, and the readings on the cryogenic cylinders before he starts any treatment in the hyperbaric chamber, but did not realize the master panel was not working.

At 1:55 p.m., results from the survey by the accreditation organization, conducted from 2/2/16 to 2/4/16, were reviewed. Finding 2 on Page 35 stated that the medical gas alarm panel in the Wound Care Offsite Location was faulty and that staff at the Wound Center were unaware that the panel was in alarm. The surveyor noted that staff continued to use the system even though it was in alarm.

An estimate for the cost of the repair from the medical gas vendor was dated 2/3/16. The vendor indicated that outstanding bills must be paid before an order for the panel parts can be placed. A purchase requisition from hospital staff for the panel repair, requested 2/5/16, also indicated that past due bills to the medical gas vendor be paid. Records showed that the vendor was paid on 2/25/16 and he made a service call to repair the panel on 3/2/16. In his field report, he stated the "back circuit board" was defective and a custom manufactured part will need to be ordered. He estimated the part would arrive within four to six weeks.

During an interview at 2:00 p.m., DFS1 confirmed that the panel repairs were delayed due to outstanding bills owed to the vendor.

2. At 10:39 a.m., on 3/9/16, the main fire alarm control panel (FACP) was in the lobby directly outside the hyperbaric holding area. There were no indicators lit on the panel and the screen on the panel was not functioning. When the panel box was open, there were scorch marks on the power board.

During a telephone interview at 10:40 a.m., the representative from the remote monitoring station stated that the last signal received from the facility's panel was a trouble signal on 3/6/15 at 11:29 a.m.

At 10:45 a.m., the pull station near the FACP was tested by POE1 while the monitoring station representative was on the phone. No alarms were activated in the facility and the monitoring station representative did not receive any signal from the facility after more than two minutes. There were nine patients in the facility at the time, one of them in a hyperbaric chamber.

At 3:06 p.m., the Detailed Activity Report from the monitoring company showed that on 3/7/16 at 12:41 p.m., and on 3/8/16 at 1:53 p.m., "the test signal not received." (Refer to K51)

Facility staff failed to inspect the fire alarm system before administering treatment to a patient in the hyperbaric chamber, as required by NFPA 99.


There was one patient in a hyperbaric chamber, and one patient in the hyperbaric holding area, during the time the failed medical gas alarm panel and fire alarm panel were observed.

An IJ was called at 12:21 p.m., in the presence of the COO and Chief Nursing Officer (CNO).

The IJ was removed at 5:55 p.m., in the presence of the COO, after the facility ended procedures, evacuated the building, initiated repairs to the fire alarm and medical gas alarm panels, and after an acceptable POC was received. (See LSC K142)

During a telephone interview at 2:01 p.m., on 3/15/16, the city's Fire Marshal, who is the local authority having jurisdiction (AHJ), stated no patients should be treated in the hyperbaric chambers when the fire alarm system and the oxygen alarm system are not working.

Based on observation, the facility failed to maintain their emergency generators. This was evidenced by the failure to provide battery-powered emergency lights at locations of the Emergency Power Supply (EPS) equipment. This could result in a delay in repairing a generator malfunction and the increased risk of complete loss of power. This affected the generator for the entire main hospital except the Magnetic Resonance Imaging (MRI) building.

NFPA 101, Life Safety Code, 2000 Edition,
9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition.
5-3.1 The level 1 and Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room shall be supplied from the load side of the transfer switch.

5-3.2 The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.
Exception: This requirement shall not apply to units housed outdoors.

Findings:

During a tour of the facility with staff from 3/7/16 to 3/10/16, the generators were observed.

MAIN HOSPITAL
CENTRAL PLANT

1. At 10:40 a.m., on 3/7/16, there was no battery-powered emergency lighting in the electrical room housing the three automatic transfer switches (ATSs) for the main generator.

2. At 11:02 a.m., on 3/7/16, the battery-powered emergency light in the generator enclosure failed to illuminate when tested.

Based on observation, record review, and interview, the facility failed to maintain their electrical wiring. This was evidenced by the unapproved use of power strips and extension cords, by electrical fixtures with open, missing, or broken covers, by electrical panels that were blocked, and by a newly installed outlet that was not inspected for safety. This was also evidenced by the failure to provide records of load tests and periodic manufacturer-recommended maintenance inspections on the Uninterruptible Power Supply (UPS) systems. This affected three of five floors and the basement of the main hospital, the Women's Care Center, and one of four floors in the 101 Building. This could result in the increased risk of an electrical fire, the increased risk of failure of the UPS systems, and the increased risk of injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
90-7 Examination of Equipment for Safety. For specific items of equipment and materials referred to in this Code, examinations for safety made under standard conditions will provide a basis for approval where the record is made generally available through promulgation by organization properly equipped and qualified for experimental testing, inspections of the run of goods at factories, and service-value determination through field inspections. This avoids the necessity for repetition of examinations by different examiners, frequently with inadequate facilities for such work, and the confusion that would result from conflicting reports as to the suitability of devices and materials examined for a given purpose.
It is the intent of this Code that factory-installed internal wiring or the construction of equipment need not be inspected at the time of installation of the equipment, except to detect alterations or damage, if the equipment has been listed by a qualified electrical testing laboratory that is recognized as having the facilities described above and that require suitability for installation in accordance with this Code.

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

110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
(b) Subsurface Enclosures. Conductors shall be racked to provide ready and safe access in underground and subsurface enclosures, into which persons enter for installation and maintenance.
(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, abrasives, 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.

110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.

Table 210-21(b)(2). Maximum Cord- and Plug-Connected Load to Receptacle
Circuit Rating (Amperes): 20
Receptacle Rating (Amperes): 20
Maximum Load (Amperes): 16

210-23. Permissible Loads. In no case shall the load exceed the branch-circuit ampere rating. An individual circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) through (d) and as summarized in Section 210-24 and Table 210-24.

370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

Article 700 - Emergency Systems
700-4 Tests and Maintenance
(a) Conduct or Witness Test. The authority having jurisdiction shall conduct or witness a test of the complete system upon installation and periodically afterward.
(b) Tested Periodically. Systems shall be tested periodically on a schedule acceptable to the authority having jurisdiction to ensure the systems are maintained in proper operating condition.
(c) Battery Systems Maintenance. Where battery systems or unit equipment are involved, including batteries used for starting, control, or ignition in auxiliary engines, the authority having jurisdiction shall require periodic maintenance.
(d) Written Record. A written record shall be kept of such tests and maintenance.
(e) Testing Under Load. Means for testing all emergency lighting and power systems during maximum anticipated load conditions shall be provided.

Finding:

During a facility tour with staff from 3/7/16 to 3/10/16, the electrical wiring was observed.

MAIN HOSPITAL
CENTRAL PLANT

1. At 10:50 a.m., on 3/7/16, the water softener in the boiler room was plugged into a three-plug extension cord. That extension cord was plugged into a second extension cord.

BASEMENT

2. At 1:33 p.m., on 3/7/16, the chemotherapy preparation hood in the pharmacy's biohazard room was plugged into an extension cord.

3. At 1:38 p.m., on 3/7/16, the refrigerator in the pharmacy's narcotics room was plugged into a six-plug power strip.

4. At 2:56 p.m., on 3/7/16, there were four battery-powered UPS units in the electrical room. One was labeled "Cath Lab", one "IT", one "PACs", and one was labeled "Tele."

During an interview at 2:57 p.m., the Manager of Facilities Services (MFS1) stated that the Cath Lab UPS supplies emergency power to the entire catheterization laboratory.

At 5:05 p.m., Page 73 of the manufacturer's specifications for the Cath Lab UPS indicated that daily, monthly, and annual maintenance checks.

At 12:48 p.m., on 3/8/16, records showed that the UPS systems were inspected by a vendor on 9/24/15. The vendor indicated that he inspected batteries and battery voltages.

During an interview at 2:52 p.m., on 3/8/16, Biomed1 confirmed that the UPS units were only inspected once a year.

There were no records of load tests conducted on these UPS units and no records of inspections in accordance with manufacturer's specifications.

5. At 3:15 p.m., on 3/7/16, the two ballast lights behind the old sterilizer, in the sterile processing room, were missing their covers. The lights were in close proximity to a leaking steam line (Refer to K12 and K67).

FOURTH FLOOR

6. At 10:39 a.m., on 3/8/16, the refrigerator and ice machine in the nourishment room were plugged into a duplex outlet with a broken cover. Internal parts of the electrical box were exposed.

THIRD FLOOR

7. At 11:41 a.m., on 3/8/16, access to Electrical Panel 3ECL2 in the corridor, across from Room 316, was blocked by a scale. There was a signage on the panel stating "Emergency Panel. Do Not Block. 36" Clearance."

8. At 11:47 a.m., on 3/8/16, the portable air conditioner (Refer to K67) in the storage/data room was plugged into an 8-plug power strip.

9. At 11:53 a.m., on 3/8/16, the refrigerator in the Tower 3 medication room was plugged into an extension cord. The extension cord was mounted on the wall.


WOMEN'S CARE CENTER

10. At 9:43 a.m., on 3/9/16, the computer in the Consultation Room was plugged into a three-plug extension cord with no surge protection.

11. At 9:49 a.m., on 3/9/16, there was a duplex outlet in the data closet of the Consultation Room that was connected via an approximately 1 foot conduit to a ceiling light fixture. The data boxes were plugged into that duplex outlet.

During an interview at 9:50 a.m., the Director of Facilities Services (DFS1) and MFS1 stated that this set-up was installed by the IT Department approximately one year ago. DFS1 and MFS1 stated that they were unsure if the outlets were correctly installed or properly grounded. DFS1 stated that he would look to see if a certified electrician drew from the light fixture to power the duplex outlet.

No documentation was provided regarding the installation and safety of this duplex outlet.

12. At 9:52 a.m., on 3/9/16, there was a refrigerator plugged into a six-plug power strip in Exam Room 3.



29566

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101 BUILDING
FIRST FLOOR

13. At 2:25 p.m., on 3/9/16, there was a microwave plugged into a multi-plug power strip in Suite 104.

Based on observation, record review and interview, the facility failed to implement interim safety procedures in areas where the fire alarm system was compromised. This was evidenced by the failure to conduct fire watch rounds at construction sites where the smoke detectors were disabled. This affected two of five floors in the main hospital and could result in a delay in fire discovery and response.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.9.1 Construction, repair, and improvement operations shall comply with 4.6.10.

4.6.10.1 Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place.

Findings:

During a facility tour with 3/7/16 to 3/10/16, the construction areas were observed.

MAIN HOSPITAL
FOURTH FLOOR

1. At 10:30 a.m., on 3/8/16, the smoke detector outside the elevator lobby, and the two smoke detectors inside the lobby, were entirely covered with tape.

During an interview at 10:31 a.m., the construction contractor (CC1) stated that they have been working on replacing the floor in the elevator lobby since 6:30 a.m.

During an interview at 10:32 a.m., the Manager of Facilities Services (MFS1) stated that the Project Manager for Construction (PMC1) told him over the phone that fire watch was only being conducted at the stairwells and not at the elevator lobby renovation locations. She stated fire watch was not required at the other construction sites.

The facility was issued Building Permit S152541-19-00 by the Office of Statewide Health Planning and Development (OSHPD) on 12/11/15 for cosmetic upgrades on multiple floors. The Interim Life Safety Measure (ILSM) plan connected to this permit was signed by the OSHPD Fire Life Safety Officer (FLSO) on 1/6/16. The ILSM plan stated that "dedicated individual to be posted at working phase to provide fire watch for that specific area."

The facility's Life Safety Management policy, last revised 10/27/15, listed ILSM measures during construction or fire alarm system failures as one of the objectives required to meet the hospitals "fire safety and prevention needs."

FIRST FLOOR

2. At 3:00 p.m., on 3/8/16, a door labeled "Room 8" in the Radiology Department was closed off for construction. There were four smoke detectors entirely covered with tape. The area was nonsprinklered, unsupervised, and housed some construction material.

There were no records of conducting a fire watch at this construction area with the covered smoke detectors.

3. At 3:24 p.m., on 3/8/16, the construction area near the Radiology Department, called by MFS1 as the "old corridor leading to Radiology," was observed. The smoke detector in that area was completely covered with tape. The area was nonsprinklered, unsupervised, and housed some construction material.

There were no records of conducting a fire watch at this construction area with the covered smoke detectors.

During a telephone interview at 8:18 a.m., on 3/9/16, the OSHPD FLSO stated that fire watch is needed in areas where fire alarm devices are disabled. He stated that the facility should follow the ILSM procedures.

Based on observation, the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers away from hazards. This was evidenced by an ABHR dispenser mounted on a wall between two ignition sources. This could result in the increased risk of an electrical fire and injury to patients, visitors and staff. This affected one of four floors of the 101 Building.

Findings:

During a tour of the facility with staff from 3/7/16 to 3/10/16, the ABHR dispensers were observed.

101 BUILDING
SUITE 104 (FAMILY CARE CENTER)

1. At 2:19 p.m., on 3/9/16, there was an ABHR dispenser mounted on the wall, near the door of the Mammogram Room, between two electrical light switches.

Based on observation, the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers away from hazards. This was evidenced by an ABHR dispenser mounted on a wall between two ignition sources. This could result in the increased risk of an electrical fire and injury to patients, visitors and staff. This affected one of four floors of the 101 Building.

Findings:

During a tour of the facility with staff from 3/7/16 to 3/10/16, the ABHR dispensers were observed.

101 BUILDING
SUITE 104 (FAMILY CARE CENTER)

1. At 2:19 p.m., on 3/9/16, there was an ABHR dispenser mounted on the wall, near the door of the Mammogram Room, between two electrical light switches.