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The facility failed to provide/maintain corridor doors which would close and resist the passage of smoke. Findings include:

The door of "OR" #14 was observed with a gap at the top of the door allowing viewing into the room from the corridor, not closing/latching in the frame with installed hardware.

NFPA 101, 19.3.6.3.2 Doors in corridor walls shall be provided with suitable means to keep the doors closed.

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The facility failed to maintain clearly marked access to exits. Findings include:
During the survey, the exit sign (passed O.R. Rooms 7 and 8) was observed not to clearly indicate access to the exit.
2000 NFPA 101, 7.10.1.4 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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Based on interviews and observations performed during the survey, the facility failed to provide/maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke. Findings include:

1) The smoke wall was observed with an unsealed penetration which would allow fire and smoke to transfer from one smoke compartment at Four North Nursing Station.

2) Smoke walls were observed unsealed between the top of the wall and the deck above as follows:

a) Inside the closet near room 407
c) Over the smoke doors near room 474
d) Inside room 274
e) Over the single smoke door entering Two South Nursing Station from the corridor
f) Over the smoke door near room 274
g) Over the smoke door near room 255


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3) Non-rated insulation observed as follows:
First Floor: a) Corridor by Pathology/Lab: unsealed penetrations observed above double doors.
b) Corridor by Pharmacy/Atrium: non-rated insulation observed above double doors along top of wall.
c) Inside Pharmacy: non-rated insulation observed above the ceiling tile at center of wall by column.
d) Corridor by Doctors Center: non-rated insulation observed above double doors along top of wall.


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4) Mineral wool was not sealed at the corrugated roof deck at the 45 degree corner at the front corridor from Vascular Holding to Cath. Lab.
5) One conduit not sealed at the end at the Radiology smoke doors at X-Ray Room 6.
Surveyor: Jim Free
6) Unsealed penetrations around a beam in Medical Preparation Room North Tower.

7) Unsealed penetrations around conduit, and computer cable in Out Source Group Room Third Floor North Tower.

8) Unsealed penetrations at the deck by Out Source Group Room Third Floor North Tower.

9) Unsealed penetrations around condui, in Telemetry Office Third Floor South Tower.

10) Unsealed penetrations at the end of a sleeve by CCU Third Floor South Tower.

11) Unsealed penetrations at the end of two sleeve's Patient Room 365 South Tower.

12) Unsealed penetrations around a sleeve also a sprinkler line Two South Stairwell.

13) Unsealed penetrations around a beam, and at the end of a sleeve by Nurses' Station Two North at Patient Room 229.

14) Unsealed penetrations around (2) sections of conduit by the West End of the Nursey Two North Tower.

NFPA 101, Section 8.3.6: Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (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 for 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 sleeveshall 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 conditions: 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.

2000 NFPA 101, 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.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to provide/maintain required smoke doors that will close flush in the door frame. Findings include:

A) A door closure with a hold-open feature (not a magnetic hold open device) was observed on the smoke wall, single door near Four South Nursing Station which did not allow the door to close automatically upon fire alarm activation.


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B) First Floor:
1) Corridor by Dining Room: double doors did not self-close due to door coordinator.
2) Corridor by Pharmacy: double doors did not close smoke-tight at upper left side of right door.


NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.

.NFPA 101, Section 8.3.4.1: Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Based on observations performed during the survey, the facility failed to separate hazardous areas in accordance with NFPA 101, Section 19.3.2.1. Findings include:

1)The door of the Soiled Utility Room near room 272 was observed with unsealed holes at the door knob.


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2) The following door was observed without required self-closing hardware:
First Floor Doctors' Lounge: food storage area observed without self- closing hardware.


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3)During the survey, the following storage rooms were over 50 sq. ft., sprinklered, but did not have self-closing devices on the doors:
a. Sleep Study Storage Room next to room 12
b. Cardiac Testing "Computer Room" Storage Room
c. C.T. Storage Room at "CAT Scan 2"
Surveyor: Jim Free

d. Med Room Storage door had been removed in CCU.

e. Patient room 236 North Tower has been converted to combustible storage, closing device not provided for the door.

f. Janitor Clost, 65 sq. feet used for combustible storage (2)North Tower in Labor/Delivery.

NFPA 101, Section 19.3.2.1: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following: (1) Boiler and Fuel-Fired Heater Rooms, (2) Central/bulk laundries larger than 100 ft2 (9.3 m2), (3) Paint Shops, (4) Repair Shops, (5) Soiled Linen Rooms, (6) Trash Collection Rooms, (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction, (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard

The facility failed to provide/maintain stairways with at least 1 hour fire resistance rating. Findings include:

An unsealed sprinkler pipe penetration was observed in the Fourth Floor North Stairwell wall.

NFPA 101, 19.3.1.1, 8.2.5.2* Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

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The facility failed to provide a reliable means of egress to the public way. Based upon observation during the survey, the following findings include:

1. The Exit from Generator Set/Controls Room.

2. The Exit from the Boiler Room.

NFPA 101, 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.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to provide/maintain fire barriers that limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include:

1) Fire walls were observed unsealed between the top of the wall and the deck above as follows:
a) Over the fire doors entering the Fourth Floor North Wing (only rock wool)
b) Over the fire doors entering the Center Connecting Corridor from Two South
c) Fire barrier inside the Storage Room at the entrance to Four North

NFPA 101, 7.2.4.3.1 Requires a continuous building separation at a two-hour resistance rating.


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2) During the survey, the following was observed:
Cath. Lab. Locker Room - 2 hour fire rated wall:
a. One unsealed penetration
b. One unsealed penetration around a pipe
c. One unsealed end of a pipe
3) Electrical Room at the Cath. Lab., front corridor - 2 hour rated fire wall:
a. Two conduits not sealed at the ends (left of the door)
b. Three unsealed penetrations around conduits (left of the door)
2000 NFPA 101, 19.2.2.5 Horizontal exits complying with 7.2.4 and the modifications of 19.2.2.5.1 through 19.2.2.5.4 shall be permitted.
2000 NFPA 101, 7.2.4.3.1 Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)
2000 NFPA 101, 8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1)The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2)Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3)* Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:

Based on observations and interviews performed during the survey, the facility failed to conduct fire drills under varied conditions. Findings include:
First Shift: 8:36 am (4/26/10), 8:24 am (1/19/10), 8:38 am (10/6/09), 8:30 am (7/9/09)
Second Shift: 8:08 pm (2/9/10), 8:00 pm (11/12/09, 8/19/09, 5/25/09)
Third Shift: 5:45 am (3/10/10), 5:30 am (12/10/09, 6/10/09), 5:00 am (8/17/09)
NFPA 101, Section 19.7.1.2: Fire drills shall be conducted under varied conditions.

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The facility failed to provide a fire alarm system per code. Findings include:

During the survey, the following was observed:
1. The corridor visual fire alarm devices were not in sync. and were approximately 30'-0" apart throughout the facility.

1999 NFPA 72, 4-4.4.2.3 In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.
Surveyor: Jim Free
2. A local audible/visual signal/alarm did not annunciate in the facility at a location which is staffed continuously for the automatic dialer function of the fire alarm system for line interruption during the survey.

NFPA 101 Sections 19.3.4.1 and 9.6. The indication shall be an audible and visual notification at location where it is likely to be heard in the facility.

The facility failed to maintain the fire alarm system in proper working order. Findings include:

1) Audible Notification Appliances were observed not working as follows:
a) 1-SIG-104 near the Transcription Office, First Floor
b) 1-SIG-103 near Radiology #6, First Floor
c) 1-SIG-102 near Radiology #3, First Floor
d) 1-SIG-105 near Employee Health Hallway, First Floor
e) 1-SIG-106 near Employee Health Hallway, First Floor
f) 1-SIG-107 near Employee Health Hallway, First Floor

NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.

2) The Elevator Recall failed to operate as observed on the South Tower while testing the fire alarm.

NFPA 72 National Fire Alarm Code, 1999 Edition 3-9.3.2 Each elevator lobby, elevator hoistway, and Elevator Machine Room smoke detector or other automatic fire detection as permitted by 3-9.3.5 shall be capable of initiating elevator recall when all other devices on the same initiating device circuit have been manually or automatically placed in the alarm condition.

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Based on observations performed during the survey, the facility failed to comply with NFPA 13. Findings include:
Ceiling tile observed missing in the following sprinklered areas on the first floor: Accounting Closet, Electrical Closet by Nursing Administration, and Electrical Closet by Nutrition Classroom.
NFPA 13, Section 5-6.4.1.1: (Standard Pendent and Upright Spray Sprinklers) Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm). Exception: Ceiling-type sprinklers (concealed, recessed, and flush types) shall be permitted to have the operating element above the ceiling and the deflector located nearer to the ceiling where installed in accordance with their listing.
NFPA 101, Section 5-6.4.1.2: (Standard Pendent and Upright Spray Sprinklers) Under obstructed construction, the sprinkler deflector shall be located within the horizontal planes of 1 in. to 6 in. (25.4 mm to 152 mm) below the structural members and a maximum distance of 22 in. (559 mm) below the ceiling/roof deck. Exception No. 1: Sprinklers shall be permitted to be installed with the deflector at or above the bottom of the structural member to a maximum of 22 in. (559 mm) below the ceiling/roof deck where the sprinkler is installed in conformance with 5-6.5.1.2. Exception No. 2: Where sprinklers are installed in each bay of obstructed construction, deflectors shall be permitted to be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) below the ceiling. Exception No. 3: Sprinkler deflectors shall be permitted to be 1 in. to 6 in. below composite wood joists to a maximum distance of 22 in. below the ceiling/roof deck only where joist channels are fire-stopped to the full depth of the joists with material equivalent to the web construction so that individual channel areas do not exceed 300 ft2 (27.9 m2). Exception No. 4: *Deflectors of sprinklers under concrete tee construction with stems spaced less than 71/2 ft (2.3 m) but more than 3 ft (0.9 m) on centers shall, regardless of the depth of the tee, be permitted to be located at or above a horizontal plane 1 in. (25.4 mm) below the bottom of the stems of the tees and shall comply with Table 5-6.5.1.2.
NFPA 101, Section 5-8.4.1.1: (Extended Coverage Upright and Pendent Spray Sprinklers) Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm). Exception No. 1: Ceiling-type sprinklers (concealed, recessed, and flush types) shall be permitted to have the operating element above the ceiling and the deflector located nearer to the ceiling where installed in accordance with their listing. Exception No. 2: Where sprinklers are listed for use under other ceiling construction features or for different distances, they shall be permitted to be installed in accordance with their listing.
NFPA 13, Section 5-8.4.1.2: (Extended Coverage Upright and Pendent Spray Sprinklers) Under obstructed construction, the sprinkler deflector shall be located 1 in. to 6 in. (25.4 mm to 152 mm) below the structural members and a maximum distance of 22 in. (559 mm) below the ceiling/roof deck. Exception No. 1: Sprinklers shall be permitted to be installed with the deflector at or above the bottom of the structural member to a maximum of 22 in. (559 mm) below the ceiling/roof deck where the sprinkler is installed in conformance with 5-6.5.1.2. Exception No. 2: Where sprinklers are installed in each bay of obstructed construction, deflectors shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) below the ceiling. Exception No. 3: Where sprinklers are listed for use under other ceiling construction features or for different distances, they shall be permitted to be installed in accordance with their listing.
1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.



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The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, several ceiling tiles were observed missing in the smaller Equipment Room in Interventional Radiology Room 1.

2000 NFPA 101, 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.

2000 NFPA 101, 9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
Surveyor: Jim Free
During the survey, the Electrical Clost across from MICU waiting area, observed to have missing ceiling tiles.
2000 NFPA 101, 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.
During the suvey, the following locations failed to provide sprinkler coverage:
1. Conference Room/Break Room in MICU 3.
2. The Asst. Plant Operations Director Office had lay in ceiling tile with upright sprinklers above the ceiling.
3. Two South Breeze Electrical Closet, not provide with proper coverage.
2000 NFPA 101, 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.
2000 NFPA 101, 9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The facility failed to maintain the sprinkler system. Findings include:

1) Wires were observed attached to sprinkler piping with electrical tie wraps in the following locations:
a) Room 429
b) Room 407
c) Room 418 Bath Room
d) Room 435

1998 NFPA 25, 2-2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

2) The facility failed to provide/maintain sprinkler coverage. Findings include:

Sprinkler coverage was observed not provided near the "SICU" in the corridor next to the elevator on the low part of the ceiling. (Sprinkler head was observed on the high level of the two different ceiling levels)

NFPA 13, 5-6.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge.


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3) During the survey, the following locations were missing escutcheon plates:
a. E.R. Emergency Department Director Office
b. E.R. Corridor at X-Ray
c. E.R. Doctors' Lounge - Bathroom
d. EMS Lounge - Bathroom
e. C.T. Storage Room at CAT Scan 2
f. C.T. Pantry

1999 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
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a) The facility failed to protect fire/smoke wall duct penetrations. Findings include:

1) The damper inside room 406 was observed with the Activation Arm disconnected.

2) An access panel was not observed in the duct over the closet door at Two South Nursing Station.

NFPA 101, 9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A.

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



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b) Based on observation and interviews performed during the survey, the facility failed to provide smoke dampers in accordance with NFPA 90A. Findings include:
1. Staff at the facility informed the Surveyor of deficiencies with several smoke dampers. Document review verified this. Deficiencies were cited on the Inspection and Test Report dated February 9-12, 2010. Procurement records for March 22, 2010, indicated the facility was taking corrective action.
2. First Floor, Corridor by Respiratory / Nursing Administration: Damper failed to close during activation of the fire alarm and nearby smoke detection devices.
NFPA 101, Section 8.3.5.2: Smoke dampers in ducts penetrating smoke barriers shall close upon detection of smoke by approved smoke detectors in accordance with NFPA 72, National Fire Alarm Code.
NFPA 90A, Section 4-3.1 Smoke dampers shall be controlled by an automatic alarm initiating device.
NFPA 90A, Section 3-3.5.2: Where penetration of a smoke barrier is required to be provided with a fire damper, a combination fire and smoke damper equipped and arranged to be both smoke responsive and heat responsive shall be permitted.


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c) The facility failed to maintain the HVAC System per code. Findings include:

During the survey, the following was observed:
1. The HVAC duct (at the Cancer Center doors) penetrating the smoke barrier separating the front corridor from the Cancer Center was observed not to have a smoke damper.
2. The smoke damper at the smoke doors at the front corridor for Endo. did not close upon activation of the fire alarm.

1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier.
1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
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The facility failed to maintain the means of egress per code. Findings include:

1) During the survey, the "Trash Corridor" was observed with obstructions blocking the means of egress.
Surveyor: Jim Free
2) During the survey, (2) cabinets were observed in the means of egress by the Nursey (2) North Tower.
2000 NFPA 101, 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.

The facility failed to provide proper storage of oxygen cylinders. Findings include:

An "E" cylinder was observed stored in the Storage Room near room 273, which is not the dedicated storage area according to staff.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately with appropriate signage.

CGA g-4, 4.1.1. Cylinders shall be in a definitely assigned location.

Alabama Department of Public Health Memo dated 4/25/03. Health Care Facility Oxygen Storage Requirements, d.1. A single cylinder of any size may be kept indoors, secured to a mobile carrier, where required for emergency use (such as one cylinder at each nurses' station).

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The facility failed to provide smoke venting per code. Findings include:

During the survey, none of the twenty windowless O.R.s could be verified having a smoke venting system.

2000 NFPA 101, 19.3.2.3 Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
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Based on observations performed during the survey, the facility failed to comply with NFPA 70. Findings include:
A. Electrical cover plates were missing from the following areas on the first floor: inside the elevator pit by the Nutrition Classroom, above the ceiling in the corridor by Rehab / staff elevators.
B. First floor, Computer Technology Office: two power strips were observed "piggy-backed" (One was plugged into the other instead of a receptacle outlet).
1999 NFPA 70, 370-25 and 410-12: Each box in completed installations to have a cover, face plate, or fixture canopy.
1999 NFPA 70, 400-7(b): Each flexible cord to "be energized from a receptacle outlet." Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

C) Based upon observation during the survey, battery-powered lights were not provided for C-Section Rooms 1 and 2, Two North Tower.

1999 NFPA 70, 517-63 Grounded Power Systems in Anesthetizing Locations, (a) Battery-Powered Emergency Lighting Units.

One or more battery-powered emergency lighting units shall be provided in accordance with
Section 700-12(e).


D) Documentation was not provided for annual service of the fire hydrants.

NFPA 25, 4-4.3.1 Hydrants shall be lubricated annually to ensure that all stems, caps, plugs, and threads are in proper operating condition.

The facility failed to maintain a Medical Gas Alarm Panel per code. Findings include:

During the survey, the E.R. Medical Gas Alarm Panel "MGA 1 - 11 Emergency" did not give an audible or a visual alarm when tested.

1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems. (a) * General. 1. All local, master, and area alarm panels used for medical gas systems shall provide the following: a. Separate visual indicators for each condition monitored, b. Cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal.
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The facility failed to provide approved electrical utilities. Findings include:
1) An extension cord was observed extending through the area above the ceiling plugged into a wall receptacle inside the Fourth Floor Bronch Room

NFPA 70, 400-8 Flexible cords and cables shall not be used where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.


2) Junction boxes were observed above the ceiling without a covers as follows:

a) Two inside the Staff Conference Room near room 420
b) Inside the Fourth Floor Clinical Supervisor Office
c) Over the fire doors entering the Center Connecting Corridor from Two South

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover faceplate, or fixture canopy.


3) A microwave oven was observed plugged into overcurrent protected cords in the Employee Lounge on Two South.
Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.


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4) During the survey, the following was observed:
a. Sleep Study Lounge - microwave and refrigerator were plugged into a surge protector.
b. Jon Joiner's Office - refrigerator plugged into a surge protector.
c. Cardiac Testing ("Store Room") - microwave and refrigerator were plugged into an extension cord.
d. PACU Staff Break Room - microwave and refrigerator were plugged into a surge protector.
e. O.R. Employee Lounge - microwave plugged into a surge protector.
f. E.R Admissions - refrigerator plugged into a surge protector.
g. Radiology X-Ray Lounge - refrigerator plugged into a surge protector.
h. Employee Health - refrigerator plugged into a surge protector.
1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle.

Surveyor: Jim Free

5) During the survey, the following was observed:

a. Junction box missing cover above Smoke Doors at CVICU.

b. Several junction boxes missing covers in the Boiler Room.

c. Junction box missing cover above Smoke Doors, Two North by Elevators.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover faceplate or fixture canopy.

Based on observations performed during the survey, the facility failed to comply with ANSI 17.3. Findings include:
Furnishings stored in the Elevator Equipment Room by the Lobby.
ASME A17.3-2008, Section 2.2: Equipment that is not used in connection with operation of the elevator shall not be added to the enclosed area of the Elevator Machine and Control Equipment Room.

The facility failed to provide/maintain corridor doors which would close and resist the passage of smoke. Findings include:

The door of "OR" #14 was observed with a gap at the top of the door allowing viewing into the room from the corridor, not closing/latching in the frame with installed hardware.

NFPA 101, 19.3.6.3.2 Doors in corridor walls shall be provided with suitable means to keep the doors closed.

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The facility failed to maintain clearly marked access to exits. Findings include:
During the survey, the exit sign (passed O.R. Rooms 7 and 8) was observed not to clearly indicate access to the exit.
2000 NFPA 101, 7.10.1.4 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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Based on interviews and observations performed during the survey, the facility failed to provide/maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke. Findings include:

1) The smoke wall was observed with an unsealed penetration which would allow fire and smoke to transfer from one smoke compartment at Four North Nursing Station.

2) Smoke walls were observed unsealed between the top of the wall and the deck above as follows:

a) Inside the closet near room 407
c) Over the smoke doors near room 474
d) Inside room 274
e) Over the single smoke door entering Two South Nursing Station from the corridor
f) Over the smoke door near room 274
g) Over the smoke door near room 255


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3) Non-rated insulation observed as follows:
First Floor: a) Corridor by Pathology/Lab: unsealed penetrations observed above double doors.
b) Corridor by Pharmacy/Atrium: non-rated insulation observed above double doors along top of wall.
c) Inside Pharmacy: non-rated insulation observed above the ceiling tile at center of wall by column.
d) Corridor by Doctors Center: non-rated insulation observed above double doors along top of wall.


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4) Mineral wool was not sealed at the corrugated roof deck at the 45 degree corner at the front corridor from Vascular Holding to Cath. Lab.
5) One conduit not sealed at the end at the Radiology smoke doors at X-Ray Room 6.
Surveyor: Jim Free
6) Unsealed penetrations around a beam in Medical Preparation Room North Tower.

7) Unsealed penetrations around conduit, and computer cable in Out Source Group Room Third Floor North Tower.

8) Unsealed penetrations at the deck by Out Source Group Room Third Floor North Tower.

9) Unsealed penetrations around condui, in Telemetry Office Third Floor South Tower.

10) Unsealed penetrations at the end of a sleeve by CCU Third Floor South Tower.

11) Unsealed penetrations at the end of two sleeve's Patient Room 365 South Tower.

12) Unsealed penetrations around a sleeve also a sprinkler line Two South Stairwell.

13) Unsealed penetrations around a beam, and at the end of a sleeve by Nurses' Station Two North at Patient Room 229.

14) Unsealed penetrations around (2) sections of conduit by the West End of the Nursey Two North Tower.

NFPA 101, Section 8.3.6: Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (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 for 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 sleeveshall 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 conditions: 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.

2000 NFPA 101, 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.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to provide/maintain required smoke doors that will close flush in the door frame. Findings include:

A) A door closure with a hold-open feature (not a magnetic hold open device) was observed on the smoke wall, single door near Four South Nursing Station which did not allow the door to close automatically upon fire alarm activation.


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B) First Floor:
1) Corridor by Dining Room: double doors did not self-close due to door coordinator.
2) Corridor by Pharmacy: double doors did not close smoke-tight at upper left side of right door.


NFPA 101, 19.3.7.6., 8.3.4 Doors in smoke barriers to be self-closing. Doors in smoke barriers shall close the opening in the wall leaving only a minimum clearance to allow door(s) to function properly.

.NFPA 101, Section 8.3.4.1: Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Based on observations performed during the survey, the facility failed to separate hazardous areas in accordance with NFPA 101, Section 19.3.2.1. Findings include:

1)The door of the Soiled Utility Room near room 272 was observed with unsealed holes at the door knob.


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2) The following door was observed without required self-closing hardware:
First Floor Doctors' Lounge: food storage area observed without self- closing hardware.


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3)During the survey, the following storage rooms were over 50 sq. ft., sprinklered, but did not have self-closing devices on the doors:
a. Sleep Study Storage Room next to room 12
b. Cardiac Testing "Computer Room" Storage Room
c. C.T. Storage Room at "CAT Scan 2"
Surveyor: Jim Free

d. Med Room Storage door had been removed in CCU.

e. Patient room 236 North Tower has been converted to combustible storage, closing device not provided for the door.

f. Janitor Clost, 65 sq. feet used for combustible storage (2)North Tower in Labor/Delivery.

NFPA 101, Section 19.3.2.1: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following: (1) Boiler and Fuel-Fired Heater Rooms, (2) Central/bulk laundries larger than 100 ft2 (9.3 m2), (3) Paint Shops, (4) Repair Shops, (5) Soiled Linen Rooms, (6) Trash Collection Rooms, (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction, (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard

The facility failed to provide/maintain stairways with at least 1 hour fire resistance rating. Findings include:

An unsealed sprinkler pipe penetration was observed in the Fourth Floor North Stairwell wall.

NFPA 101, 19.3.1.1, 8.2.5.2* Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

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The facility failed to provide a reliable means of egress to the public way. Based upon observation during the survey, the following findings include:

1. The Exit from Generator Set/Controls Room.

2. The Exit from the Boiler Room.

NFPA 101, 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.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to provide/maintain fire barriers that limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include:

1) Fire walls were observed unsealed between the top of the wall and the deck above as follows:
a) Over the fire doors entering the Fourth Floor North Wing (only rock wool)
b) Over the fire doors entering the Center Connecting Corridor from Two South
c) Fire barrier inside the Storage Room at the entrance to Four North

NFPA 101, 7.2.4.3.1 Requires a continuous building separation at a two-hour resistance rating.


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2) During the survey, the following was observed:
Cath. Lab. Locker Room - 2 hour fire rated wall:
a. One unsealed penetration
b. One unsealed penetration around a pipe
c. One unsealed end of a pipe
3) Electrical Room at the Cath. Lab., front corridor - 2 hour rated fire wall:
a. Two conduits not sealed at the ends (left of the door)
b. Three unsealed penetrations around conduits (left of the door)
2000 NFPA 101, 19.2.2.5 Horizontal exits complying with 7.2.4 and the modifications of 19.2.2.5.1 through 19.2.2.5.4 shall be permitted.
2000 NFPA 101, 7.2.4.3.1 Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)
2000 NFPA 101, 8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1)The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2)Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3)* Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:

Based on observations and interviews performed during the survey, the facility failed to conduct fire drills under varied conditions. Findings include:
First Shift: 8:36 am (4/26/10), 8:24 am (1/19/10), 8:38 am (10/6/09), 8:30 am (7/9/09)
Second Shift: 8:08 pm (2/9/10), 8:00 pm (11/12/09, 8/19/09, 5/25/09)
Third Shift: 5:45 am (3/10/10), 5:30 am (12/10/09, 6/10/09), 5:00 am (8/17/09)
NFPA 101, Section 19.7.1.2: Fire drills shall be conducted under varied conditions.

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The facility failed to provide a fire alarm system per code. Findings include:

During the survey, the following was observed:
1. The corridor visual fire alarm devices were not in sync. and were approximately 30'-0" apart throughout the facility.

1999 NFPA 72, 4-4.4.2.3 In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.
Surveyor: Jim Free
2. A local audible/visual signal/alarm did not annunciate in the facility at a location which is staffed continuously for the automatic dialer function of the fire alarm system for line interruption during the survey.

NFPA 101 Sections 19.3.4.1 and 9.6. The indication shall be an audible and visual notification at location where it is likely to be heard in the facility.

The facility failed to maintain the fire alarm system in proper working order. Findings include:

1) Audible Notification Appliances were observed not working as follows:
a) 1-SIG-104 near the Transcription Office, First Floor
b) 1-SIG-103 near Radiology #6, First Floor
c) 1-SIG-102 near Radiology #3, First Floor
d) 1-SIG-105 near Employee Health Hallway, First Floor
e) 1-SIG-106 near Employee Health Hallway, First Floor
f) 1-SIG-107 near Employee Health Hallway, First Floor

NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.

2) The Elevator Recall failed to operate as observed on the South Tower while testing the fire alarm.

NFPA 72 National Fire Alarm Code, 1999 Edition 3-9.3.2 Each elevator lobby, elevator hoistway, and Elevator Machine Room smoke detector or other automatic fire detection as permitted by 3-9.3.5 shall be capable of initiating elevator recall when all other devices on the same initiating device circuit have been manually or automatically placed in the alarm condition.

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Based on observations performed during the survey, the facility failed to comply with NFPA 13. Findings include:
Ceiling tile observed missing in the following sprinklered areas on the first floor: Accounting Closet, Electrical Closet by Nursing Administration, and Electrical Closet by Nutrition Classroom.
NFPA 13, Section 5-6.4.1.1: (Standard Pendent and Upright Spray Sprinklers) Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm). Exception: Ceiling-type sprinklers (concealed, recessed, and flush types) shall be permitted to have the operating element above the ceiling and the deflector located nearer to the ceiling where installed in accordance with their listing.
NFPA 101, Section 5-6.4.1.2: (Standard Pendent and Upright Spray Sprinklers) Under obstructed construction, the sprinkler deflector shall be located within the horizontal planes of 1 in. to 6 in. (25.4 mm to 152 mm) below the structural members and a maximum distance of 22 in. (559 mm) below the ceiling/roof deck. Exception No. 1: Sprinklers shall be permitted to be installed with the deflector at or above the bottom of the structural member to a maximum of 22 in. (559 mm) below the ceiling/roof deck where the sprinkler is installed in conformance with 5-6.5.1.2. Exception No. 2: Where sprinklers are installed in each bay of obstructed construction, deflectors shall be permitted to be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) below the ceiling. Exception No. 3: Sprinkler deflectors shall be permitted to be 1 in. to 6 in. below composite wood joists to a maximum distance of 22 in. below the ceiling/roof deck only where joist channels are fire-stopped to the full depth of the joists with material equivalent to the web construction so that individual channel areas do not exceed 300 ft2 (27.9 m2). Exception No. 4: *Deflectors of sprinklers under concrete tee construction with stems spaced less than 71/2 ft (2.3 m) but more than 3 ft (0.9 m) on centers shall, regardless of the depth of the tee, be permitted to be located at or above a horizontal plane 1 in. (25.4 mm) below the bottom of the stems of the tees and shall comply with Table 5-6.5.1.2.
NFPA 101, Section 5-8.4.1.1: (Extended Coverage Upright and Pendent Spray Sprinklers) Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm). Exception No. 1: Ceiling-type sprinklers (concealed, recessed, and flush types) shall be permitted to have the operating element above the ceiling and the deflector located nearer to the ceiling where installed in accordance with their listing. Exception No. 2: Where sprinklers are listed for use under other ceiling construction features or for different distances, they shall be permitted to be installed in accordance with their listing.
NFPA 13, Section 5-8.4.1.2: (Extended Coverage Upright and Pendent Spray Sprinklers) Under obstructed construction, the sprinkler deflector shall be located 1 in. to 6 in. (25.4 mm to 152 mm) below the structural members and a maximum distance of 22 in. (559 mm) below the ceiling/roof deck. Exception No. 1: Sprinklers shall be permitted to be installed with the deflector at or above the bottom of the structural member to a maximum of 22 in. (559 mm) below the ceiling/roof deck where the sprinkler is installed in conformance with 5-6.5.1.2. Exception No. 2: Where sprinklers are installed in each bay of obstructed construction, deflectors shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) below the ceiling. Exception No. 3: Where sprinklers are listed for use under other ceiling construction features or for different distances, they shall be permitted to be installed in accordance with their listing.
1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.



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The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, several ceiling tiles were observed missing in the smaller Equipment Room in Interventional Radiology Room 1.

2000 NFPA 101, 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.

2000 NFPA 101, 9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
Surveyor: Jim Free
During the survey, the Electrical Clost across from MICU waiting area, observed to have missing ceiling tiles.
2000 NFPA 101, 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.
During the suvey, the following locations failed to provide sprinkler coverage:
1. Conference Room/Break Room in MICU 3.
2. The Asst. Plant Operations Director Office had lay in ceiling tile with upright sprinklers above the ceiling.
3. Two South Breeze Electrical Closet, not provide with proper coverage.
2000 NFPA 101, 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.
2000 NFPA 101, 9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The facility failed to maintain the sprinkler system. Findings include:

1) Wires were observed attached to sprinkler piping with electrical tie wraps in the following locations:
a) Room 429
b) Room 407
c) Room 418 Bath Room
d) Room 435

1998 NFPA 25, 2-2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

2) The facility failed to provide/maintain sprinkler coverage. Findings include:

Sprinkler coverage was observed not provided near the "SICU" in the corridor next to the elevator on the low part of the ceiling. (Sprinkler head was observed on the high level of the two different ceiling levels)

NFPA 13, 5-6.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge.


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3) During the survey, the following locations were missing escutcheon plates:
a. E.R. Emergency Department Director Office
b. E.R. Corridor at X-Ray
c. E.R. Doctors' Lounge - Bathroom
d. EMS Lounge - Bathroom
e. C.T. Storage Room at CAT Scan 2
f. C.T. Pantry

1999 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
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a) The facility failed to protect fire/smoke wall duct penetrations. Findings include:

1) The damper inside room 406 was observed with the Activation Arm disconnected.

2) An access panel was not observed in the duct over the closet door at Two South Nursing Station.

NFPA 101, 9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A.

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



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b) Based on observation and interviews performed during the survey, the facility failed to provide smoke dampers in accordance with NFPA 90A. Findings include:
1. Staff at the facility informed the Surveyor of deficiencies with several smoke dampers. Document review verified this. Deficiencies were cited on the Inspection and Test Report dated February 9-12, 2010. Procurement records for March 22, 2010, indicated the facility was taking corrective action.
2. First Floor, Corridor by Respiratory / Nursing Administration: Damper failed to close during activation of the fire alarm and nearby smoke detection devices.
NFPA 101, Section 8.3.5.2: Smoke dampers in ducts penetrating smoke barriers shall close upon detection of smoke by approved smoke detectors in accordance with NFPA 72, National Fire Alarm Code.
NFPA 90A, Section 4-3.1 Smoke dampers shall be controlled by an automatic alarm initiating device.
NFPA 90A, Section 3-3.5.2: Where penetration of a smoke barrier is required to be provided with a fire damper, a combination fire and smoke damper equipped and arranged to be both smoke responsive and heat responsive shall be permitted.


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c) The facility failed to maintain the HVAC System per code. Findings include:

During the survey, the following was observed:
1. The HVAC duct (at the Cancer Center doors) penetrating the smoke barrier separating the front corridor from the Cancer Center was observed not to have a smoke damper.
2. The smoke damper at the smoke doors at the front corridor for Endo. did not close upon activation of the fire alarm.

1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier.
1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
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The facility failed to maintain the means of egress per code. Findings include:

1) During the survey, the "Trash Corridor" was observed with obstructions blocking the means of egress.
Surveyor: Jim Free
2) During the survey, (2) cabinets were observed in the means of egress by the Nursey (2) North Tower.
2000 NFPA 101, 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.

The facility failed to provide proper storage of oxygen cylinders. Findings include:

An "E" cylinder was observed stored in the Storage Room near room 273, which is not the dedicated storage area according to staff.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately with appropriate signage.

CGA g-4, 4.1.1. Cylinders shall be in a definitely assigned location.

Alabama Department of Public Health Memo dated 4/25/03. Health Care Facility Oxygen Storage Requirements, d.1. A single cylinder of any size may be kept indoors, secured to a mobile carrier, where required for emergency use (such as one cylinder at each nurses' station).

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The facility failed to provide smoke venting per code. Findings include:

During the survey, none of the twenty windowless O.R.s could be verified having a smoke venting system.

2000 NFPA 101, 19.3.2.3 Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, "Electrical Systems."
.

Based on observations performed during the survey, the facility failed to comply with NFPA 70. Findings include:
A. Electrical cover plates were missing from the following areas on the first floor: inside the elevator pit by the Nutrition Classroom, above the ceiling in the corridor by Rehab / staff elevators.
B. First floor, Computer Technology Office: two power strips were observed "piggy-backed" (One was plugged into the other instead of a receptacle outlet).
1999 NFPA 70, 370-25 and 410-12: Each box in completed installations to have a cover, face plate, or fixture canopy.
1999 NFPA 70, 400-7(b): Each flexible cord to "be energized from a receptacle outlet." Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

C) Based upon observation during the survey, battery-powered lights were not provided for C-Section Rooms 1 and 2, Two North Tower.

1999 NFPA 70, 517-63 Grounded Power Systems in Anesthetizing Locations, (a) Battery-Powered Emergency Lighting Units.

One or more battery-powered emergency lighting units shall be provided in accordance with
Section 700-12(e).


D) Documentation was not provided for annual service of the fire hydrants.

NFPA 25, 4-4.3.1 Hydrants shall be lubricated annually to ensure that all stems, caps, plugs, and threads are in proper operating condition.

The facility failed to maintain a Medical Gas Alarm Panel per code. Findings include:

During the survey, the E.R. Medical Gas Alarm Panel "MGA 1 - 11 Emergency" did not give an audible or a visual alarm when tested.

1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems. (a) * General. 1. All local, master, and area alarm panels used for medical gas systems shall provide the following: a. Separate visual indicators for each condition monitored, b. Cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal.
.

The facility failed to provide approved electrical utilities. Findings include:
1) An extension cord was observed extending through the area above the ceiling plugged into a wall receptacle inside the Fourth Floor Bronch Room

NFPA 70, 400-8 Flexible cords and cables shall not be used where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.


2) Junction boxes were observed above the ceiling without a covers as follows:

a) Two inside the Staff Conference Room near room 420
b) Inside the Fourth Floor Clinical Supervisor Office
c) Over the fire doors entering the Center Connecting Corridor from Two South

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover faceplate, or fixture canopy.


3) A microwave oven was observed plugged into overcurrent protected cords in the Employee Lounge on Two South.
Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.


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4) During the survey, the following was observed:
a. Sleep Study Lounge - microwave and refrigerator were plugged into a surge protector.
b. Jon Joiner's Office - refrigerator plugged into a surge protector.
c. Cardiac Testing ("Store Room") - microwave and refrigerator were plugged into an extension cord.
d. PACU Staff Break Room - microwave and refrigerator were plugged into a surge protector.
e. O.R. Employee Lounge - microwave plugged into a surge protector.
f. E.R Admissions - refrigerator plugged into a surge protector.
g. Radiology X-Ray Lounge - refrigerator plugged into a surge protector.
h. Employee Health - refrigerator plugged into a surge protector.
1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle.

Surveyor: Jim Free

5) During the survey, the following was observed:

a. Junction box missing cover above Smoke Doors at CVICU.

b. Several junction boxes missing covers in the Boiler Room.

c. Junction box missing cover above Smoke Doors, Two North by Elevators.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover faceplate or fixture canopy.