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Based on observations made during tour of the facility on February 3, 2010, it was determined that the facility failed to ensure that the exits are readily accessible at all times. This could delay or deny escape from one area of the structure to another or outside.

The findings include:

1. During the tour of the facility with the director of maintenance it observed at 11:20 a.m. two housekeeping carts located in the stairwell. This stairwell was tabled as north stairwell on the 5th floor. The director of maintenance had the carts removed immediately.

2. During the tour of the facility with the director of maintenance it observed at 11:30 a.m. a housekeeping cart located in the stairwell. This stairwell was tabled as west stairwell on the 5th floor. The director of maintenance had the cart removed immediately.

NFPA 101-2000 7.1. 19.2.1
FAC 59A-3

Based on a review of the facility records, and interview with the staff on 02/02/10, it was determined that the facility failed to maintain documentation of the emergency light tests as required. A lack of documentation could cause confusion on the frequency of testing and render the equipment unreliable leading to a delay in safe exiting from the facility in an emergency.

The findings include:

There was no documentation at the time of the survey to show that the emergency lights were being tested for 30 seconds a month and 90 minutes once a year. The director of maintenance stated that they were performing these tests, however they do not document the testing.

NFPA 101 (2000) 7.9. 19.2.9.1.
FAC 59A-3

Based on observation and staff interview it was determined that University Of Miami Hospital failed to properly maintained the fire sprinkler system. This condition could cause the fire sprinkler system to fail during a fire situation, thus endangering the occupants of the facility.

Findings include:

During the tour of the facility with the director of maintenance on 02/03/2010 in the pharmacy it was observed a painted sprinkler head. This condition was observed at 3:30 p.m.

NFPA 101-2000
NFPA 25, 9.7.5
FAC 59A-3

Based on observations and interview with the director of maintenance between 9:35 a.m. and 10:15 a.m on 02/02/2010, it was determined that the facility failed to ensure that the fire extinguisher signage was available and adequate. This could lead to confusion on proper use.

The findings include:

During the tour of the kitchen area it was observed (4) four K - Type extinguisher without a placard identifying the use of the portable extinguisher as a secondary backup means to the automatic fire-extinguishing system.

10.2 Types of Equipment.
10.2.1 Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.
10.2.2 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire-extinguishing system shall be conspicuously placed near each portable fire extinguisher in the cooking area.
10.2.2.1 The language and wording for the placard shall be approved by the authority having jurisdiction.
10.2.3* Automatic fire-extinguishing systems shall comply with standard UL 300, Standard for Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with the requirements of the listing.


NFPA 101-2000
NFPA 96
FAC 59A-3

K-0130 Infection Control Risk Assessment, (ICRA)

Base on observation and staff interview on 02/02/2010 it was determined the facility failed to maintain a negative pressure within construction work site on the fourth floor. This condition would allow airborne contaminants to travel outside the construction area and could affect occupants within the facility.

The findings include:

During the tour of the facility on 02/02/2010 with the director of maintenance at 9:35 a.m. in the main dish washing room it was observed the area was being remodeled. The director of maintenance explained they are was having a new floor installed. There was no vapor barrier leading into this space or a portable exhaust unit being utilized to duct to the outside atmosphere as required. The next day 02/03/2010 it was observed the facility had installed two portable exhaust units vented to the outside atmosphere. The facility needs to install a vapor barrier equipped with a zipper for entrance and exiting this construction area.

NFPA 101-2000
FAC 59A-3