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Based on observation and interview, the facility failed to keep combustibles stored out of an exit stairway in accordance with NFPA 101, 2000 Edition, Sections 38.2.2.3.1 and 7.2.2.5.3. The deficiency affected 1 of 1 stairway.

Findings include:

The north stairway in the Clinic was observed on 10/5/15 at 2:25 p.m. There was a box of plastic bottles full of sand and a plastic garbage container tucked under the exit stairway.¹ ²

In an interview with staff member A, maintenance supervisor, on 10/5/15 at 2:26 p.m., she stated they had just moved the garbage containers in from outdoors due to bear problems. She stated the sand in the bottles was for winter weather so that employees could use them to get out of the parking lots in inclement weather.

¹ NFPA 101, 2000 Edition, Section 38.2.2.3.1; Stairs complying with 7.2.2 shall be permitted.

² NFPA 101, 2000 Edition, Section 7.2.2.5.3; There shall be no enclosed, usable space within an exit enclosure, including under stairs, not shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

Based on observation and interview, the facility failed to keep combustibles stored out of an exit stairway in accordance with NFPA 101, 2000 Edition, Sections 7.1.3.2.3 and 7.2.2.5.3. The deficiency affected 1 of 1 stairways in the hospital.

Findings include:

The south stairway in the hospital was observed on 10/5/15 at 2:15 p.m. There was a box of plastic bottles full of sand and a plastic garbage container tucked under the exit stairway.¹ ²

In an interview with staff member A, maintenance supervisor, on 10/5/15 at 2:16 p.m., she stated they had just moved the garbage containers in from outdoors due to bear problems. She stated the sand in the bottles was for winter weather so that employees could use them to get out of the parking lots in inclement weather.

¹ NFPA 101, 2000 Edition, Section 7.1.3.2.3; An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

² NFPA 101, 2000 Edition, Section 7.2.2.5.3; There shall be no enclosed, usable space within an exit enclosure, including under stairs, not shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

Based on observation, the facility failed to ensure that an automatic sprinkler system was installed in accordance with NFPA 101, 2000 Edition, Section 4.6.12.2 and NFPA 13, 1999 Edition, Sections 5-6.5.3.1. The deficiency could affect one of one smoke compartment for the B Type Occupancy.

Findings include:

The mechanical room, located on the upper level of the B Type Occupancy, was observed on 10/5/15 at 1:50 p.m. The mechanical room which holds the large Heating, Ventilating and Air-Conditioning (HVAC) ducting was observed for proper sprinkler coverage. The supply and return air ducting on the floor is larger than 4 feet across and there is no sprinkler protection beneath the ducting for the four ends of the ducting.¹ ² The ducting measured approximately 12 feet at its widest point and most portions were deeper than 5 feet.

¹ NFPA 101, 2000 Edition, Section 4.6.12.2; Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

² NFPA 13 Standard for Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.3.1; Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place, such as conference tables.

Based on observation and interview, the facility failed to meet the medical gas storage requirements in accordance with NFPA 99, 1999 Edition, Section 4-3.1.1.2 (a) (4) and NFPA 50, 1996 Edition, Section 4-2.1. The deficiencies had the potential to affect both smoke compartments.

Findings include:

1. The oxygen storeroom for the patient care area was observed on 10/5/15 at 11:00 a.m. The electric eye for the light was located at 40 inches from the floor and not the required 60 inches from the floor.¹

2. The medical gas storeroom on the east side of the hospital was observed on 10/5/15 at 11:05 a.m. The amount of stored oxygen would qualify the area as a bulk oxygen storage area as it exceeded 20,000 cubic feet of stored oxygen.²

During an interview with staff member A, maintenance supervisor, on 10/5/15 at 11:07 a.m., she stated that she did not know they were required to perform an annual review for the bulk oxygen storage area.² ³

¹ NFPA 99, 1999 Edition, Section 4-3.1.1.2 (a) (4); The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

² NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites
1996 Edition, Section 1-3 Definitions; Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

³ NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on interview and record review, the facility failed to complete and document a weekly generator inspection as required by NFPA 99, 1999 Edition, Section 3-4.4.2 and NFPA 110, 1999 Edition, Section 6.4.1. This deficiency has potential to affect 2 of 2 smoke compartments and 1 of 1 smoke compartments.

Findings include:

The records for the generator were reviewed on 10/5/15 at 10:30 a.m. The generator that provides emergency lighting and power did not include weekly reviews.¹ ²

During an interview with staff member A, maintenance supervisor, on 10/5/15 at 10:33 a.m., she confirmed with staff that some weekly reports had not been done.

¹ NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-4.1, Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded. Further, Annex A-6-4-1 should be referenced for the type of weekly items that should be reviewed or the manufacturer recommendations should be used.

² NFPA 99, Standard for Health Care Facilities, 1999 Edition, Section 3-4.4.2 Record keeping, A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

Based on observation and interview, the facility failed to keep combustibles stored out of an exit stairway in accordance with NFPA 101, 2000 Edition, Sections 38.2.2.3.1 and 7.2.2.5.3. The deficiency affected 1 of 1 stairway.

Findings include:

The north stairway in the Clinic was observed on 10/5/15 at 2:25 p.m. There was a box of plastic bottles full of sand and a plastic garbage container tucked under the exit stairway.¹ ²

In an interview with staff member A, maintenance supervisor, on 10/5/15 at 2:26 p.m., she stated they had just moved the garbage containers in from outdoors due to bear problems. She stated the sand in the bottles was for winter weather so that employees could use them to get out of the parking lots in inclement weather.

¹ NFPA 101, 2000 Edition, Section 38.2.2.3.1; Stairs complying with 7.2.2 shall be permitted.

² NFPA 101, 2000 Edition, Section 7.2.2.5.3; There shall be no enclosed, usable space within an exit enclosure, including under stairs, not shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

Based on observation and interview, the facility failed to keep combustibles stored out of an exit stairway in accordance with NFPA 101, 2000 Edition, Sections 7.1.3.2.3 and 7.2.2.5.3. The deficiency affected 1 of 1 stairways in the hospital.

Findings include:

The south stairway in the hospital was observed on 10/5/15 at 2:15 p.m. There was a box of plastic bottles full of sand and a plastic garbage container tucked under the exit stairway.¹ ²

In an interview with staff member A, maintenance supervisor, on 10/5/15 at 2:16 p.m., she stated they had just moved the garbage containers in from outdoors due to bear problems. She stated the sand in the bottles was for winter weather so that employees could use them to get out of the parking lots in inclement weather.

¹ NFPA 101, 2000 Edition, Section 7.1.3.2.3; An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

² NFPA 101, 2000 Edition, Section 7.2.2.5.3; There shall be no enclosed, usable space within an exit enclosure, including under stairs, not shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

Based on observation, the facility failed to ensure that an automatic sprinkler system was installed in accordance with NFPA 101, 2000 Edition, Section 4.6.12.2 and NFPA 13, 1999 Edition, Sections 5-6.5.3.1. The deficiency could affect one of one smoke compartment for the B Type Occupancy.

Findings include:

The mechanical room, located on the upper level of the B Type Occupancy, was observed on 10/5/15 at 1:50 p.m. The mechanical room which holds the large Heating, Ventilating and Air-Conditioning (HVAC) ducting was observed for proper sprinkler coverage. The supply and return air ducting on the floor is larger than 4 feet across and there is no sprinkler protection beneath the ducting for the four ends of the ducting.¹ ² The ducting measured approximately 12 feet at its widest point and most portions were deeper than 5 feet.

¹ NFPA 101, 2000 Edition, Section 4.6.12.2; Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

² NFPA 13 Standard for Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.3.1; Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place, such as conference tables.

Based on observation and interview, the facility failed to meet the medical gas storage requirements in accordance with NFPA 99, 1999 Edition, Section 4-3.1.1.2 (a) (4) and NFPA 50, 1996 Edition, Section 4-2.1. The deficiencies had the potential to affect both smoke compartments.

Findings include:

1. The oxygen storeroom for the patient care area was observed on 10/5/15 at 11:00 a.m. The electric eye for the light was located at 40 inches from the floor and not the required 60 inches from the floor.¹

2. The medical gas storeroom on the east side of the hospital was observed on 10/5/15 at 11:05 a.m. The amount of stored oxygen would qualify the area as a bulk oxygen storage area as it exceeded 20,000 cubic feet of stored oxygen.²

During an interview with staff member A, maintenance supervisor, on 10/5/15 at 11:07 a.m., she stated that she did not know they were required to perform an annual review for the bulk oxygen storage area.² ³

¹ NFPA 99, 1999 Edition, Section 4-3.1.1.2 (a) (4); The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

² NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites
1996 Edition, Section 1-3 Definitions; Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

³ NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on interview and record review, the facility failed to complete and document a weekly generator inspection as required by NFPA 99, 1999 Edition, Section 3-4.4.2 and NFPA 110, 1999 Edition, Section 6.4.1. This deficiency has potential to affect 2 of 2 smoke compartments and 1 of 1 smoke compartments.

Findings include:

The records for the generator were reviewed on 10/5/15 at 10:30 a.m. The generator that provides emergency lighting and power did not include weekly reviews.¹ ²

During an interview with staff member A, maintenance supervisor, on 10/5/15 at 10:33 a.m., she confirmed with staff that some weekly reports had not been done.

¹ NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-4.1, Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded. Further, Annex A-6-4-1 should be referenced for the type of weekly items that should be reviewed or the manufacturer recommendations should be used.

² NFPA 99, Standard for Health Care Facilities, 1999 Edition, Section 3-4.4.2 Record keeping, A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.