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NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 18, Section 18.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On 8/9/11 between 9:30 AM and 3:30 PM, while inspecting the 2008 Addition, the following observations were made:
A). The elevator machine room located in the 2008 Addition was not equipped with automatic fire sprinklers;
B). The elevator in the 2008 Addition did utilize combustible hydraulic fluid, yet fire sprinklering at the bottom of the elevator hoistway could not be confirmed, as facility staff were unable to access the area.

These findings were confirmed with the chief building engineer [WK].

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On 8/9/11 between 9:30 AM and 3:30 PM, while inspecting the Fire Sprinkler Control Room, observation revealed a segment of piping serving the facility's water softening system, which was suspended from - and supported by - a section of the fire sprinkler branch line. This arrangement was not in conformance with NFPA 13 (1999 edition) Chapter 6, Section 6-1.1.5, requiring [that] fire sprinkler piping shall not be used to support non-system components.

In a fire emergency, this deficient practice could adversely affect the safety of 25 of 25 patients, visitors and staff.

This finding was confirmed with the chief building engineer [WK].

NFPA 101 [2000] LIFE SAFETY CODE SURVEY STANDARD - Required automatic sprinkler systems have valves supervised so that at least a local alarm will sound when the valves are closed, in accordance with NFPA 101 [2000] Chapter 18, Section 18.3.5 and Chapter 9, Section 9.7.2 and NFPA 72 [1999]. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, visitors and staff throughout the facility.

FINDINGS INCLUDE:

On 8/9/11 between 9:30 AM and 3:30 PM, observation revealed a post indicator valve [PIV] located on the southwest corner of the grounds. The PIV was not equipped with an electrically interconnected supervisory attachment, such as a tamper switch. This existing arrangement was not in accordance with the requirements at NFPA 101 [2000] Sections 9.7.2.1 and 9.7.2.2 and NFPA 72 [1999].

This finding was confirmed with the chief building engineer [WK].

NFPA 101 [2000] LIFE SAFETY CODE SURVEY STANDARD - Required automatic sprinkler systems have valves supervised so that at least a local alarm will sound when the valves are closed, in accordance with NFPA 101 [2000] Chapter 19, Section 19.3.5 and Chapter 9, Section 9.7.2 and NFPA 72 [1999]. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, visitors and staff throughout the facility.

FINDINGS INCLUDE:

On 8/9/11 between 9:30 AM and 3:30 PM, observation revealed a post indicator valve [PIV] located on the southwest corner of the grounds. The PIV was not equipped with an electrically interconnected supervisory attachment, such as a tamper switch. This existing arrangement was not in accordance with the requirements at NFPA 101 [2000] Sections 9.7.2.1 and 9.7.2.2 and NFPA 72 [1999].

This finding was confirmed with the chief building engineer [WK].

Based on observation and a staff interview, the facility failed to provide battery-powered emergency lighting at all anesthetizing locations, in accordance with NFPA 101 (2000 edition) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999 edition). In a power failure situation, this deficient practice could adversely affect the safety of an anesthetized patient, rendered incapable of self-preservation.

FINDINGS INCLUDE:

On 8/9/11 between 9:30 AM and 3:30 PM, while inspecting the facility's Operating Room, it was confirmed that no battery-powered emergency lighting units were provided. This arrangement was not in accordance with NFPA 99 (1999 edition) Chapter 3, Section 3-3.2.1.2 (5)(e).

This finding was verified with surgical staff during the survey.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 18, Section 18.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On 8/9/11 between 9:30 AM and 3:30 PM, while inspecting the 2008 Addition, the following observations were made:
A). The elevator machine room located in the 2008 Addition was not equipped with automatic fire sprinklers;
B). The elevator in the 2008 Addition did utilize combustible hydraulic fluid, yet fire sprinklering at the bottom of the elevator hoistway could not be confirmed, as facility staff were unable to access the area.

These findings were confirmed with the chief building engineer [WK].

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On 8/9/11 between 9:30 AM and 3:30 PM, while inspecting the Fire Sprinkler Control Room, observation revealed a segment of piping serving the facility's water softening system, which was suspended from - and supported by - a section of the fire sprinkler branch line. This arrangement was not in conformance with NFPA 13 (1999 edition) Chapter 6, Section 6-1.1.5, requiring [that] fire sprinkler piping shall not be used to support non-system components.

In a fire emergency, this deficient practice could adversely affect the safety of 25 of 25 patients, visitors and staff.

This finding was confirmed with the chief building engineer [WK].

NFPA 101 [2000] LIFE SAFETY CODE SURVEY STANDARD - Required automatic sprinkler systems have valves supervised so that at least a local alarm will sound when the valves are closed, in accordance with NFPA 101 [2000] Chapter 18, Section 18.3.5 and Chapter 9, Section 9.7.2 and NFPA 72 [1999]. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, visitors and staff throughout the facility.

FINDINGS INCLUDE:

On 8/9/11 between 9:30 AM and 3:30 PM, observation revealed a post indicator valve [PIV] located on the southwest corner of the grounds. The PIV was not equipped with an electrically interconnected supervisory attachment, such as a tamper switch. This existing arrangement was not in accordance with the requirements at NFPA 101 [2000] Sections 9.7.2.1 and 9.7.2.2 and NFPA 72 [1999].

This finding was confirmed with the chief building engineer [WK].

NFPA 101 [2000] LIFE SAFETY CODE SURVEY STANDARD - Required automatic sprinkler systems have valves supervised so that at least a local alarm will sound when the valves are closed, in accordance with NFPA 101 [2000] Chapter 19, Section 19.3.5 and Chapter 9, Section 9.7.2 and NFPA 72 [1999]. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, visitors and staff throughout the facility.

FINDINGS INCLUDE:

On 8/9/11 between 9:30 AM and 3:30 PM, observation revealed a post indicator valve [PIV] located on the southwest corner of the grounds. The PIV was not equipped with an electrically interconnected supervisory attachment, such as a tamper switch. This existing arrangement was not in accordance with the requirements at NFPA 101 [2000] Sections 9.7.2.1 and 9.7.2.2 and NFPA 72 [1999].

This finding was confirmed with the chief building engineer [WK].

Based on observation and a staff interview, the facility failed to provide battery-powered emergency lighting at all anesthetizing locations, in accordance with NFPA 101 (2000 edition) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999 edition). In a power failure situation, this deficient practice could adversely affect the safety of an anesthetized patient, rendered incapable of self-preservation.

FINDINGS INCLUDE:

On 8/9/11 between 9:30 AM and 3:30 PM, while inspecting the facility's Operating Room, it was confirmed that no battery-powered emergency lighting units were provided. This arrangement was not in accordance with NFPA 99 (1999 edition) Chapter 3, Section 3-3.2.1.2 (5)(e).

This finding was verified with surgical staff during the survey.