HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the wall and ceiling. This affected one of three buildings, and could result in the increased potential for the spread of fire and smoke to other areas of the facility.

Findings:

During a tour of the facility and interview with ES, the walls and ceilings were observed.

Main Hospital

1. On 5/17/17 at 1:10 p.m., the Business Office Copy Room was observed with an approximately 1/4 inch penetration around a brown wire in the ceiling.

2. On 5/17/17 at 1:15 p.m., the Business Office Restroom Hallway 0072 was observed with an approximately 1/4 inch penetration around a ceiling sprinkler escutcheon ring.

3. On 5/17/17 at 1:17 p.m., the Business Office Old Copy Room was observed with a cover plate loosely hanging, and exposed an approximately 2 inch by 1/2 inch penetration in the wall. In the upper corner ceiling, there was an approximately 1/4 inch penetration around a blue wire.

4. On 5/17/17 at 1:24 p.m., the Business Office 2 was observed with an approximately 2 inch by 2 inch penetration in the wall.

5. On 5/17/17 at 1:39 p.m., the Emergency Service Doctor Office was observed with an approximately 1 inch penetration around a thick gray cord in the ceiling.

6. On 5/17/17 at 1:48 p.m., the Radiology X-Ray Room 2 was observed with four approximately 1/4 inch penetrations in the wall below an electrical equipment.

7. On 5/17/17 at 1:51 p.m., the Radiology Office 0083 was observed with an approximately 1/4 inch penetration around a ceiling sprinkler escutcheon ring.

8. On 5/17/17 at 2 p.m., the Lab was observed with an approximately 3 inch penetration in the southwest wall. The penetration was covered with frail masking tape.

9. On 5/17/17 at 2:01 p.m., the Lab was observed with an approximately 1/2 inch penetration in the northeast corner ceiling around a yellow cord.

10. On 5/17/17 at 2:16 p.m., the Outpatient Surgery Clean Utility Room was observed with an approximately 1/4 inch penetration around a ceiling sprinkler escutcheon ring.

11. On 5/17/17 at 2:34 p.m., OR 2 was observed with an approximately 1/2 inch penetration in the ceiling above the door.

12. On 5/17/17 at 3:21 p.m., the outside Electrical Mechanical Room was observed with an approximately 3 inch penetration in the northeast ceiling with two wires running out.

13. On 5/17/17 at 3:24 p.m., the outside cover by Emergency was observed with an approximately 3 inch penetration in the ceiling.

Upon interview, ES1 confirmed the findings.

Based on observation and interview, the facility failed to maintain the emergency lights. This was evidenced by four emergency lights that failed when tested. This affected one of three buildings, and could result in a loss of lighting during a power outage if the battery back-up lights were to fail.

Findings:

During a tour of the facility and interview with ES, the emergency lights were observed.

Main Hospital

1. On 5/17/17 at 1:36 p.m., two emergency lights in the Emergency Service failed when tested.

2. On 5/17/17 at 2:33 p.m., an emergency light in OR 2 failed when tested.

3. On 5/17/17 at 2:37 p.m., an emergency light in OR 1 failed when tested.

Upon interview, ES1 confirmed the findings.

Based on record review and interview, the facility failed to maintain the exit signs. This was evidenced by failure to perform the required inspections and testing. This affected two of three buildings, and could result in potentially delay evacuation.

NFPA 101 Life Safety Code, 2012 edition
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.
39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.
7.10.9 Testing and Maintenance.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3.
7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding 30 days.
(5) Functional testing shall be conducted annually for a minimum of 11/2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 11/2-hour test.
(7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Computer-based, self-testing/self-diagnostic batteryoperated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 11/2 hours.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3).
(5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times.

Findings:

During record review and interview with ES, the exit signs records were reviewed and requested.

Main Hospital

1. On 5/18/17 at 2:26 p.m., the facility provided a incomplete inspection log for 6/2016. The log failed to show any inspection check mark for all exit signs. Upon interview, ES1 confirmed the finding.

2. On 5/18/17 at 2:27 p.m., the facility was not able to provide current annual testing log for the exit signs at the time of survey. The last annual testing was performed on 9/23/15. Upon interview, ES1 confirmed the finding.

Physical Therapy

3. On 5/18/17 at 2:19 p.m., no monthly inspection of exit sign log was provided at the time of survey. The last monthly inspection was unknown. Upon interview, ES1 confirmed the finding.

4. On 5/18/17 at 2:20 p.m., no annual testing of exit sign log was provided at the time of survey. The last annual testing was unknown. Upon interview, ES1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the hazardous areas.
This was evidenced by doors to the hazardous areas that were not equipped with a self-closing device, and penetrations in the room. This affected one of three buildings, and could result in the increased potential for the spread of fire and/or smoke to other areas.

Findings:

During a tour of the facility and interview with ES, the hazardous areas were observed.

Main Hospital

1. On 5/17/17 at 2:04 p.m., a Lab Storage was observed without a self closing device on the door. The room measured approximately 120 square feet, and there was storage of combustible items such as supplies, boxes, and plastic items.

2. On 5/17/17 at 2:19 p.m., Office Room 1017 was observed with another attached room. The room was housing a fuel fire heater unit. The door was not equipped with a self closure.

3. On 5/17/17 at 2:20 p.m., Office Room 1017 was observed with another attached room. There was an approximately 3 inch penetration observed in the ceiling in the fuel fire heater room.

4. On 5/17/17 at 2:42 p.m., the Surgery Manager office was observed without a self closing device. The room was measured at approximately 200 square feet and was housing combustible items such as supplies, papers, and boxes.

5. On 5/17/17 at 2:44 p.m., Nurse Station 3 Hopper Room was observed without a self closing device. The room had four 35 gallon soiled linen barrels stored in the room.

Upon interview, ES1 confirmed the findings above.

Based on record review and interview, the facility failed to maintain the laboratory. This was evidenced by incomplete fire prevention procedure. This affected one of three buildings and could result in the increased risk of a hazardous condition.

NFPA 99 Health Care Facilities Code, 2012 Edition.
6.6.2 Maintenance Procedures. Maintenance procedures shall be established.
6.6.3 Emergency Plans.
6.6.3.1 Plans for laboratory emergencies shall be developed, which shall include the following:
(3) Shutdown procedures or applicable emergency operations for equipment, processes, ventilation devices, and enclosures

Findings:

During record review and interview with ES, the laboratory procedures were requested.

Main Hospital

1. On 5/18/17 at 2:48 p.m., no laboratory safety equipment shutdown procedure was provided at the time of the survey. Upon interview, ES3 confirmed the finding.

Based on record review and interview, the facility failed to maintain the fire alarm system and components. This was evidenced by no inspection and testing for a fire roll down door. This affected one of three buildings, and result in a delay in notification in the event of a fire emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.7.6 Maintenance and Testing. See 4.6.12
4.6.12 Maintenance, Inspection, and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system,
condition, arrangement, level of protection, fire-resistive
construction, or any other feature is required for compliance
with the provisions of this Code, such device, equipment, system,
condition, arrangement, level of protection, fire-resistive
construction, or other feature shall thereafter be continuously
maintained. Maintenance shall be provided in accordance
with applicable NFPA requirements or requirements developed
as part of a performance-based design, or as directed by
the authority having jurisdiction.

NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 edition
5.2.14.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure.
5.2.14.3.2 A written record shall be maintained and shall be made available to the AHJ.
5.2.14.3.3 When the annual test for proper operation and full closure is conducted, rolling steel fire doors shall be droptested twice.
5.2.14.3.4 The first test shall be to check for proper operation and full closure.
5.2.14.3.5 A second test shall be done to verify that the automatic-closing device has been reset correctly

Findings:

During record review and interview with ES, the fire alarm system and components records was requested.

Main Hospital

1. On 5/18/17 at 1:56 p.m., the facility was observed with a roll down fire door at the Business Office Receptionist Area. No inspection and testing record was provided at the time of record review. The last inspection and testing of the roll down fire door was unknown. Upon interview, ES1 confirmed the finding.

Based on observation, record review, and interview, the facility failed to maintain the battery operated smoke detectors. This was evidenced by failure to test the smoke detectors in accordance with manufacturer specifications. This affected one of three buildings and could result in a malfunction smoke detectors.

NFPA 101, Life Safety Code, 2000 edition
39.1.1.3 General. The provisions of Chapter 4, General, shall apply.
39.3.4.2 Initiation. Initiation of the required fire alarm system
shall be by one of the following means:
(1) Manual means in accordance with 9.6.2.1(1)
(2) Means of an approved automatic fire detection system that complies with 9.6.2.1(2) and provides protection throughout the building
(3) Means of an approved automatic sprinkler system that complies with 9.6.2.1(3) and provides protection throughout the building
4.6.12 Maintenance, Inspection, and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system,
condition, arrangement, level of protection, fire-resistive
construction, or any other feature is required for compliance
with the provisions of this Code, such device, equipment, system,
condition, arrangement, level of protection, fire-resistive
construction, or other feature shall thereafter be continuously
maintained. Maintenance shall be provided in accordance
with applicable NFPA requirements or requirements developed
as part of a performance-based design, or as directed by
the authority having jurisdiction.

NFPA 72, National Fire Alarm Signaling Code, 2010 edition
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.1.2 The inspection, testing, and maintenance of single and multiple-station smoke and heat alarms and household fire alarm systems shall comply with the requirements of this
chapter.
14.2.1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this Code and conform to the equipment manufacturer ' s published instructions.

Findings:

During a tour of the facility, record review, and interview with ES, the battery operated smoke detectors were observed and record was reviewed.

Physical Therapy

1. On 5/18/17 at 2:19 p.m., the facility was observed with two battery operated smoke detectors in the corridor. The facility was not able to provide testing log for the battery operated smoke detector at the time of survey. Upon interview, ES1 confirmed the finding.

Based on observation, record review, and interview, the facility failed to maintain the integrity of the automatic fire sprinkler system. This was evidenced by the failure to maintain the sprinkler heads, and the failure to perform the required sprinkler inspections. This affected two of three buildings, and could result in the ineffective operation of the automatic fire sprinkler system in the event of a fire.

NFPA 101 Life Safety Code, 2012 Edition.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1).
39.1.1.3 General. The provisions of Chapter 4, General, shall apply.
4.6.12 Maintenance, Inspection, and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system,
condition, arrangement, level of protection, fire-resistive
construction, or any other feature is required for compliance
with the provisions of this Code, such device, equipment, system,
condition, arrangement, level of protection, fire-resistive
construction, or other feature shall thereafter be continuously
maintained. Maintenance shall be provided in accordance
with applicable NFPA requirements or requirements developed
as part of a performance-based design, or as directed by
the authority having jurisdiction.
9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in
One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in
Residential Occupancies up to and Including Four Stories in Height
NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition

NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition
6.2.7 Escutcheons and Cover Plates.
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.
6.2.7.3 Cover plates used with concealed sprinklers shall be part of the listed sprinkler assembly.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
Chapter 5 Sprinkler Systems.
4.3 Records.
4.3.1* Records shall be made for all inspections, tests, and maintenance
of the system and its components and shall be made
available to the authority having jurisdiction upon request.
4.3.2 Records shall indicate the procedure performed (e.g.,
inspection, test, or maintenance), the organization that performed
the work, the results, and the date.
5.1.1 Minimum Requirements.
5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be
free of corrosion, foreign materials, paint, and physical damage;
and shall be installed in the correct orientation (e.g., upright,
pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following
shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer
5.2.1.1.3* Any sprinkler that has been installed in the incorrect
orientation shall be replaced that has sign of leakage; is painted; other than by the sprinkler manufacturer; corroded
damaged, or loaded; or is in the improper orientation.
5.2.4 Gauges.
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
13.3.2 Inspection.
13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
Table 13.1.1.2 Summary of Valves, Valve Components, and Trim Inspection, Testing,
and Maintenance.
Inspection-Control Valves: Sealed Weekly, Locked Monthly, Tamper switches Monthly

Findings:

During record review and and interview with ES, the automatic fire sprinkler systems were observed and records were requested.

Burney Annex

1. On 5/18/17 at 11:21 a.m., the facility was not able to provide eight of 12 monthly pressure gauge inspections at the time of survey. The last pressure gauge inspections were performed
on 4/1/17, 6/29/16, 9/17/16, and 12/15/16. Upon interview, ES2 confirmed the findings.

Main Hospital

2. On 5/17/17 at 1:16 p.m., Restroom 0070 was observed with paint on the sprinkler deflector plate.

3. On 5/17/17 at 1:39 p.m., the Emergency Service Hallway was observed with a sprinkler head with heavy foreign material-cobweb build-up.

4. On 5/17/17 at 2:36 p.m., the Anesthesia Surgery Closet near OR 2 was observed missing a sprinkler escutcheon ring. It exposed an approximately 1/2 inch in diameter penetration in the ceiling.

5. On 5/17/17 at 2:37 p.m., one of four sprinklers was missing an escutcheon ring in OR 1. It exposed an approximately 1/4 inch in diameter penetration in the ceiling.

6. On 5/17/17 at 2:46 p.m., one of two sprinkler heads in the Surgery/OB Waiting Room 402 was observed with paint on the deflector plate.

7. On 5/17/17 at 2:53 p.m., the Pharmacy Room 4016 was observed missing a sprinkler escutcheon ring. It exposed an approximately 1 inch in diameter ceiling penetration.

8. On 5/17/17 at 3:24 p.m., the outside cover by Emergency was observed with three of seven sprinkler heads with heavy foreign material-cobweb build up on the deflector plates.

9. On 5/18/17 at 1:52 p.m., the facility was not able to provide four of 12 monthly pressure gauge inspections at the time of survey. The last pressure gauge inspections were performed
on 1/19/17, 2/21/17, 3/15/17, 4/11/17, 6/29/16, 9/14/16, 11/30/16, and 12/13/16. Upon interview, ES1 confirmed the finding.

10. On 5/18/17 at 1:53 p.m., the facility was not able to provide eight of 12 monthly control valve inspections at the time of survey. The last control valve inspections were performed
on 3/15/17, 6/29/16, 9/17/16, and 12/13/16. Upon interview, ES1 confirmed the finding.

11. On 5/18/17 at 3:39 p.m., the Inspector's Test Valve (ITV) located in the Distinct Part of the Skill Nursing (DP SNF) Office was tested. The ITV failed to alarm within 90 seconds, and beyond two minutes. During the second attempt, the ITV alarm within 90 seconds. Upon interview, ES1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the fire extinguishers. This was evidenced by fire extinguishers that were mounted greater than 5 feet above the floor, and by an extinguisher that was missing a service tag. This affected two of three buildings, and could result in the delay in access in the event of a emergency.

NFPA 101 Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all
health care occupancies in accordance with 9.7.4.1.
39.3.5 Extinguishment Requirements. Portable fire extinguishers
shall be provided in every business occupancy in accordance
with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section
of this Code, portable fire extinguishers shall be selected, installed,
inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10 Standard for Portable Fire Extinguisher, 2010 Edition
6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm).
7.3.1.1 All Fire Extinguishers.
7.3.1.1.1 Fire extinguishers shall be subjected to maintenance
at intervals of not more than 1 year, at the time of hydrostatic
test, or when specifically indicated by an inspection or electronic notification

Findings:

Main Hospital

During a tour of the facility and interview with ES, the fire extinguishers were observed.

1. On 5/17/17 at 1:07 p.m., the Lobby fire extinguisher was observed mounted with the handle at approximately 68 inches from the floor.

2. On 5/17/17 at 1:18 p.m., the Business office fire extinguisher was observed mounted with the handle at approximately 70 inches from the floor.

3. On 5/17/17 at 1:26 p.m., Room 0058 fire extinguisher was observed mounted with the handle at approximately 68 inches from the floor.

Physical Therapy

4. On 5/17/17 at 3:29 p.m., a portable fire extinguisher near the Office Manager corridor was observed with missing a service tag.

Upon interview, ES1 confirmed the findings above.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by two doors that were obstructed, four doors with penetrations, and a door that failed to latch. This affected one of three buildings and could result in the inability to contain a fire to a room.

Findings:

During a tour of the facility and interview with ES, the corridor doors were observed.

Main Hospital

1. On 5/17/17 at 1:06 p.m., the self closing door to the Lobby Gift Shop was obstructed by a item cart that prevented the door from closing. The door was equipped with a magnetic hold-open device that interfaced with the automatic fire alarm system.

2. On 5/17/17 at 1:09 p.m., the door to the Business Office was observed with three approximately 1/4 inch penetrations in the door.

3. On 5/17/17 at 1:12 p.m., the roll down door in the Business Office was obstructed by a plastic sign holder that was placed within the path of the door closing.

4. On 5/17/17 at 1:23 p.m., door 0064 by Office 0066 was observed with an approximately 1/4 inch penetration in the door.

5. On 5/17/17 at 2:57 p.m., the door to the Material Environment Serve Room 4007 was observed with an approximately 1/4 inch penetration in the door.

6. On 5/17/17 at 2:29 p.m., the door to the Nurse Station 3 Room 308 was observed with two approximately 1/4 inch penetrations in the door.

7. On 5/1717 at 3:30 p.m., the self closing door to the Private Restroom failed to latch.

Upon interview, ES1 confirmed the findings.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls. This was evidenced by smoke barrier walls that were not protected by sealing penetrations with a fire rated material. This affected one of three buildings, and could potentially allow the spread of smoke and/or fire to other areas of the facility, being unable to defend in-place, exposing residents to a full facility evacuation.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1)This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a)Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b)Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.
8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.
8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.
8.5.6.4 Where sprinklers penetrate a single membrane of a fire resistance-rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 1/2 in. (13 mm), measured between the edge of the membrane and the sprinkler.
8.5.6.5 Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be securely set in the smoke barrier, and the space between the item and the sleeve shall be filled with a material capable of restricting the transfer of smoke.

Findings:

During a tour of the facility with ES, the smoke barrier walls were observed.

Main Hospital

1. On 5/18/17 at 1:50 p.m., the smoke barrier wall located in the attic above the Surgical Waiting Room was observed. There was an approximately 1 inch diameter penetration located in the lower-right wall area with a metal conduit traveling through it, and an approximately 3 inch diameter penetration in the upper left wall area with a metal conduit traveling through it.

2. On 5/18/17 at 2:10 p.m., the smoke barrier wall located in the attic above the Pharmacy Room entry door was observed. There was an approximately 1 inch diameter penetration located in the upper-right area of the wall with 2 metal conduits traveling through it, and an approximately 1/2 inch by 2 inch penetration in the lower left wall with a wood beam traveling through it.

Based on observation and interview, the facility failed to maintain the electrical wiring and connections. This was evidenced by missing cover plates, an obstructed electrical panel, and electrical panels that were not properly labeled. This affected three of three buildings, and could result in an increased risk of an electrical fire.

NFPA 101 Life Safety Code, 2012 edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
39.1.1.3 General. The provisions of Chapter 4, General, shall apply
39.5. Building Services
39.5.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment
shall be in accordance with NFPA 70, National Electrical Code,
unless such installations are approved existing installations,
which shall be permitted to be continued in service.
4.6.12 Maintenance, Inspection, and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system,
condition, arrangement, level of protection, fire-resistive
construction, or any other feature is required for compliance
with the provisions of this Code, such device, equipment, system,
condition, arrangement, level of protection, fire-resistive
construction, or other feature shall thereafter be continuously
maintained. Maintenance shall be provided in accordance
with applicable NFPA requirements or requirements developed
as part of a performance-based design, or as directed by
the authority having jurisdiction.

NFPA 70 National Electrical Code, 2011 edition
110.12 Mechanical Execution of Work. Electrical equipment
shall be installed in a neat and workmanlike manner
(B) Integrity of Electrical Equipment and Connections.
Internal parts of electrical equipment, including busbars,
wiring terminals, insulators, and other surfaces, shall not be
damaged or contaminated by foreign materials such as
paint, plaster, cleaners, abrasives, or corrosive residues.
There shall be no damaged parts that may adversely affect
safe operation or mechanical strength of the equipment
such as parts that are broken; bent; cut; or deteriorated by
corrosion, chemical action, or overheating.
110.22 Identification of Disconnecting Means.
(A) General. Each disconnecting means shall be legibly
marked to indicate its purpose unless located and arranged
so the purpose is evident. The marking shall be of sufficient
durability to withstand the environment involved.
110.26 Spaces About Electrical Equipment. Access and
working space shall be provided and maintained about all
electrical equipment to permit ready and safe operation and
maintenance of such equipment.
(2) Width of Working Space. The width of the working
space in front of the electrical equipment shall be the width
of the equipment or 762 mm (30 in.), whichever is greater.
In all cases, the work space shall permit at least a 90 degree
opening of equipment doors or hinged panels.
408.4 Field Identification Required.
(A) Circuit Directory or Circuit Identification. Every circuit
and circuit modification shall be legibly identified as to
its clear, evident, and specific purpose or use. The identification
shall include sufficient detail to allow each circuit to
be distinguished from all others. Spare positions that contain
unused overcurrent devices or switches shall be described
accordingly. The identification shall be included in
a circuit directory that is located on the face or inside of the
panel door in the case of a panelboard, and located at each
switch or circuit breaker in a switchboard. No circuit shall
be described in a manner that depends on transient conditions
of occupancy.
408.7 Unused Openings. Unused openings for circuit breakers
and switches shall be closed using identified closures, or
other approved means that provide protection substantially
equivalent to the wall of the enclosure.
406.6 Receptacle Faceplates (Cover Plates). Receptacle
faceplates shall be installed so as to completely cover the
opening and seat against the mounting surface.
Receptacle faceplates mounted inside a box having a
recess-mounted receptacle shall effectively close the opening
and seat against the mounting surface.

NFPA 72 National Fire Alarm and signaling Code, 2010 edition
10.5.5.2 Circuit Identification and Accessibility.
10.5.5.2.1 The location of the dedicated branch circuit disconnecting
means shall be permanently identified at the control unit.
10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."
10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.
10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.

Findings:

During a tour of the facility and interview with ES, the electrical wiring and connections were observed.

Burney Annex

1. On 5/18/17 at 9:51 a.m., a corridor electrical panel L had circuit breaker switch 1 that was labeled on the directory list for the fire alarm. There was no red marking on the circuit that identified as the fire alarm circuit control. Upon interview, ES2 confirmed the finding.

Main Hospital

2. On 5/17/17 at 1:25 p.m., Office 0056 was observed with a cracked electrical outlet plate.

3. On 5/17/17 at 1:54 p.m., the Lab/Blood Draw was observed with a cracked electrical outlet plate.

4. On 5/17/17 at 1:55 p.m., the Lab was observed with a cracked electrical light switch plate.

5. On 5/17/17 at 2:48 p.m., a corridor electrical panel EME near Room 404 was observed with circuit breaker switches 20, 21, 23, and 29 that were in the on position, but they were not labeled for anything.

6. On 5/17/17 at 2:49 p.m., a corridor electrical panel H near Room 404 was observed with circuit breaker switches 19, 22, 23, and 24 that were in the on position, but they were not labeled for anything.

7. On 5/17/17 at 2:52 p.m., electrical panel J near Room 4002 was observed with circuit breaker switches 6, 7, 8, 9, 10, 11, and 12 that were in the on position, but they were not labeled for anything.

8. On 5/17/17 at 2:55 p.m., the Purchasing Room was observed missing a cover plate for a junction box in the northeast wall.

9. On 5/17/17 at 3:18 p.m., electrical panel PE-10 located at the outside Electrical Mechanical Room was observed missing a blank after circuit breaker switch 21.

10. On 5/17/17 at 3:19 p.m., electrical panel DP located at the outside Electrical Mechanical Room was observed missing a blank for circuit breaker switch 30.

11. On 5/17/17 at 3:20 p.m., electrical panel POE located at the outside Electrical Mechanical Room was observed with circuit breaker switches 5 and 24 that were in the on position, but they were not labeled for anything.

Physical Therapy

12. On 5/17/17 at 3:34 p.m., a corridor electrical panel was observed missing a blank for circuit breaker switches 29, 42, and 44.

13. On 5/17/17 at 3:35 p.m., Room D was observed missing a cover plate for an electrical outlet.

14. On 5/17/17 at 3:37 p.m., a corridor electrical panel near CFO Office was obstructed by a box that was stationed within approximately one inch in front of it.

Upon interview, ES1 confirmed the findings.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices. This was evidenced by the failure to following manufactured specifications for the portable space heating devices. This affected one of three buildings and could result in the ignition of fire.

Findings:

Main Hospital

During a tour of the facility and interview with ES, the space heaters were observed.

1. On 5/17/17 at 1:13 p.m., the Business Office Front Desk was observed with a portable space heater. The space heater was plugged directly to a wall outlet and it was not turned on.
The manufacturer specification indicated, "High temperature; keep electrical cords, drapery, and other furnishings at least 3 feet from the front of the heater and away from the side and rear." The space heater was stationed within approximately one inch in front of a plastic plant and two inches from the side and rear of a wood desk and a table.

2. On 5/17/17 at 2:15 p.m., the Outpatient Surgery Office was observed with a portable space heater. The space heater was plugged directly into a power strip and it was not turned on.
The manufacturer specification indicated, "High temperature; keep electrical cords, drapery, and other furnishings at least 3 feet from the front of the heater and away from the side and rear." The space heater was stationed within approximately one inch from the side and rear of a wood desk.

Upon interview, ES1 confirmed the findings.

Based on observation, record review, and interview, the facility failed to maintain the electrical system. This was evidenced by no receptacle testing in patient bed locations. This affected one of three buildings, and could result in the risk of electrical fire.

NFPA 99 Health Care Facilities Code, 2012 edition
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient
bed locations and in locations where deep sedation or general
anesthesia is administered, shall be tested at intervals not exceeding
12 months.
6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

Findings:

During record review and interview with ES, the receptacle records were requested.

Physical Therapy

1. On 5/18/17 a 2:18 p.m., four patient room bed locations were observed without hospital grade receptacles. The facility was not able to provide receptacle testing log at the time of survey. The last receptacle testing was unknown. Upon interview, ES1 confirmed the finding.

Based on record review and interview, the facility failed to maintain the electrical power supply (EPS). This was evidenced by failure to perform the require inspections and test. This affected two of three buildings, and could potentially result in a generator failure during an emergency.

NFPA 101 Life Safety Code, 2012 edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
39.5 Building Services.
39.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110 Standard for Emergency and Standby Power Systems, 2010 edition.
8.3.3 A written schedule for routine maintenance and operational
testing of the EPSS shall be established.
8.3.4 A permanent record of the EPSS inspections, tests, exercising,
operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.
8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.
8.4.9* Level 1 EPSS shall be tested at least once within every 36 months.
8.4.9.5 The minimum load for this test shall be as specified in
8.4.9.5.1, 8.4.9.5.2, or 8.4.9.5.3.
8.4.9.5.1 For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement.
8.4.9.5.2 For a diesel-powered EPS, loading shall be that which
maintains the minimum exhaust gas temperatures as recommended
by the manufacturer.
8.4.9.5.3 For spark-ignited EPSs, loading shall be the available
EPSS load.
8.4.9.6 The test required in 8.4.9 shall be permitted to be combined with one of the monthly tests required by 8.4.2 and one of the annual tests required by 8.4.2.3 as a single test.
8.4.9.7 Where the test required in 8.4.9 is combined with the annual load bank test, the first 3 hours shall be at not less than the minimum loading required by 8.4.9.5 and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS.

Findings:

During record review and interview with ES, the generators records were reviewed and requested.

Burney Annex

1. On 5/18/17 at 10:57 a.m., the facility was observed with a diesel fueled 125 kilowatt (KW) generator. The facility was not able to provide monthly testing and recording of electrolyte specific gravity lead-acid battery test. Records of the battery conductance test was not available. Upon interview, ES2 confirmed the finding.

2. On 5/18/17 at 11:04 a.m., the facility was not able to provide weekly inspections from 6/2016, through 11/2016 at the time of survey. Upon interview, ES2 stated the facility at that time was not aware of the weekly inspections requirement.

3. On 5/18/17 at 11:30 a.m., the facility was not able to provide an annual fuel quality testing record for the stored diesel fuel supply at the time of survey. Upon interview, ES2 stated the facility was not aware of the requirement.

Main Hospital

4. On 5/18/17 at 1:39 p.m., the facility was observed with a diesel fueled generator. The facility was not able to provide monthly testing and recording of electrolyte specific gravity lead-acid battery test. Battery conductance testing was not available. Upon interview, ES1 confirmed the finding.

5. On 5/18/17 at 1:40 p.m., the facility was not able to provide weekly inspections from 6/2016 through 11/2016 at the time of survey. Upon interview, ES1 stated the facility at that time was not aware of the weekly inspections requirement.

6. On 5/18/17 at 1:41 p.m., the facility was not able to provide an annual fuel quality testing record for the stored diesel fuel supply at the time of survey. Upon interview, ES1 stated the facility was not aware of the requirement.

7. On 5/18/17 at 1:46 p.m., the facility was observed with a diesel fueled EPS and provide level 1 care. No documentation was available for an every three years, four hour load bank test. Upon interview, ES1 confirmed the findings.

Based on observation and interview, the facility failed to maintain the electrical wiring and connections. This was evidenced by the use of unapproved power strips for medical equipment, power strips suspended off the floor, power strips connected to another power strips, use of extension cords, a power strip that exceed the allowed amperage (AMP).
This affected one of three buildings and could potentially result in electrical shock or the ignition of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of section 9.1
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition.
400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals.
Exception: Listed portable single-pole devices that are intended to accommodate such tension at their terminals shall be permitted to be used with single-conductor flexible cable.
Informational Note: Some methods of preventing pull on a cord from being transmitted to joints or terminals are knotting the cord, winding with tape, and fittings designed for the purpose.

NFPA 99 Health Care Facilities Code, 2012 Edition
10.2.3.6 Multiple Outlet Connection. Two or more power receptacles
supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cartmounted, provided that all of the following conditions are met:
(2)*The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.

Findings:

Main Hospital

During a tour of the facility and interview with ES, the electrical wiring and connections were observed.

1. On 5/17/17 at 1:11 p.m., the Business Copy Room was observed with a 12 amp copy machine equipment plugged into a 15 amp power strip.

2. On 5/17/17 at 1:22 p.m., Office Room 0066 was observed with a power strip that was suspended off the floor and had a coffee maker and a microwave connected to it.

3. On 5/17/17 at 1:30 p.m., Room 0062 was observed with a commercial air conditioner (AC) unit equipment that was connected to a power strip.

4. On 5/17/17 at 1:33 p.m., Triage Room 0061 was observed with a fetal monitor, a suction/vacuum equipment, and a therapeutic bed that were plugged into a non-approved power strip.

5. On 5/17/17 at 1:43 p.m., the Sonogram Imaging/Sleep Room was observed with a power strip connected to another power strip.

6. On 5/17/17 at 1:55 p.m., the Lab was observed with microscope equipment plugged into a extension cord.

7. On 5/17/17 at 2:04 p.m., the Lab Storage was observed with a APC power strip connected to a extension cord, and was plugged into a another extension cord.

8. On 5/17/17 at 2:09 p.m., Nurse Station 1 Break Room was observed with a coffee maker plugged into a power strip.

9. On 5/17/17 at 2:13 p.m., the Outpatient Surgery Small Hallway was observed with a lifepak equipment that was connected to a non-approved power strip.

10. On 5/17/17 at 2:15 p.m., the Outpatient Surgery Office was observed with a power strip that was suspended off the floor.

11. On 5/17/17 at 2:23 p.m., Nurse Station 3 was observed with a computer monitor connected to a extension cord and was plugged into a power strip that was suspended off the floor.

12. On 5/17/17 at 2:26 p.m., Nurse Station 3 Nursery was observed with a radiology monitor connected to a un-approved power strip.

13. On 5/17/17 at 2:33 p.m., OR 2 was observed with a endoscopy television connected to a extension cord and another endoscopy cart connected to a orange extension cord.

14. On 5/17/17 at 2:54 p.m., Purchasing Room 4016 was observed with a refrigerator and toaster equipment connected to a power strip.

15. On 5/17/17 at 2:56 p.m., Purchasing Room 4016 was observed with a power strip suspended off the floor in the north wall.

16. On 5/17/17 at 3 p.m., the Staff Development Room 409 was observed with a microwave and refrigerator connected to a power strip.

17. On 5/17/17 at 3:03 p.m., the Director of Nurse Room 401 was observed with a orange extension cord connected to a power strip.

18. On 5/17/17 at 3:14 p.m., Administration Office 1 was observed with three personal items connected to a white extension cord.

19. On 5/17/17 at 3:15 p.m., Administration Office 3 was observed with a extension cord connected to a power strip.

Upon interview, ES1 confirmed the findings.

Based on observation and interview, the facility failed to maintain the Oxygen Storage. This was evidenced by failure to secure portable cylinder tanks and portable oxygen tanks being stored against a potential source of ignition. This affected two of three buildings and could result in a fire hazard and an unsafe environment due to potential tank damage.

NFPA 101 Life Safety Code, 2012 edition
39.1.1.3 General. The provisions of Chapter 4, General, shall apply.
4.6.12 Maintenance, Inspection, and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system,
condition, arrangement, level of protection, fire-resistive
construction, or any other feature is required for compliance
with the provisions of this Code, such device, equipment, system,
condition, arrangement, level of protection, fire-resistive
construction, or other feature shall thereafter be continuously
maintained. Maintenance shall be provided in accordance
with applicable NFPA requirements or requirements developed
as part of a performance-based design, or as directed by
the authority having jurisdiction.
NFPA 99 Health Care Facilities Code, 2012 edition
11.3 Cylinder and Container Storage Requirements.
11.3.2.7 Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 6.1 m (20 ft) of outside storage locations.
11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(8) Sparks and flame shall be kept away from cylinders.
11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility and interview with ES, the Oxygen Storage were observed.

Burney Annex

1. On 5/18/17 at 3:40 p.m., the outside Oxygen Storage Room was observed with five portable tanks that were free-standing on the floor unsecured. Upon interview, ES2 confirmed the finding.

Main Hospital

2. On 5/17/17 at 1:45 p.m., the X-Ray Room 1 was observed with a unsecured E cylinder tank that was free-standing on the floor.

3. On 5/17/17 at 3:11 p.m., the Oxygen/Riser Room was observed with an electrical light switch that was installed at approximately 48 inches high from the floor level. There were 15 E-cylinder tanks store inside the room. Electrical wall fixtures in supply room shall be installed in fixed locations not less than 5 ft above the floor to avoid physical damage.

4. On 5/17/17 at 3:44 p.m., the outside Oxygen Storage was observed with a unsecured D cylinder tank that was free-standing on the concrete floor.

Upon interview, ES1 confirmed the findings.

Based on observation, record review, and interview, the facility failed to maintain oxygen delivery system safety. This was evidenced by the absence of a continuing in-service/training program for all personnel associated with oxygen delivery equipment and maintenance. This affected one of three buildings, and could result in unsafe handling and maintenance of oxygen delivery equipment.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.5.2 Gases in Cylinders and Liquefied Gases in Containers.
11.5.2.1 Qualification and Training of Personnel.
11.5.2.1.1* Personnel concerned with the application and
maintenance of medical gases and others who handle medical
gases and the cylinders that contain the medical gases shall be
trained on the risks associated with their handling and use.
11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel.
11.5.2.1.3 Continuing education programs shall include periodic
review of safety guidelines and usage requirements for
medical gases and their cylinders.
11.5.2.1.4 Equipment shall be serviced only by personnel
trained in the maintenance and operation of the equipment.
11.5.2.1.5 If a bulk cryogenic system is present, the supplier shall provide annual training on its operation.

Findings:

Main Hospital

During a facility tour, interview, and record review with AS, the oxygen delivery equipment was observed, and training records requested.

1. On 5/18/17 at 3:40 p.m., the facility was observed with portable oxygen supply tank delivery, and liquid oxygen reservoir based piped systems. No documentation was available for safety/risk education of all personnel associated with the handling/maintenance of the oxygen delivery systems. Upon interview, AS1 confirmed the findings.

Based on record review and interview, the facility failed to maintain the feature of fire protections. This was evidenced by incomplete fire loss prevention procedure for OR.
This affected one of three buildings and could result in the increased risk of a hazardous condition.

Findings:

During record review and interview with ES, the feature of fire protections were requested and reviewed.

Main Hospital

1. On 5/18/17 at 2:48 p.m., no OR safety procedure for chemical spills and equipment shutdown were provided at the time of survey. Upon interview, ES3 confirmed the finding.