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Facility failed to maintain corridor opening in accordance with the 2000 edition of NFPA 101. Findings included the following:

Surveyor observed during the walk over in the 1st floor Pavilion, 3/11/14, that the blood bank had pass-thru window which was not protected.


28433

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to assure the doors in suites had the required smoke control amenities. At first floor MRI department, pair of suite doors did not have astragals installed to provide a smoke tight seal at the meeting edges of the doors when closed.

Facility failed to maintain hazardous room in accordance with the 2000 edition of NFPA 101. Findings included the following:

Surveyor observed during walkover of the TSP inpatient psychiatric building, 3/11/14, that on the second floor, one of the two corridor doors to the soiled utility room did not have a self closing device.


28433

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the integrity of the egress corridors. Positive latching hardware was not operational at first floor physical therapy exit doors. Additionally, second floor c-section supply room double doors were not latching.



32167

The inspector observed, while accompanied by the Hospital Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 am on 01/12/2014 that a door hold open device (which was not held open by automatic by an automatic release device) was installed on the door of Endoscopy Storage Room on the 3rd floor. This is not in accordance with NFPA 101, 2000: 19.3.6.2 and 19.3.6.3.4.

The inspector observed, while accompanied by the Hospital Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 am on 01/12/2014 that the facility failed to provide a " NO EXIT " sign on the Stair door 19 on the 3rd floor. This is not in accordance with NFPA 101, 2000: 19.2.10.1 and 7.10.8.1.

The inspector observed, while accompanied by the Hospital Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 am on 01/12/2014 that the facility fail to provide fire caulk for the penetration located at the smoke barriers walls at the following locations: 1) On the 3rd floor above the ceiling of the west smoke barrier cross corridor doors out of observation B. 2) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors south of the nurse station of old OR. 3) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors between observation A and C. 4) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors west of old OR suite. 5) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors by the Electrical room 03-0184. 6) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors at the OR ramp. 7) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors east of Endoscopy suite. 8) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors between the Endoscopy waiting room and E3. 9) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors by Staff Recourse E3. 10) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors by Room E313. 11) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors by Room E325.
This is not in accordance with NFPA 101, 2000: 19.3.7.3 and 8.3.6.

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that the facility fail to provide fire caulk for the penetration located at the smoke barriers walls at the following locations: 1) On the eleven floor above the ceiling of the smoke barrier cross corridor doors by the electrical room.

The inspector observed, while accompanied by the Hospital Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 am on 01/12/2014, that the smoke barrier cross corridor doors was not fully closed located at the smoke barriers walls at the following locations: 1) On the 3rd floor the west smoke barrier cross corridor doors out of observation B. 2) On the 3rd floor the smoke barrier cross corridor doors south of the nurse station of old OR suite. 3) On the 3rd floor the smoke barrier cross corridor doors between observation A and C. 4) On the 3rd floor the smoke barrier cross corridor doors by the Stair 3. 5) On the 3rd floor the smoke barrier cross corridor doors north of the Elevator 8 and 9. 6) On the 3rd floor the smoke barrier cross corridor doors west of old OR suite.
This is not in accordance with NFPA 101, 2000: 19.3.7.6.


The inspector observed, while accompanied by the Hospital Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 am on 01/12/2014 that the was a latch installed at the smoke barrier cross corridor doors at the following locations: 1) On the 3rd floor the smoke barrier cross corridor doors south of the nurse station of old OR.
This is not in accordance with NFPA 101, 2000: 19.3.7.6.

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that a door hold open device (which was not held open by an automatic release device) was installed on the door of Soiled Work Room on the 7th and on the 3rd floor. This is not in accordance with NFPA 101, 2000: 19.3.2.1.

Facility failed to maintain storage room which opens to stairs in accordance with the 2000 edition of the Life Safety Code, NFPA (NAtional Fire Protection Association) 101. Findings included the following:

Surveyor observed during walkover in the Pavilion, 3/11/14, that 6th floor storage room opens to stair. This is not in accordance with NFPA 101, 2000: 7.1.3.2.1(d).

Based on observations during the survey walk of the facility on the afternoon of 3/10/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to provide egress direction. No exit sign existed at lower level ' s ob office department. No exit sign existed at lower level ' s arcade corridor, outside of medical records department.


Based on observations during the survey walk of the facility on the afternoon of 3/10/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain egress directional signage. Exit sign ' s chevron (directional arrow) led staff from first floor pharmacy dispensing area through its storage (hazardous) room to the exit egress door. This egress path is not a required exit and people shall not exit through a hazardous room.


Based on observations during the survey walk of the facility on the morning and afternoon of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to provide egress direction. No signage existed at 1) garage stair ' s solid door. Going through this door, down the stairs leads into an area which has no exit. This also occurred at the gate leading to lower level in exit stair 18 and first floor ' s clinic stair. NFPA 101 .....Stairs that continue beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means. The interruption shall be marked " No Exit".


Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to provide egress direction. The exit sign appeared not to be lit at medical records.


Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility did not have an available egress path. IT ' s break room door had an exit sign over it. This door had a lock that required the use of a key to open the door. This is not a required exit.

Based on observations during the survey walk of the facility on the morning of 3/12/2014, with the Plant operation manager, Plant operator, Risk regulatory and Scribe; the facility failed to maintain a clear and unobstructed egress path. Boxes and furniture impeded egress path at second floor L&D resident corridor. This is not a required exit.

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the fire alarm system. The fire alarm system trouble signal light was on at several nodes located on both lower level and first floor. Please explain why.



Based on observations during the survey walk of the facility on the morning of 3/12/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the fire alarm system. When testing the fire alarm system, no strobes existed in the lower level corridor near the library. Additionally the older strobes in the 1938 building were extremely dim when flashing.




32167

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that the facility failed to maintain the fire alarm system. When testing the fire alarm system the older strobes in the 1938 building were extremely dim when flashing on 8th floor purple elevator lobby.

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility ' s fire sprinkler system did not comply with NFPA 13. No sprinkler head existed at lower level ' s plant operation ante room. This was near the lab department.



32167

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that the sprinkler escutcheon plate was missing at the following locations: 1) Medication Room 1127 on the eleventh floor. 2) Staff Lounge 623 on 6th floor. 3) Patient Room 613 on 6th floor. 4) Bio Hazard Room on 4th floor. 5) Electrical room 334 on 3rd floor. 6) Office copy room on 3rd floor.

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that a sprinkler head was missing at the following locations: 1) Under the four-foot ducts at the Mechanical room on eighth floor. 2) Under the four-foot ducts at the Mechanical room 04-0302 on the fourth floor.

This is not in accordance with NFPA 101, 2000: 19.3.5 and NFPA 13.
Escutcheons are part of the listed assembly per 1999 NFPA 13 §3-2.7.2.
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. - NFPA 13, 1999, 5-5.5.3.1.

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the fire alarm system. Sprinkler cage was inside the duct insulation at lower level lab department ' s mechanical room. Additionally, a duct rested directly on a sprinkler head in this mechanical room.


Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the sprinkler system. Paint was on sprinkler head at first floor janitor closet, near purple elevators.
NFPA 13, 2002: 6.2.6.4.4.... Sprinklers that have painted or coated shall be replaced in accordance with the requirements of 6.2.6.2.2 ....Where sprinklers have had paint applied by other than the sprinkler manufacturer, they shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.



Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the fire alarm system. Escutcheon plates used with a recessed or flush-type sprinkler head were not part of a listed assembly at several locations throughout the facility.

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility did not have reliable fire extinguishers. Pressure gauge reading was over charged at first floor dietary ' s bakery extinguisher.

Facitily failed to maintain medical gas storage in accordance with the 1999 edition of the Standard for Health Care, NFPA 99. Findings included the following:

Surveyor observed during walkover of facility, 3/12/14, that in the medical gas storage room approximately six (6) "E" size oxygen cylinders were not secured properly in racks. This is not in accordance with NFPA 99, 1999: 4-3.1.1.2(a)3.

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that the facility failed to provide adequate receptacles and battery powered lighting units.

There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the essential automatic transfer switch location inside the Electrical rooms on 3rd floor, 4th floor, and 10th floor. This is not in accordance with NFPA 99, 1999: 3-4.2.2.2.(b)5. " The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location "

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that there is no separation between dissimilar metal between the copper pipes and the galvanized metal at the following locations: 1) Electrical Rooms on the 10th floor, 8th floor, 7th floor, 6th floor, 5th floor, 4th floor. 2) Mechanical room on the 8th floor,

Based on observations during the survey walk of the facility on the afternoon of 3/11/2014, with the Plant operation manager, Plant operator, Risk regulatory and Scribe; the facility failed to maintain the type I EES system. Electrical panel boards were unlocked at first and second floor green elevator lobby. Additionally MRI #4 panel board was unlocked. These areas do have patients or public access.


Based on observations during the survey walk of the facility on the afternoon of 3/11/2014, with the Plant operation manager, Plant operator, Risk regulatory and Scribe; the facility failed to ensure that the Type I essential electrical service (EES) is in accordance with NFPA 99. Life Safety and Critical branch panel boards did not have a permanent label reading in English what the panel powers. Ensure all panel boards powered by generator are labeled "LIFE SAFETY", "CRITICAL" or "EQUIPMENT", as applicable to identify which branch they serve.



Based on review of records during the survey of facility on the morning of 3/12/2014, with the Facility Management of Plant Operations and Life Safety coordinator, the facility failed to conduct testing of the grounding system biannually in critical care areas. Facility must initiate a log to retain these records.
Receptacle testing in patient care areas was being conducted annually.

Facility failed to maintain essential electrical system components in accordance with the 1999 edtion of the Standard for Health Care, NFPA 99. Findings included the following:

Surveyor observed during the walkover in the JPS Surgical Center- Arlington, 3/12/14, that in the emergency electrical room the life safety branch panel LSL had receptacles and sterlizer circuits in flex conduit which are not allowed in the Life Safety Branch in accordance with NFPA 99, 1999: 3-4.2.2.2 (a) Life Safety Branch. In addition, a critical branch panel, CBLC, in this room had circuits added to panel using flex conduit which does not meet NFPA 99, 3-4.2.2.4(d) Mechanical Protection of the Emergency System.

Facility failed to maintain essential electrical system wiring in accordance with the 1999 edition of the Standard for Health Care, NFPA 99. Findings included the following:

Surveyor observed during the walkover in the Pavilion, 3/11/14, that on the 5th floor, life safety panel LSC M-5, was powering pneumatic tubes. This is not in accordance with NFPA 99, 1999: 4.4.2.2.2.2. Further observed on this floor, an equipment panel did not identify which fan was powering airborne infectious isolation rooms. This is not in accordance with NFPA 99, 1999: 4.4.2.2.3.4.


32167

The inspector observed, while accompanied by the Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 pm on 03/12/2014 that the facility failed to provide receptacles powered from critical branch for the crash cart on the 3rd floor within the cardiology clinic suite.
The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that life safety electrical panel located on 11th floor supply power to AHU which are not allowed in Life Safety Branch panel in accordance with NFPA 99, 1999: 3-4.2.2.2 (a) Life Safety Branch.

Based on observations during the survey walk of the facility on the morning of 3/12/2014, with the Plant operation manager, Plant operator, Risk regulatory and Scribe; the facility failed to provide acceptable location for alcohol based hand rub dispensers at second floor women wing ' s corridor, near breast feed room.

Facility failed to maintain corridor opening in accordance with the 2000 edition of NFPA 101. Findings included the following:

Surveyor observed during the walk over in the 1st floor Pavilion, 3/11/14, that the blood bank had pass-thru window which was not protected.


28433

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to assure the doors in suites had the required smoke control amenities. At first floor MRI department, pair of suite doors did not have astragals installed to provide a smoke tight seal at the meeting edges of the doors when closed.

Facility failed to maintain hazardous room in accordance with the 2000 edition of NFPA 101. Findings included the following:

Surveyor observed during walkover of the TSP inpatient psychiatric building, 3/11/14, that on the second floor, one of the two corridor doors to the soiled utility room did not have a self closing device.


28433

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the integrity of the egress corridors. Positive latching hardware was not operational at first floor physical therapy exit doors. Additionally, second floor c-section supply room double doors were not latching.



32167

The inspector observed, while accompanied by the Hospital Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 am on 01/12/2014 that a door hold open device (which was not held open by automatic by an automatic release device) was installed on the door of Endoscopy Storage Room on the 3rd floor. This is not in accordance with NFPA 101, 2000: 19.3.6.2 and 19.3.6.3.4.

The inspector observed, while accompanied by the Hospital Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 am on 01/12/2014 that the facility failed to provide a " NO EXIT " sign on the Stair door 19 on the 3rd floor. This is not in accordance with NFPA 101, 2000: 19.2.10.1 and 7.10.8.1.

The inspector observed, while accompanied by the Hospital Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 am on 01/12/2014 that the facility fail to provide fire caulk for the penetration located at the smoke barriers walls at the following locations: 1) On the 3rd floor above the ceiling of the west smoke barrier cross corridor doors out of observation B. 2) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors south of the nurse station of old OR. 3) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors between observation A and C. 4) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors west of old OR suite. 5) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors by the Electrical room 03-0184. 6) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors at the OR ramp. 7) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors east of Endoscopy suite. 8) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors between the Endoscopy waiting room and E3. 9) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors by Staff Recourse E3. 10) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors by Room E313. 11) On the 3rd floor above the ceiling of the smoke barrier cross corridor doors by Room E325.
This is not in accordance with NFPA 101, 2000: 19.3.7.3 and 8.3.6.

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that the facility fail to provide fire caulk for the penetration located at the smoke barriers walls at the following locations: 1) On the eleven floor above the ceiling of the smoke barrier cross corridor doors by the electrical room.

The inspector observed, while accompanied by the Hospital Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 am on 01/12/2014, that the smoke barrier cross corridor doors was not fully closed located at the smoke barriers walls at the following locations: 1) On the 3rd floor the west smoke barrier cross corridor doors out of observation B. 2) On the 3rd floor the smoke barrier cross corridor doors south of the nurse station of old OR suite. 3) On the 3rd floor the smoke barrier cross corridor doors between observation A and C. 4) On the 3rd floor the smoke barrier cross corridor doors by the Stair 3. 5) On the 3rd floor the smoke barrier cross corridor doors north of the Elevator 8 and 9. 6) On the 3rd floor the smoke barrier cross corridor doors west of old OR suite.
This is not in accordance with NFPA 101, 2000: 19.3.7.6.


The inspector observed, while accompanied by the Hospital Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 am on 01/12/2014 that the was a latch installed at the smoke barrier cross corridor doors at the following locations: 1) On the 3rd floor the smoke barrier cross corridor doors south of the nurse station of old OR.
This is not in accordance with NFPA 101, 2000: 19.3.7.6.

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that a door hold open device (which was not held open by an automatic release device) was installed on the door of Soiled Work Room on the 7th and on the 3rd floor. This is not in accordance with NFPA 101, 2000: 19.3.2.1.

Facility failed to maintain storage room which opens to stairs in accordance with the 2000 edition of the Life Safety Code, NFPA (NAtional Fire Protection Association) 101. Findings included the following:

Surveyor observed during walkover in the Pavilion, 3/11/14, that 6th floor storage room opens to stair. This is not in accordance with NFPA 101, 2000: 7.1.3.2.1(d).

Based on observations during the survey walk of the facility on the afternoon of 3/10/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to provide egress direction. No exit sign existed at lower level ' s ob office department. No exit sign existed at lower level ' s arcade corridor, outside of medical records department.


Based on observations during the survey walk of the facility on the afternoon of 3/10/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain egress directional signage. Exit sign ' s chevron (directional arrow) led staff from first floor pharmacy dispensing area through its storage (hazardous) room to the exit egress door. This egress path is not a required exit and people shall not exit through a hazardous room.


Based on observations during the survey walk of the facility on the morning and afternoon of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to provide egress direction. No signage existed at 1) garage stair ' s solid door. Going through this door, down the stairs leads into an area which has no exit. This also occurred at the gate leading to lower level in exit stair 18 and first floor ' s clinic stair. NFPA 101 .....Stairs that continue beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means. The interruption shall be marked " No Exit".


Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to provide egress direction. The exit sign appeared not to be lit at medical records.


Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility did not have an available egress path. IT ' s break room door had an exit sign over it. This door had a lock that required the use of a key to open the door. This is not a required exit.

Based on observations during the survey walk of the facility on the morning of 3/12/2014, with the Plant operation manager, Plant operator, Risk regulatory and Scribe; the facility failed to maintain a clear and unobstructed egress path. Boxes and furniture impeded egress path at second floor L&D resident corridor. This is not a required exit.

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the fire alarm system. The fire alarm system trouble signal light was on at several nodes located on both lower level and first floor. Please explain why.



Based on observations during the survey walk of the facility on the morning of 3/12/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the fire alarm system. When testing the fire alarm system, no strobes existed in the lower level corridor near the library. Additionally the older strobes in the 1938 building were extremely dim when flashing.




32167

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that the facility failed to maintain the fire alarm system. When testing the fire alarm system the older strobes in the 1938 building were extremely dim when flashing on 8th floor purple elevator lobby.

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility ' s fire sprinkler system did not comply with NFPA 13. No sprinkler head existed at lower level ' s plant operation ante room. This was near the lab department.



32167

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that the sprinkler escutcheon plate was missing at the following locations: 1) Medication Room 1127 on the eleventh floor. 2) Staff Lounge 623 on 6th floor. 3) Patient Room 613 on 6th floor. 4) Bio Hazard Room on 4th floor. 5) Electrical room 334 on 3rd floor. 6) Office copy room on 3rd floor.

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that a sprinkler head was missing at the following locations: 1) Under the four-foot ducts at the Mechanical room on eighth floor. 2) Under the four-foot ducts at the Mechanical room 04-0302 on the fourth floor.

This is not in accordance with NFPA 101, 2000: 19.3.5 and NFPA 13.
Escutcheons are part of the listed assembly per 1999 NFPA 13 §3-2.7.2.
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. - NFPA 13, 1999, 5-5.5.3.1.

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the fire alarm system. Sprinkler cage was inside the duct insulation at lower level lab department ' s mechanical room. Additionally, a duct rested directly on a sprinkler head in this mechanical room.


Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the sprinkler system. Paint was on sprinkler head at first floor janitor closet, near purple elevators.
NFPA 13, 2002: 6.2.6.4.4.... Sprinklers that have painted or coated shall be replaced in accordance with the requirements of 6.2.6.2.2 ....Where sprinklers have had paint applied by other than the sprinkler manufacturer, they shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.



Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility failed to maintain the fire alarm system. Escutcheon plates used with a recessed or flush-type sprinkler head were not part of a listed assembly at several locations throughout the facility.

Based on observations during the survey walk of the facility on the morning of 3/11/2014, with the Plant operation manager, Patient Safety Officer, Plant operator and Scribe; the facility did not have reliable fire extinguishers. Pressure gauge reading was over charged at first floor dietary ' s bakery extinguisher.

Facitily failed to maintain medical gas storage in accordance with the 1999 edition of the Standard for Health Care, NFPA 99. Findings included the following:

Surveyor observed during walkover of facility, 3/12/14, that in the medical gas storage room approximately six (6) "E" size oxygen cylinders were not secured properly in racks. This is not in accordance with NFPA 99, 1999: 4-3.1.1.2(a)3.

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that the facility failed to provide adequate receptacles and battery powered lighting units.

There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the essential automatic transfer switch location inside the Electrical rooms on 3rd floor, 4th floor, and 10th floor. This is not in accordance with NFPA 99, 1999: 3-4.2.2.2.(b)5. " The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location "

The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that there is no separation between dissimilar metal between the copper pipes and the galvanized metal at the following locations: 1) Electrical Rooms on the 10th floor, 8th floor, 7th floor, 6th floor, 5th floor, 4th floor. 2) Mechanical room on the 8th floor,

Based on observations during the survey walk of the facility on the afternoon of 3/11/2014, with the Plant operation manager, Plant operator, Risk regulatory and Scribe; the facility failed to maintain the type I EES system. Electrical panel boards were unlocked at first and second floor green elevator lobby. Additionally MRI #4 panel board was unlocked. These areas do have patients or public access.


Based on observations during the survey walk of the facility on the afternoon of 3/11/2014, with the Plant operation manager, Plant operator, Risk regulatory and Scribe; the facility failed to ensure that the Type I essential electrical service (EES) is in accordance with NFPA 99. Life Safety and Critical branch panel boards did not have a permanent label reading in English what the panel powers. Ensure all panel boards powered by generator are labeled "LIFE SAFETY", "CRITICAL" or "EQUIPMENT", as applicable to identify which branch they serve.



Based on review of records during the survey of facility on the morning of 3/12/2014, with the Facility Management of Plant Operations and Life Safety coordinator, the facility failed to conduct testing of the grounding system biannually in critical care areas. Facility must initiate a log to retain these records.
Receptacle testing in patient care areas was being conducted annually.

Facility failed to maintain essential electrical system components in accordance with the 1999 edtion of the Standard for Health Care, NFPA 99. Findings included the following:

Surveyor observed during the walkover in the JPS Surgical Center- Arlington, 3/12/14, that in the emergency electrical room the life safety branch panel LSL had receptacles and sterlizer circuits in flex conduit which are not allowed in the Life Safety Branch in accordance with NFPA 99, 1999: 3-4.2.2.2 (a) Life Safety Branch. In addition, a critical branch panel, CBLC, in this room had circuits added to panel using flex conduit which does not meet NFPA 99, 3-4.2.2.4(d) Mechanical Protection of the Emergency System.

Facility failed to maintain essential electrical system wiring in accordance with the 1999 edition of the Standard for Health Care, NFPA 99. Findings included the following:

Surveyor observed during the walkover in the Pavilion, 3/11/14, that on the 5th floor, life safety panel LSC M-5, was powering pneumatic tubes. This is not in accordance with NFPA 99, 1999: 4.4.2.2.2.2. Further observed on this floor, an equipment panel did not identify which fan was powering airborne infectious isolation rooms. This is not in accordance with NFPA 99, 1999: 4.4.2.2.3.4.


32167

The inspector observed, while accompanied by the Senior Manager and one Mechanic II during the hours of the inspection from 8:30 am to 11:30 pm on 03/12/2014 that the facility failed to provide receptacles powered from critical branch for the crash cart on the 3rd floor within the cardiology clinic suite.
The inspector observed, while accompanied by the Life Safety Coordinator and one Mechanic II during the hours of the inspection from 8:30 am to 2:30 pm on 03/11/2014 that life safety electrical panel located on 11th floor supply power to AHU which are not allowed in Life Safety Branch panel in accordance with NFPA 99, 1999: 3-4.2.2.2 (a) Life Safety Branch.