HospitalInspections.org

Based on tests to doors and observations made during the survey for life safety from fire with the safety department director(employee #14) and safety officer (employee #11), it was determined that the facility failed to ensure that the mechanic room door , boiler room door and housekeeping closets doors in the first floor, x-ray surgery, emergency departments, respiratory care area, medicine AA ward and medicine BB ward can resist the passage of smoke in accordance with the 2012 edition of the Life Safety Code of the NFPA Section 8.3.4.1 as evidenced by louvers on these doors.

Findings include:

1. A mechanic room located in the first floor beside the elevators was observed on 2/24/15 at 9:00 am with louvers on its door that open in the corridor. In the event of a fire in this area, this door would not resist the passage of smoke to the outside corridor.

2. The boiler room located in the first floor on front the mechanic room was observed on 2/24/15 at 9:00 am with louvers on its door that open in the corridor. In the event of a fire in this area, this door would not resist the passage of smoke to the outside corridor.

3.Electrical room located in the X-Ray department besides the x-ray rooms was observed on 2/24/15 at 3:00 pm until 3:25 pm has wooden door and the two supplies storages has wooden doors with louvers that open in the corridor. In the event of a fire in this area, this door would not resist the passage of smoke to the outside corridor.

4. Electrical room located in front the emergency room admission area on 2/24/15 at 1:35 pm has wooden door and the electrical panel base is in wood. A trash can with water, paint brush and a red cloth under the electrical panel was observed. In the event of a fire in this area, this door would not resist the passage of smoke to the outside corridor.
5. In the respiratory care area on 2/26/15 at 11:45 am it was observed the mechanical room with wooden door and louvers.
6. A housekeeping closet located in third floor on medicine AA ward (Oncology) and fourth floor on medicine BB ward with wooden doors and louvers this was observed on 2/26/15 at 5:00 pm. In the event of a fire in this area, this door would not resist the passage of smoke to the outside corridor.

Based on observations made during the survey for life safety from fire with the safety department director (employee #14) and safety officer (employee #11), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided in some areas of the X-ray and nuclear medicine departments, triage rooms, operating suites #1 and #2, nursing station of the observation area of the emergency department and the back exit stairs of the intensive care unit, two emergency lamps did not work in the acute dialysis unit and the facility is not testing existing emergency lighting of the acute dialysis unit and surgery department for 30 seconds monthly and 90 minutes at least once a year as required by the 2012 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency lighting (battery operated lamps) for a period of 90 minutes as determined by the observational tour from 2/24/15 through 2/27/15 from 9:00 am till 5:00 pm in the following areas:
a. The corridor that leads from the X-ray department.
b. The triage rooms of the emergency room.
c. The back nursing station of observation area #2 of the emergency room.
d. Within the X-ray rooms.
e. In operating suites #1 and #2 and the hallways of the surgery department.
f. The back exit staircase of the intensive care unit.
g. The nuclear medicine department.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

Based on observations, record review and interview made during the survey for life safety from fire with the safety department director (employee #14) and safety officer (employee #11), it was determined that the facility failed to ensure that the emergency room and other wards have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2012 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

1. No evidence was found on 2/24/15 at 11:00 am that emergency room personnel have a plan or assignments with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off. All emergency personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

2. Record review performed on 2/27/15 at 7:00 am until 11:00 am revealed that drills performed on 2014 the ER staff participates just in 5 drills. Evidence reveals 2 physician and 1 register nurses participates in the drills performs in 11:00 pm thru 7:00 am shift. Surveyor asked on 2/24/15 to employee # 17 emergency room supervisor for the assignment of duties in case of a fire and it never present the program. On 2/27/15 at 8:00 am surveyor asked to employee # 11 evidence of the assignment of duties in the ER in case of fire. The program never was presented.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the safety officer (employee #11), it was determined that the facility failed to ensure that sufficient fire drills are conducted under varying conditions as evidenced by only eleven fire drills performed out of twelve, as required by LSC 2012 19.7.1.2 (the facility performed four during the 7:00 am until 3:00 pm shifts, four during the 3:00 pm until 11:00 pm shifts and three during the 11:00 pm until 7:00 am shifts).

Findings include:

Written documents about conducted fire drills for the off-site express emergency room were reviewed on 2/27/15 at 7:30 am and it was found that the facility failed to perform at least one fire drill during a twelve month period, at least one quarterly on each shift. The facility has three shifts and provided evidence of eleven fire drills during the past twelve months. The facility performed four fire drills during the 7:00 am until 3:00 pm shifts, four during the 3:00 pm until 11:00 pm shifts and three during the 11:00 pm until 7:00 am shifts. The facility failed to comply with this regulation due to the lack of one fire drill during the third shifts.

Based on observations made during the survey for life safety from fire with safety officer (employee #11), it was determined that the facility failed to ensure that smoke detectors are available in required areas such as office doctor ' s #1,#2 in the ER pediatric area, #3, #4 and #5 in the emergency room for adult, operating suites #5 and #6, pixy room in the emergency room area for adult, medical surgical and nursery storage , office supply in front the emergency room admission area , dirty linen closets of the entire facility and communication room located in the "Institute of Women" in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Office doctors #1, # 2 in pediatric emergency room area and #3, #4 and #5, pixy room and the office supplies storage located in the emergency room were visited on 2/24/15 at 9:30 pm and provided evidence that they do not have smoke detectors.

2. The "Institute of Women" was visited on 2/24/15 at 8:45 am and was observed without a smoke detector in the communication room.

3. During the observational tour of the entire facility from 2/24/15 through 2/27/15 from 8:30 am till 5:00 pm it was determined that all dirty linen closets are not protected as hazardous areas. These closets do not have smoke detectors.

4. Nursery Storage was visited on 2/26/15 at 1:50 pm thru 2:20 pm and was observed without smoke detector.

Based on observations made during the survey for life safety from fire with the facility's safety director (employee #14) and safety officer (employee #11), it was determined that the facility failed to monitor means of egress near the back exit door of the operating room department to ensure that it is maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. On 2/25/15 at 3:45 pm until 4:30 pm the surgery department was visited and provided evidence that the department received the supplies in the morning and were stock in plastic pallet in front of the scrub dispenser. The space between them is less than 3 feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency " .

2.On 2/25/15 at 1:45 pm the observational tour perform at the outside of the facility the operating department exit was observed and provided evidence that the department has a back emergency exit door, it was found that two large movable garbage containers were blocking this exit and the exit door of a nearby staircase. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".
3. On 2/24/15 at 3:45 pm the intensive care unit was visited a clean mechanic ventilator was observed in front of the main exit of the unit blocking part of this exit. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".
4. On 2/26/15 at 11:05 am a red mop cube was observed in front of room #228 (Isolation) pediatric ward blocking part of the door. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".
5. On 2/25/15 at 12:10 pm the OB-Gyn ward a bed was observed in front of room #209 and #210 blocking both exit door room.
During interview with (employee # 28) OB-Gyn coordinator on 2/25/15 at 12:10 pm she states " Room #210 is an isolation room and it was borrowed to a pediatric patient who needs to be isolate. This patient has to use a crib; so physical plant employees move the crib to this room and put the bed on front the door. We have to do this because if we send the bed to another place or other floor another area they take the bed and we lose it " .

"Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

6. On 2/24/15 at 3:00 pm the radiology department was visited and provided evidence that the hallway has a waiting room area with 6 chairs. Also it was used to place stretchers with patients waiting to be attended for the radiologist. At the moment of the tour it was observed 3 stretchers in this exit hallway reducing width of the hallway by more than four feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

7. On 2/24/15 it was observed in the waiting room area " cernimiento" screening for Adult ER area an exit door that separates the hallway of the CPR or critical area cubicles of the ER and the waiting room area " cernimiento " locked limiting the free passage through this door. This door does not have a " No Exit " sign. In the other side of the door it was observed a stretcher with a patient blocking the door and reducing width of the hallway by more than four feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations made during the survey for life safety from fire with the Safety Director Department (employee #14) and safety officer(employee #11) and interview, it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 2012 edition of the Life Safety Code of the NFPA Section 19.7.5.5.
Findings include:
During the observational tour of the entire facility from 2/24/15 through 2/27/15 from 9:00 am until 5:00 pm, it was determined that personnel are using closets to place dirty linen, however they are not protected as hazardous areas. The wings on the second, third and fourth floors, emergency rooms and intensive care units were found with full plastic bags of dirty linen in hampers.
During an interview on 2/24/15 at 10:20 am with the safety director department employee #14 stated that " these closets are used as a holding area until personnel makes their rounds and removes them from the closet. This is temporarily we are working on this. "
These closets do not have smoke detectors connected to the alarm panel or extractors, some doors lack positive latching and these doors must provide a one hour fire-rated barrier. Collection container cannot exceed 32 gallons within any 64 square foot area and these closets are to be protected as a hazardous area. Most of these rooms were not 64 square feet and exceeded the 32 gallon capacity.

Based on observation made during the survey for life from fire with the Safety Director Department (employee # 14) and safety officer (employee#11) , it was determined that the facility failed filling penetrations of smoke barriers by ducts are protected as required by the 2012 edition of the Life Safety Code of the NFPA Section 8.3.6
Findings include:
1. During the touring on 2/24/14 from 9:00 am until 5:00 pm in the electrical room in front of emergency room admissions, electrical room in the radiology area and mechanical room in respiratory therapy unit, pipes crossing the walls and the ceiling without filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

Based on observations during the survey for Life safety from fire with the safety director department (employee #14) and safety officer (employee #11), it was found that the facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to the storage of oxygen tanks, the lack of floor plans in the Emergency Room for adult and pediatric, Radiology area, kitchen hood exhaust system maintenance, fire extinguisher test, defibrillator plugged into a receptacle that is supplied by the essential electrical system, fans without being inspected by the facility and Not an exit needed it in emergency room area.

Findings include:

1. No floor plans were found in the Emergency Room adult area and pediatric area and the Radiology department on 2/24/15 from 9:00 am until 5:00 pm.

2. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the surgery area on 2/25/15 at 3:00 pm 6 type H oxygen tanks were found in a hallway near recovery area.

3. Kitchen's hood exhaust system maintenance was requested on 2/24/15 at 9:00 am, on 2/25/15 at 1:40 pm to employee # 25 and on 2/27/15 at 8: 30 am to employee #14, however no evidence was found of the updated required hood, duct and exhaust fans inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule.
4. Fire extinguisher documentation was reviewed with the safety officer (employee #11) on 2/27/15 from 8:30 am and provided evidence of a monthly check list, but did not include what is performed to test them.

5. Five defibrillators located on the CPR or Intensive care cubicle #1, and #2 on Emergency room adult area and CPR or intensive care in the emergency room pediatric area, second floor pediatric ward on font of pharmacy and room #207 on 2/24/and 2/25/15 at 9:00 until 5:00 pm. The defibrillators were not plugged into a receptacle that is supplied by the essential electrical system (generator).

6. Fans were observed in the second floor; one in the nursery storage and the other one on room #271 in the intensive care unit as observed on 2/24 and 2/25/15 at 9:00 a.m. until 5:00 pm. A total of two fans were observed in the second floor without being inspected by the facility's safety officer and the infection control coordinator.
During interview with employee # 31 on 2/26/15 at 1:55 pm she states after surveyor asked about the fan " In all the floors an areas there is a fan in case of problem with the air conditioning or in case of hurricane. This fan is always located in this storage " .
During interview with employee #19 Intensive care unit supervisor on 2/24/15 at 3:55 pm surveyor asked why a fan is located inside the isolation room. She states " because the room is to hot and the patient and the employee sweat. We have this fan inside the supply storage in case of hurricane o problems with the air conditioning " .
7. A "Not an Exit" sign is needed on front of the door located in the emergency room adult area "Cernimiento " Screening waiting room as observed on 2/24/15 at 10:30 am.
8. The circuit breaker panel located in the electrical room in front of the emergency room admission area it was observed on 2/24/11 at 1:35 pm installed on a wooden base.

9. An oxygen regulator was found hanging from the wall and bended in the cubicle # 1 of the intensive care of the emergency room adult area on 2/24/15 at 11:40 am.

Based on observations and documents reviewed during the survey for life safety from fire with the safety officer (employee #11) and safety director department (employee #14) , it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence was reviewed on 2/27/15 at 8:40 am about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.

Based on tests to doors and observations made during the survey for life safety from fire with the safety department director(employee #14) and safety officer (employee #11), it was determined that the facility failed to ensure that the mechanic room door , boiler room door and housekeeping closets doors in the first floor, x-ray surgery, emergency departments, respiratory care area, medicine AA ward and medicine BB ward can resist the passage of smoke in accordance with the 2012 edition of the Life Safety Code of the NFPA Section 8.3.4.1 as evidenced by louvers on these doors.

Findings include:

1. A mechanic room located in the first floor beside the elevators was observed on 2/24/15 at 9:00 am with louvers on its door that open in the corridor. In the event of a fire in this area, this door would not resist the passage of smoke to the outside corridor.

2. The boiler room located in the first floor on front the mechanic room was observed on 2/24/15 at 9:00 am with louvers on its door that open in the corridor. In the event of a fire in this area, this door would not resist the passage of smoke to the outside corridor.

3.Electrical room located in the X-Ray department besides the x-ray rooms was observed on 2/24/15 at 3:00 pm until 3:25 pm has wooden door and the two supplies storages has wooden doors with louvers that open in the corridor. In the event of a fire in this area, this door would not resist the passage of smoke to the outside corridor.

4. Electrical room located in front the emergency room admission area on 2/24/15 at 1:35 pm has wooden door and the electrical panel base is in wood. A trash can with water, paint brush and a red cloth under the electrical panel was observed. In the event of a fire in this area, this door would not resist the passage of smoke to the outside corridor.
5. In the respiratory care area on 2/26/15 at 11:45 am it was observed the mechanical room with wooden door and louvers.
6. A housekeeping closet located in third floor on medicine AA ward (Oncology) and fourth floor on medicine BB ward with wooden doors and louvers this was observed on 2/26/15 at 5:00 pm. In the event of a fire in this area, this door would not resist the passage of smoke to the outside corridor.

Based on observations made during the survey for life safety from fire with the safety department director (employee #14) and safety officer (employee #11), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided in some areas of the X-ray and nuclear medicine departments, triage rooms, operating suites #1 and #2, nursing station of the observation area of the emergency department and the back exit stairs of the intensive care unit, two emergency lamps did not work in the acute dialysis unit and the facility is not testing existing emergency lighting of the acute dialysis unit and surgery department for 30 seconds monthly and 90 minutes at least once a year as required by the 2012 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency lighting (battery operated lamps) for a period of 90 minutes as determined by the observational tour from 2/24/15 through 2/27/15 from 9:00 am till 5:00 pm in the following areas:
a. The corridor that leads from the X-ray department.
b. The triage rooms of the emergency room.
c. The back nursing station of observation area #2 of the emergency room.
d. Within the X-ray rooms.
e. In operating suites #1 and #2 and the hallways of the surgery department.
f. The back exit staircase of the intensive care unit.
g. The nuclear medicine department.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

Based on observations, record review and interview made during the survey for life safety from fire with the safety department director (employee #14) and safety officer (employee #11), it was determined that the facility failed to ensure that the emergency room and other wards have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2012 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

1. No evidence was found on 2/24/15 at 11:00 am that emergency room personnel have a plan or assignments with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off. All emergency personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

2. Record review performed on 2/27/15 at 7:00 am until 11:00 am revealed that drills performed on 2014 the ER staff participates just in 5 drills. Evidence reveals 2 physician and 1 register nurses participates in the drills performs in 11:00 pm thru 7:00 am shift. Surveyor asked on 2/24/15 to employee # 17 emergency room supervisor for the assignment of duties in case of a fire and it never present the program. On 2/27/15 at 8:00 am surveyor asked to employee # 11 evidence of the assignment of duties in the ER in case of fire. The program never was presented.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the safety officer (employee #11), it was determined that the facility failed to ensure that sufficient fire drills are conducted under varying conditions as evidenced by only eleven fire drills performed out of twelve, as required by LSC 2012 19.7.1.2 (the facility performed four during the 7:00 am until 3:00 pm shifts, four during the 3:00 pm until 11:00 pm shifts and three during the 11:00 pm until 7:00 am shifts).

Findings include:

Written documents about conducted fire drills for the off-site express emergency room were reviewed on 2/27/15 at 7:30 am and it was found that the facility failed to perform at least one fire drill during a twelve month period, at least one quarterly on each shift. The facility has three shifts and provided evidence of eleven fire drills during the past twelve months. The facility performed four fire drills during the 7:00 am until 3:00 pm shifts, four during the 3:00 pm until 11:00 pm shifts and three during the 11:00 pm until 7:00 am shifts. The facility failed to comply with this regulation due to the lack of one fire drill during the third shifts.

Based on observations made during the survey for life safety from fire with safety officer (employee #11), it was determined that the facility failed to ensure that smoke detectors are available in required areas such as office doctor ' s #1,#2 in the ER pediatric area, #3, #4 and #5 in the emergency room for adult, operating suites #5 and #6, pixy room in the emergency room area for adult, medical surgical and nursery storage , office supply in front the emergency room admission area , dirty linen closets of the entire facility and communication room located in the "Institute of Women" in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Office doctors #1, # 2 in pediatric emergency room area and #3, #4 and #5, pixy room and the office supplies storage located in the emergency room were visited on 2/24/15 at 9:30 pm and provided evidence that they do not have smoke detectors.

2. The "Institute of Women" was visited on 2/24/15 at 8:45 am and was observed without a smoke detector in the communication room.

3. During the observational tour of the entire facility from 2/24/15 through 2/27/15 from 8:30 am till 5:00 pm it was determined that all dirty linen closets are not protected as hazardous areas. These closets do not have smoke detectors.

4. Nursery Storage was visited on 2/26/15 at 1:50 pm thru 2:20 pm and was observed without smoke detector.

Based on observations made during the survey for life safety from fire with the facility's safety director (employee #14) and safety officer (employee #11), it was determined that the facility failed to monitor means of egress near the back exit door of the operating room department to ensure that it is maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. On 2/25/15 at 3:45 pm until 4:30 pm the surgery department was visited and provided evidence that the department received the supplies in the morning and were stock in plastic pallet in front of the scrub dispenser. The space between them is less than 3 feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency " .

2.On 2/25/15 at 1:45 pm the observational tour perform at the outside of the facility the operating department exit was observed and provided evidence that the department has a back emergency exit door, it was found that two large movable garbage containers were blocking this exit and the exit door of a nearby staircase. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".
3. On 2/24/15 at 3:45 pm the intensive care unit was visited a clean mechanic ventilator was observed in front of the main exit of the unit blocking part of this exit. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".
4. On 2/26/15 at 11:05 am a red mop cube was observed in front of room #228 (Isolation) pediatric ward blocking part of the door. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".
5. On 2/25/15 at 12:10 pm the OB-Gyn ward a bed was observed in front of room #209 and #210 blocking both exit door room.
During interview with (employee # 28) OB-Gyn coordinator on 2/25/15 at 12:10 pm she states " Room #210 is an isolation room and it was borrowed to a pediatric patient who needs to be isolate. This patient has to use a crib; so physical plant employees move the crib to this room and put the bed on front the door. We have to do this because if we send the bed to another place or other floor another area they take the bed and we lose it " .

"Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

6. On 2/24/15 at 3:00 pm the radiology department was visited and provided evidence that the hallway has a waiting room area with 6 chairs. Also it was used to place stretchers with patients waiting to be attended for the radiologist. At the moment of the tour it was observed 3 stretchers in this exit hallway reducing width of the hallway by more than four feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

7. On 2/24/15 it was observed in the waiting room area " cernimiento" screening for Adult ER area an exit door that separates the hallway of the CPR or critical area cubicles of the ER and the waiting room area " cernimiento " locked limiting the free passage through this door. This door does not have a " No Exit " sign. In the other side of the door it was observed a stretcher with a patient blocking the door and reducing width of the hallway by more than four feet. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations made during the survey for life safety from fire with the Safety Director Department (employee #14) and safety officer(employee #11) and interview, it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 2012 edition of the Life Safety Code of the NFPA Section 19.7.5.5.
Findings include:
During the observational tour of the entire facility from 2/24/15 through 2/27/15 from 9:00 am until 5:00 pm, it was determined that personnel are using closets to place dirty linen, however they are not protected as hazardous areas. The wings on the second, third and fourth floors, emergency rooms and intensive care units were found with full plastic bags of dirty linen in hampers.
During an interview on 2/24/15 at 10:20 am with the safety director department employee #14 stated that " these closets are used as a holding area until personnel makes their rounds and removes them from the closet. This is temporarily we are working on this. "
These closets do not have smoke detectors connected to the alarm panel or extractors, some doors lack positive latching and these doors must provide a one hour fire-rated barrier. Collection container cannot exceed 32 gallons within any 64 square foot area and these closets are to be protected as a hazardous area. Most of these rooms were not 64 square feet and exceeded the 32 gallon capacity.

Based on observation made during the survey for life from fire with the Safety Director Department (employee # 14) and safety officer (employee#11) , it was determined that the facility failed filling penetrations of smoke barriers by ducts are protected as required by the 2012 edition of the Life Safety Code of the NFPA Section 8.3.6
Findings include:
1. During the touring on 2/24/14 from 9:00 am until 5:00 pm in the electrical room in front of emergency room admissions, electrical room in the radiology area and mechanical room in respiratory therapy unit, pipes crossing the walls and the ceiling without filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

Based on observations during the survey for Life safety from fire with the safety director department (employee #14) and safety officer (employee #11), it was found that the facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to the storage of oxygen tanks, the lack of floor plans in the Emergency Room for adult and pediatric, Radiology area, kitchen hood exhaust system maintenance, fire extinguisher test, defibrillator plugged into a receptacle that is supplied by the essential electrical system, fans without being inspected by the facility and Not an exit needed it in emergency room area.

Findings include:

1. No floor plans were found in the Emergency Room adult area and pediatric area and the Radiology department on 2/24/15 from 9:00 am until 5:00 pm.

2. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the surgery area on 2/25/15 at 3:00 pm 6 type H oxygen tanks were found in a hallway near recovery area.

3. Kitchen's hood exhaust system maintenance was requested on 2/24/15 at 9:00 am, on 2/25/15 at 1:40 pm to employee # 25 and on 2/27/15 at 8: 30 am to employee #14, however no evidence was found of the updated required hood, duct and exhaust fans inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule.
4. Fire extinguisher documentation was reviewed with the safety officer (employee #11) on 2/27/15 from 8:30 am and provided evidence of a monthly check list, but did not include what is performed to test them.

5. Five defibrillators located on the CPR or Intensive care cubicle #1, and #2 on Emergency room adult area and CPR or intensive care in the emergency room pediatric area, second floor pediatric ward on font of pharmacy and room #207 on 2/24/and 2/25/15 at 9:00 until 5:00 pm. The defibrillators were not plugged into a receptacle that is supplied by the essential electrical system (generator).

6. Fans were observed in the second floor; one in the nursery storage and the other one on room #271 in the intensive care unit as observed on 2/24 and 2/25/15 at 9:00 a.m. until 5:00 pm. A total of two fans were observed in the second floor without being inspected by the facility's safety officer and the infection control coordinator.
During interview with employee # 31 on 2/26/15 at 1:55 pm she states after surveyor asked about the fan " In all the floors an areas there is a fan in case of problem with the air conditioning or in case of hurricane. This fan is always located in this storage " .
During interview with employee #19 Intensive care unit supervisor on 2/24/15 at 3:55 pm surveyor asked why a fan is located inside the isolation room. She states " because the room is to hot and the patient and the employee sweat. We have this fan inside the supply storage in case of hurricane o problems with the air conditioning " .
7. A "Not an Exit" sign is needed on front of the door located in the emergency room adult area "Cernimiento " Screening waiting room as observed on 2/24/15 at 10:30 am.
8. The circuit breaker panel located in the electrical room in front of the emergency room admission area it was observed on 2/24/11 at 1:35 pm installed on a wooden base.

9. An oxygen regulator was found hanging from the wall and bended in the cubicle # 1 of the intensive care of the emergency room adult area on 2/24/15 at 11:40 am.

Based on observations and documents reviewed during the survey for life safety from fire with the safety officer (employee #11) and safety director department (employee #14) , it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence was reviewed on 2/27/15 at 8:40 am about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.