HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure ceiling tiles were smoke resistant in 1 of 8 smoke compartments. The findings were:

Observation of the information technology data center room on 9/06/11 at 4:52 PM showed there were three ceiling tiles missing, each tile measured 2 feet by 4 feet. At the time of observation the interim maintenance director reported the tiles had been removed more than a week ago to work on the ventilation system. He could not explain why the tiles had not been replaced after the repairs were completed.

Reference:
NFPA 101, 2000 Edition;
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Based on observation and staff interview, the facility failed to ensure corridor walls were continuous from floor to ceiling in 2 of 8 smoke compartments. The findings were:

Periodic observations of the sprinkler system on 9/6/11 and 9/7/11 showed the basement freezer compressor room, swing bed dining room, nurses' lounge, and outpatient electrical closet did not have sprinkler protection. Because of the lack of sprinklers, the basement west smoke compartment, the first floor west smoke compartment, and the first floor north smoke compartments, were defined as partially sprinkled. Review of the corridor walls in these areas showed the walls were not continuous from floor to ceiling. Each smoke compartment had more than 8 unsealed conduit and pipe penetrations in the corridor walls. On 9/6/11 at 4:44 PM the interim maintenance director reported he was not aware corridor walls were required to be sealed in partially sprinkled smoke compartments.

Reference:
NFPA 101, 2000 Edition;
19.3.6.2.1* Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

Based on observation and staff interview, the facility failed to ensure corridor doors were smoke resistant in 2 of 8 smoke compartments. The findings were:

1. Observation of patient room #141 on 9/7/11 at 10:33 AM showed the corridor door latch bolt was not able to insert into the strike plate. At the time of observation the interim maintenance director could not explain why this door had not been identified and repaired during the quarterly inspections.

2. Observation of patient room #102 on 9/7/11 at 10:50 AM showed the corridor door had two unsealed 1/2 inch circular holes. At the time of observation, the interim maintenance director reported he was aware of the holes and a cover plate was on order. He confirmed the doors had not been smoke resistant for more than one week, and he was not certain when the cover plates would arrive.

Based on observation and staff interview, the facility failed to ensure 3 of 6 smoke barrier walls were smoke resistant. The findings were:

Observation on 9/7/11 between 3 PM and 4 PM showed the smoke barrier walls above the outpatient double doors, above the mammography office, and above patient room #121, had several unsealed conduit and data wire penetrations. The largest hole measured 2 inches across. At 3:19 PM the interim maintenance director reported the barrier walls were not routinely inspected to ensure they were smoke resistant.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas in 5 of 8 smoke compartments. The findings were:

1. Periodic observations of hazardous areas on 9/6/11-9/7/11 showed the boiler room, cooling tower room, communication room, pharmacy, electrical room #164, and the first floor information technology closet had unsealed penetrations. The largest hole measured 4 inches across. On 9/6/11 at 4:09 PM the interim maintenance director reported hazardous areas were not routinely inspected to ensure they were smoke resistant.

2. Observation of the bio-hazard collection from on 9/6/11 at 4:28 PM showed the room was larger than 50 square feet and the corridor door was not provided with a self-closing device. The room measured 6 feet by 12 feet for a total of 72 square feet. At the time of observation, the interim maintenance director reported the room was converted to a collection room 2 years ago. He also reported that he was aware hazardous areas required self-closing devices. He could not explain why this door was not provided with a closing device.

Based on observation and staff interview, the facility failed to ensure corridors were unobstructed in 1 of 8 smoke compartments. The findings were:

Observation on 9/6/11 between 3 PM and 4:50 PM showed a four level steel rack, a wood pallet, and construction supplies were stored in the basement west corridor. At the time of observatio, the interim maintenance director reported the items were stored in the corridor out of convenience. He also said he was aware items could not be stored in corridors.

Reference:
NFPA 101, 2000 Edition, 19.2.1;
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on record review and staff interview, the facility failed to ensure fire drills were conducted on 1 of 3 shifts. The findings were:

Review of the fire drill records showed the night shift occurred between 6 PM and 6 AM. Further review revealed no documentation that a fire drill had not been conducted on the night shift during the second quarter of 2011. On 9/7/11 at 3:02 PM the interim maintenance director confirmed the fire drill had not been conducted.

Based on observation, record review, and staff interview, the facility failed to ensure alarm initiating devices were wired to the fire alarm panel and failed to ensure smoke detectors were properly mounted in 1 of 8 smoke compartments. The findings were:

1. Observation of the elevator equipment room on 9/6/11 at 5:10 PM showed the isolation valve for the sprinkler system in that room was not wired into the fire alarm control panel. Further observation showed the sprinkler control valve in the elevator shaft was also not wired into the fire alarm control panel. On 9/7/11 at 1:42 PM review of the quarterly sprinkler testing records showed this issue had been noted in the comment section for the past four quarters. During an interview at the time of the record review, the interim maintenance director could not explain why this and other sprinkler system issues had not been addressed.

2. Observation of operating room #2 on 9/6/11 at 5:36 PM showed the smoke detector was hanging from internal wires. At the time of observation, the interim maintenance director reported the surgical staff should have notified the engineering department and placed a work order.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1;
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
NFPA 101, 2000 Edition, 19.3.4.1, 9.6.1.4, NFPA 72, 1999 Edition;
2-1.3.2 In all cases, initiating devices shall be supported independently of their attachment to the circuit conductors.

Based on observation, record review, and staff interview, the facility failed to ensure identification plates were supplied for sprinkler devices, failed to ensure sprinkler heads were unobstructed in 2 of 8 smoke compartments, failed to ensure two spare sprinkler heads were provided for each type installed in the building, and failed to ensure sprinkler devices activated properly. The findings were:

1. Observation of the main sprinkler riser on 9/6/11 at 4:08 PM showed the isolation valve and main drain valve were not posted with indicating signs. The system hydraulic name plate was also not present. Observation of the dry sprinkler system on 9/7/11 at 11:49 AM showed the dry system trim piping valves were not posted with indicating signs. At 1:42 PM review of the quarterly sprinkler testing records showed this issue had been noted in the comment section for the past four quarters. During the review of the records, the interim maintenance director could not explain why this issue had not been addressed.

2. Observation of the sprinkler system on 9/6/11 between 5 PM and 6 PM showed the marketing closet, and basement telephone room, had items stored closer than 18 inches below the sprinkler heads. At the time of observation the interim maintenance director reported the facility staff had been told several times to not store items closer than 18 inches to the sprinkler heads.

3. Review of the spare sprinkler cabinet on 9/6/11 at 4:08 PM showed the facility did not have two spare sprinkler heads for each type of sprinkler installed in the building. There was not a 165 degree pendent security type head to replace the one installed in the emergency room secure room #5. The facility also did not have a sprinkler wrench for each type of sprinkler head installed. At 1:42 PM review of the quarterly sprinkler testing records showed this issue had been noted in the comment section for the past four quarters. During the review of the testing records, the interim maintenance director could not explain why these issues had not been addressed.

4. Review of the sprinkler testing records showed the waterflow alarm took longer than 90 seconds to activate the alarm. Testing conducted on 9/23/10 documented the device took 94 seconds to activate the general fire alarm system. On 9/7/11 at 1:42 PM the interim maintenance director could not explain why the aforementioned reports had not been reviewed and the device modified to meet the requirement.

Reference:
NFPA 101, 2000 Edition, 18.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
10-5 Hydraulic Design Information Sign. The installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
5-5.6. Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 101, 2000 Edition, 18.3.5.1, 9.7.5, NFPA 25, 1999 Edition;
2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 degrees Fahrenheit.
2-4.1.6 A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler installed.
9-2.7 Waterflow alarm. All waterflow alarms shall be tested quarterly in accordance with manufacture's instructions.

NFPA 101, 2000 Edition, 19.3.5.1, 9.6.1.4, NFPA 72, 1999 Edition;
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow and the alarm-initiating device when flow occurs that is equal to or greater than from a single sprinkler of the smallest orifice size installed in the system. Movement or water due to waste, surges, or variable pressure shall not be indicated.

Based on observation and staff interview, the facility failed to ensure portable fire extinguishers were inspected on a monthly basis in 1 of 8 smoke compartments. The findings were:

Observation on 9/6/11 at 5:43 PM showed the two portable fire extinguishers in the operating department sub-sterile room were not inspected for the month of August 2011. At the time of observation, the interim maintenance director reported the day the extinguishers were scheduled to be inspected, the area was unavailable due to surgical cases. He could not explain why the extinguishers had not been inspected later that month.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1, 9.7.4.1, NFPA 10, 1998 Edition;
4-3 Inspection.
4-3.1 Frequency. Extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals ....

Based on observation and staff interview, the facility failed to ensure medical gas cylinders were fastened to prevent accidental falling for 1 of 3 manifold systems. The findings were:

Observation of the nitrous oxide manifold system on 9/6/11 at 4:20 PM showed four "H" sized spare tanks were fastened by a chain that was loosely hanging around the bottom of the cylinders. When checked, the cylinders were not secure and could be tipped, to the point of failing over. At the time of observation the interim maintenance director reported he was aware of the restraint requirement, but could not explain why the chains had not been secured.

Reference:
NFPA 101, 2000 Edition, 19.3.2.3, NFPA 99, 1999 Edition;
4-3 Level 1 Piped Systems.
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (any Quantity; In-storage, Connected, or Both)
3. Provisions shall be made for racks or fastening to protect cylinders from accidental damage or dislocation.

Based on observation and staff interview, the facility failed to ensure the Essential Electrical System (EES) was divided into the Life Safety Branch and the Critical Branch for 2 of 6 EES panels. The findings were:

1. Observation of the Critical Branch electrical panel "BCC" on 9/6/11 at 4:01 PM showed it supplied power to Life Safety equipment, circuit #17 Generac Panel (emergency generator). Further observation showed the panel supplied power to Equipment Branch equipment, circuit #1 Hot water Durarch, #3 Steam Boiler Thermostat, #5 Lavrs Kit Boiler, #6 Water Softener, #7 Outside Lighting, #8 Lawn Sprinkler Control System, #10 Lawn Sprinkler Control Basement, #12 & #14 Flag Pole Lighting and #20 Cooling Tower Receptacles. At the time of observation the interim maintenance director reported he was not aware the EES circuits were required to be divided into separate branch panels. He confirmed the electrical system was last modified in 2009.

2. Observation on 9/7/11 at 12:09 PM showed the Critical Branch electrical panel ICG supplied power to Life Safety equipment, circuit #1, #3, #4, #5, #36, #40, and #42 automatic door openers and #11 fire alarm panel.

Reference:
NFPA 101, 2000 Edition, 18.2.9.2, NFPA 99, 1999 Edition;
3-4.2. Distribution (Type 1 EES)
3-4.2.2.1 General. Type I essential electrical system are comprised of two separate systems capable of supplying a limited amount of lighting and power services, which is considered essential for the life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. They are designated the life safety branch and the critical branch ...
3-4.2.2.2 Emergency System.
(a) General. These functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2 (b) and (c).

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Based on observation and staff interview, the facility failed to ensure a circuit directory was supplied for 1 of 6 Essential Electrical System (EES) panels. The findings were:

Observation of the Life Safety Branch electrical panel "BXB" on 9/6/11 at 3:45 PM showed 16 electrical circuits were installed and 14 were turned to the "ON" position. Further observation showed the panel circuit directory indicating what device or area each circuit supplied power to, was missing. At the time of observation the interim maintenance director said he was not aware the directory was missing.

Reference:
NFPA 101, 2000 Edition, 18.5.1.1, NFPA 70, 1999 Edition;
384-13 ...All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

Based on observation and staff interview, the facility failed to ensure electrical outlets had ground fault circuit interruption (GFCI) in wet locations in 4 of 6 smoke compartments. The findings were:

Periodic observations of the electrical system on 9/6/11-9/7/11 showed the electrical outlet in the basement womens' locker room, endoscope clean up room, cardiology stress test room, and the soiled utility by the nurses' station, were located less than 72 inches to a sink. Further observation showed these outlets did not have GFCI protection. On 9/6/11 at 4:46 PM the interim maintenance director reported he was aware of the GFCI requirement, but could not explain why the aforementioned outlets had not been replaced.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
517-20. Wet Locations. (a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption or power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

Based on observation and staff interview, the facility failed to ensure ceiling tiles were smoke resistant in 1 of 8 smoke compartments. The findings were:

Observation of the information technology data center room on 9/06/11 at 4:52 PM showed there were three ceiling tiles missing, each tile measured 2 feet by 4 feet. At the time of observation the interim maintenance director reported the tiles had been removed more than a week ago to work on the ventilation system. He could not explain why the tiles had not been replaced after the repairs were completed.

Reference:
NFPA 101, 2000 Edition;
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Based on observation and staff interview, the facility failed to ensure corridor walls were continuous from floor to ceiling in 2 of 8 smoke compartments. The findings were:

Periodic observations of the sprinkler system on 9/6/11 and 9/7/11 showed the basement freezer compressor room, swing bed dining room, nurses' lounge, and outpatient electrical closet did not have sprinkler protection. Because of the lack of sprinklers, the basement west smoke compartment, the first floor west smoke compartment, and the first floor north smoke compartments, were defined as partially sprinkled. Review of the corridor walls in these areas showed the walls were not continuous from floor to ceiling. Each smoke compartment had more than 8 unsealed conduit and pipe penetrations in the corridor walls. On 9/6/11 at 4:44 PM the interim maintenance director reported he was not aware corridor walls were required to be sealed in partially sprinkled smoke compartments.

Reference:
NFPA 101, 2000 Edition;
19.3.6.2.1* Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

Based on observation and staff interview, the facility failed to ensure corridor doors were smoke resistant in 2 of 8 smoke compartments. The findings were:

1. Observation of patient room #141 on 9/7/11 at 10:33 AM showed the corridor door latch bolt was not able to insert into the strike plate. At the time of observation the interim maintenance director could not explain why this door had not been identified and repaired during the quarterly inspections.

2. Observation of patient room #102 on 9/7/11 at 10:50 AM showed the corridor door had two unsealed 1/2 inch circular holes. At the time of observation, the interim maintenance director reported he was aware of the holes and a cover plate was on order. He confirmed the doors had not been smoke resistant for more than one week, and he was not certain when the cover plates would arrive.

Based on observation and staff interview, the facility failed to ensure 3 of 6 smoke barrier walls were smoke resistant. The findings were:

Observation on 9/7/11 between 3 PM and 4 PM showed the smoke barrier walls above the outpatient double doors, above the mammography office, and above patient room #121, had several unsealed conduit and data wire penetrations. The largest hole measured 2 inches across. At 3:19 PM the interim maintenance director reported the barrier walls were not routinely inspected to ensure they were smoke resistant.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas in 5 of 8 smoke compartments. The findings were:

1. Periodic observations of hazardous areas on 9/6/11-9/7/11 showed the boiler room, cooling tower room, communication room, pharmacy, electrical room #164, and the first floor information technology closet had unsealed penetrations. The largest hole measured 4 inches across. On 9/6/11 at 4:09 PM the interim maintenance director reported hazardous areas were not routinely inspected to ensure they were smoke resistant.

2. Observation of the bio-hazard collection from on 9/6/11 at 4:28 PM showed the room was larger than 50 square feet and the corridor door was not provided with a self-closing device. The room measured 6 feet by 12 feet for a total of 72 square feet. At the time of observation, the interim maintenance director reported the room was converted to a collection room 2 years ago. He also reported that he was aware hazardous areas required self-closing devices. He could not explain why this door was not provided with a closing device.

Based on observation and staff interview, the facility failed to ensure corridors were unobstructed in 1 of 8 smoke compartments. The findings were:

Observation on 9/6/11 between 3 PM and 4:50 PM showed a four level steel rack, a wood pallet, and construction supplies were stored in the basement west corridor. At the time of observatio, the interim maintenance director reported the items were stored in the corridor out of convenience. He also said he was aware items could not be stored in corridors.

Reference:
NFPA 101, 2000 Edition, 19.2.1;
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on record review and staff interview, the facility failed to ensure fire drills were conducted on 1 of 3 shifts. The findings were:

Review of the fire drill records showed the night shift occurred between 6 PM and 6 AM. Further review revealed no documentation that a fire drill had not been conducted on the night shift during the second quarter of 2011. On 9/7/11 at 3:02 PM the interim maintenance director confirmed the fire drill had not been conducted.

Based on observation, record review, and staff interview, the facility failed to ensure alarm initiating devices were wired to the fire alarm panel and failed to ensure smoke detectors were properly mounted in 1 of 8 smoke compartments. The findings were:

1. Observation of the elevator equipment room on 9/6/11 at 5:10 PM showed the isolation valve for the sprinkler system in that room was not wired into the fire alarm control panel. Further observation showed the sprinkler control valve in the elevator shaft was also not wired into the fire alarm control panel. On 9/7/11 at 1:42 PM review of the quarterly sprinkler testing records showed this issue had been noted in the comment section for the past four quarters. During an interview at the time of the record review, the interim maintenance director could not explain why this and other sprinkler system issues had not been addressed.

2. Observation of operating room #2 on 9/6/11 at 5:36 PM showed the smoke detector was hanging from internal wires. At the time of observation, the interim maintenance director reported the surgical staff should have notified the engineering department and placed a work order.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1;
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
NFPA 101, 2000 Edition, 19.3.4.1, 9.6.1.4, NFPA 72, 1999 Edition;
2-1.3.2 In all cases, initiating devices shall be supported independently of their attachment to the circuit conductors.

Based on observation, record review, and staff interview, the facility failed to ensure identification plates were supplied for sprinkler devices, failed to ensure sprinkler heads were unobstructed in 2 of 8 smoke compartments, failed to ensure two spare sprinkler heads were provided for each type installed in the building, and failed to ensure sprinkler devices activated properly. The findings were:

1. Observation of the main sprinkler riser on 9/6/11 at 4:08 PM showed the isolation valve and main drain valve were not posted with indicating signs. The system hydraulic name plate was also not present. Observation of the dry sprinkler system on 9/7/11 at 11:49 AM showed the dry system trim piping valves were not posted with indicating signs. At 1:42 PM review of the quarterly sprinkler testing records showed this issue had been noted in the comment section for the past four quarters. During the review of the records, the interim maintenance director could not explain why this issue had not been addressed.

2. Observation of the sprinkler system on 9/6/11 between 5 PM and 6 PM showed the marketing closet, and basement telephone room, had items stored closer than 18 inches below the sprinkler heads. At the time of observation the interim maintenance director reported the facility staff had been told several times to not store items closer than 18 inches to the sprinkler heads.

3. Review of the spare sprinkler cabinet on 9/6/11 at 4:08 PM showed the facility did not have two spare sprinkler heads for each type of sprinkler installed in the building. There was not a 165 degree pendent security type head to replace the one installed in the emergency room secure room #5. The facility also did not have a sprinkler wrench for each type of sprinkler head installed. At 1:42 PM review of the quarterly sprinkler testing records showed this issue had been noted in the comment section for the past four quarters. During the review of the testing records, the interim maintenance director could not explain why these issues had not been addressed.

4. Review of the sprinkler testing records showed the waterflow alarm took longer than 90 seconds to activate the alarm. Testing conducted on 9/23/10 documented the device took 94 seconds to activate the general fire alarm system. On 9/7/11 at 1:42 PM the interim maintenance director could not explain why the aforementioned reports had not been reviewed and the device modified to meet the requirement.

Reference:
NFPA 101, 2000 Edition, 18.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
10-5 Hydraulic Design Information Sign. The installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
5-5.6. Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 101, 2000 Edition, 18.3.5.1, 9.7.5, NFPA 25, 1999 Edition;
2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 degrees Fahrenheit.
2-4.1.6 A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler installed.
9-2.7 Waterflow alarm. All waterflow alarms shall be tested quarterly in accordance with manufacture's instructions.

NFPA 101, 2000 Edition, 19.3.5.1, 9.6.1.4, NFPA 72, 1999 Edition;
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow and the alarm-initiating device when flow occurs that is equal to or greater than from a single sprinkler of the smallest orifice size installed in the system. Movement or water due to waste, surges, or variable pressure shall not be indicated.

Based on observation and staff interview, the facility failed to ensure portable fire extinguishers were inspected on a monthly basis in 1 of 8 smoke compartments. The findings were:

Observation on 9/6/11 at 5:43 PM showed the two portable fire extinguishers in the operating department sub-sterile room were not inspected for the month of August 2011. At the time of observation, the interim maintenance director reported the day the extinguishers were scheduled to be inspected, the area was unavailable due to surgical cases. He could not explain why the extinguishers had not been inspected later that month.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1, 9.7.4.1, NFPA 10, 1998 Edition;
4-3 Inspection.
4-3.1 Frequency. Extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals ....

Based on observation and staff interview, the facility failed to ensure medical gas cylinders were fastened to prevent accidental falling for 1 of 3 manifold systems. The findings were:

Observation of the nitrous oxide manifold system on 9/6/11 at 4:20 PM showed four "H" sized spare tanks were fastened by a chain that was loosely hanging around the bottom of the cylinders. When checked, the cylinders were not secure and could be tipped, to the point of failing over. At the time of observation the interim maintenance director reported he was aware of the restraint requirement, but could not explain why the chains had not been secured.

Reference:
NFPA 101, 2000 Edition, 19.3.2.3, NFPA 99, 1999 Edition;
4-3 Level 1 Piped Systems.
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (any Quantity; In-storage, Connected, or Both)
3. Provisions shall be made for racks or fastening to protect cylinders from accidental damage or dislocation.

Based on observation and staff interview, the facility failed to ensure the Essential Electrical System (EES) was divided into the Life Safety Branch and the Critical Branch for 2 of 6 EES panels. The findings were:

1. Observation of the Critical Branch electrical panel "BCC" on 9/6/11 at 4:01 PM showed it supplied power to Life Safety equipment, circuit #17 Generac Panel (emergency generator). Further observation showed the panel supplied power to Equipment Branch equipment, circuit #1 Hot water Durarch, #3 Steam Boiler Thermostat, #5 Lavrs Kit Boiler, #6 Water Softener, #7 Outside Lighting, #8 Lawn Sprinkler Control System, #10 Lawn Sprinkler Control Basement, #12 & #14 Flag Pole Lighting and #20 Cooling Tower Receptacles. At the time of observation the interim maintenance director reported he was not aware the EES circuits were required to be divided into separate branch panels. He confirmed the electrical system was last modified in 2009.

2. Observation on 9/7/11 at 12:09 PM showed the Critical Branch electrical panel ICG supplied power to Life Safety equipment, circuit #1, #3, #4, #5, #36, #40, and #42 automatic door openers and #11 fire alarm panel.

Reference:
NFPA 101, 2000 Edition, 18.2.9.2, NFPA 99, 1999 Edition;
3-4.2. Distribution (Type 1 EES)
3-4.2.2.1 General. Type I essential electrical system are comprised of two separate systems capable of supplying a limited amount of lighting and power services, which is considered essential for the life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. They are designated the life safety branch and the critical branch ...
3-4.2.2.2 Emergency System.
(a) General. These functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2 (b) and (c).

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Based on observation and staff interview, the facility failed to ensure a circuit directory was supplied for 1 of 6 Essential Electrical System (EES) panels. The findings were:

Observation of the Life Safety Branch electrical panel "BXB" on 9/6/11 at 3:45 PM showed 16 electrical circuits were installed and 14 were turned to the "ON" position. Further observation showed the panel circuit directory indicating what device or area each circuit supplied power to, was missing. At the time of observation the interim maintenance director said he was not aware the directory was missing.

Reference:
NFPA 101, 2000 Edition, 18.5.1.1, NFPA 70, 1999 Edition;
384-13 ...All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

Based on observation and staff interview, the facility failed to ensure electrical outlets had ground fault circuit interruption (GFCI) in wet locations in 4 of 6 smoke compartments. The findings were:

Periodic observations of the electrical system on 9/6/11-9/7/11 showed the electrical outlet in the basement womens' locker room, endoscope clean up room, cardiology stress test room, and the soiled utility by the nurses' station, were located less than 72 inches to a sink. Further observation showed these outlets did not have GFCI protection. On 9/6/11 at 4:46 PM the interim maintenance director reported he was aware of the GFCI requirement, but could not explain why the aforementioned outlets had not been replaced.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
517-20. Wet Locations. (a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption or power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.