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Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of properly fire rated occupancy separation wall between the hospital and the Creekside clinic of business occupancy. The observed situation was not compliant with NFPA 101 19.1.1.4.1, 19.1.2.1. This deficient practice affected the entire facility.

Findings include:

1. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator) on 8/30/12, Surveyors 12316 and 12187 observed between 3 pm and 3:10 pm that in the first floor the occupancy separation wall between the hospital and the Creekside medical office building was not constructed to 2-hr fire resistance rating as required, because there were electrical or medical gas boxes with a total area of 168 square inches in a 100 square feet of a rated fire barrier wall. A maximum of 100 square inches in 100 square feet is allowed. This situation occurred in the patient room side of the rated fire barrier in 4 patient recovery rooms 1F375, 1F365, 1F355 and 1F335.

The above deficiency was acknowledged by the director of facilities services, maintenance team leader, and safety coordinator at the time of discovery, and confirmed with the above staff at the exit conference on 8/30/2012 at 9 pm.

Based on observation and interview, the facility did not provide room finishes with rated wall finishes. This deficiency occurred in 2 of the 22 smoke compartments, and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 8/30/2012 at 9:15 am, observation revealed on the 2nd floor in the room 2B365, that there was peg board mounted on the wall as a secondary finish and the facility could not confirm the peg board had the appropriate flame spread rating. This observed situation was not compliant with NFPA 101 (2000 ed.) 19.3.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).

2. On 8/30/2012 at 6:25 pm, observation revealed on the 1st floor in the Cysto room and sub-sterile room, that there was peg board mounted on the wall as a secondary finish and the facility could not confirm the peg bard had the appropriate finish rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with no combustible material storage, and smoke detection in spaces that are open to the corridor. This deficiency occurred in 3 of the 22 smoke compartments, and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors

FINDINGS INCLUDE:

1. On 8/30/2012 at 10:45 am, observation revealed on the 3rd floor by Room 3B200, that the corridor was used to store a large amount of materials and was not separated from the corridor by a compliant wall and door. Spaces are permitted to be open to the corridor provided they are not used as a hazardous area, per exception 6 to 19.3.6.1. The quantity of materials within the same smoke compartment was deemed hazardous for storage in a corridor. The amount stored exceeded the amount that would fit in a 50 sq. ft. room, which is the threshold for the quantity deemed hazardous under the code in 19.3.2.1(7). This observed situation was not compliant with NFPA 101 (2000 ed.) 19.3.6.1 (exception 6). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).

2. On 8/30/2012 at 9:00 am, observation revealed on the 2nd floor in the room open to the corridor by mechanical room, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.) 19.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).

3. On 8/30/2012 at 9:55 am, observation revealed on the 2nd floor in the corridor alcove across from room 2B290 and 2B270 (rooms 221 & 222), that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.) 19.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).


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4. During a tour of the facility with Staff M1 with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator) on 8/29/12, Surveyor 12316 observed at 4:20 pm that the Lounge PCU1 (Room 1B350) adjacent to the 1st Floor ICU was open to corridor, and did not have a smoke detector, nor was the space separated from corridor with smoke tight walls. The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader, and safety coordinator, and also at the exit conference with the above staff on 8/30/2012 at 9 pm.

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency occurred in 2 of the 22 smoke compartments, and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 8/30/2012 at 9:58 am, observation revealed on the 2nd floor in the closet 2B345, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.) 19.3.6.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).


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2. During a tour of the facility with Staff M1 with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator) on 8/29/12, Surveyor 12316 observed at 3:52 pm that the double corridor doors of the Patient Room 125 (1B180) in the Intensive Care Unit on the 1st Floor had a 3/16" gap at the meeting edge, and did not prevent smoke transfer from the patient room to corridor in the event of fire in the room. The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader, and safety coordinator, and also at the exit conference with the above staff on 8/30/2012 at 9 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to one vertical opening not protected in accordance with NFPA 101 19.3.1.1, 8.2.5.2. This deficient practice affected 2 of 22 smoke compartments in the hospital.

Findings include:

1. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator), Surveyor 12316 and Surveyor 12187 observed on 8/30/12 between 8:20 am and 10 am that the vertical opening for the main Stair #5 connecting 2 stories was not protected with 1 hour fire rated walls to separate the 1st Floor space that included egress corridor, one Lounge and one Starbucks Coffee Stand from the lower level corridor and waiting area open to the corridor.

The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader, and safety coordinator, and also at the exit conference with the above staff on 8/30/2012 at 9 pm.

Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included an adjacent smoke detector. This deficiency occurred in 2 of the 22 smoke compartments, and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 8/30/2012 at 6:38 pm, observation revealed on the 1st floor in the room 1E035, sterile processing, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.) 7.2.1.8. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).


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2. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator), Surveyor 12316 observed on 8/27/12 at 3:40 pm that there was no smoke detector, on the north side, within 5 ft of the 1 ½ hr fire-rated won-door that was held open. The won-door protected the opening in the 2-hr occupancy separation wall on the 1st Floor. The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader, and safety coordinator, and also at the exit conference with the above staff on 8/30/2012 at 9 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of exit signs in 2 locations to direct occupants to 2nd exit in accordance with NFPA 101 19.2.10.1 and 7.10.1.4. This deficient practice affected 1 of 22 smoke compartments in the facility.

Findings include:

1. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator), Surveyor 12316 observed on 8/28/12 between 1:50 pm and 2:10 pm that there was no exit signs in the Pharmacy to direct staff /occupants toward 2 of 3 exit access doors to corridor on the Ground Floor.

2. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator), Surveyor 12316 observed on 8/30/12 between 8:20 am and 10 am that there was no exit sign above the double doors to direct occupants from the 1st Floor space near the Stair 5 to a 2nd exit. The doors are located in the 1-hr fire barrier wall between the Coffee stand/Lounge and the outpatient prep/recovery rooms on the 1st Floor.

The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader, and safety coordinator, and also at the exit conference with the above staff on 8/30/2012 at 9 pm.

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors, and a smoke-tight room enclosure (in a sprinkled smoke zone). This deficiency occurred in 2 of the 22 smoke compartments, and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 8/30/2012 at 6:15 pm, observation revealed on the 1st floor in the room 1E115, surgical Core (storage room), that the hazardous room was not compliant. The doors and walls were not 1 hour fire rated. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.) 19.3.2.1. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).

2. On 8/30/2012 at 6:40 pm, observation revealed on the 1st floor in the room 1E035, sterile processing, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The holes included the water connections recessed into the one hour wall. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.) 19.3.2.1. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).

Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path, lack of two exits, and door hardware that operated with two releasing motions. This deficiency occurred in 3 of the 22 smoke compartments, and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 8/30/2012 at 7:00 pm, observation revealed on the 1st floor in the door to surgery, SMDR 107, that the door was locked from the egress side. The across corridor door to the surgery area was locked after hours and prevent exiting. There was an exit sign above the door. This observed situation was not compliant with NFPA 101 (2000 ed.) 19.2.2.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).

2. On 8/30/2012 at 10:22 am, observation revealed on the 2nd floor in the bathroom of the PCU breakroom, that the door release hardware required more than a single motion to release the door for exiting. There was a dead bolt to lock the door. This observed situation was not compliant with NFPA 101 (2000 ed.) 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).


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3. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator), Surveyor 12316 and Surveyor 12187 observed on 8/30/12 between 8:20 am and 10 am that a segment of the 1st Floor corridor located near the top of stair did not have access to 2 exits. Access to a 2nd exit from the corridor toward the Recovery/Prep area was not provided due to the double doors to the Recovery/Prep area kept locked at night. This did not meet the requirements of NFPA 101 19.2.5.9. When interviewed between 8:20 am and 10 am, Staff M2 stated that the double doors adjacent to the Lounge and Coffee stand were locked at night. The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader, and safety coordinator, and also at the exit conference with the above staff on 8/30/2012 at 9 pm. The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader, and safety coordinator, and also at the exit conference with the above staff on 8/30/2012 at 9 pm.

4. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator), Surveyor 12316 and Surveyor 12187 observed on 8/30/12 at 3 pm that the releasing device on toilet room doors in between two outpatient prep/recovery rooms did not have an obvious method of operation and required more than one releasing operation. The push button located approximately 58 in. above the floor was used to release the door from inside the toilet room. A push button mounted on the wall and turning of the door lever handle required more than one releasing operation. This did not meet the requirements of NFPA 101 7.2.1.5.4. The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader, and safety coordinator, and also at the exit conference with the above staff on 8/30/2012 at 9 pm.


NFPA 101 7.2.1.5.4
"A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation. "

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures. This deficiency occurred in 1 of the 22 smoke compartments, and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 8/30/2012 at 10:12 am, observation revealed on the 2nd floor in the Nurse Station area, that staff were not familiar with their responsibilities in the event of a fire, including Staff M4 (registered nurse) did not know where the shut off valve for the oxygen supply was. Staff EE (RN coordinator) did not know to check to ensure that the other patients were off central oxygen when the shut off valve was for the oxygen supply was closed. This observed situation was not compliant with NFPA 101 (2000 ed.) 19.7.1.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).
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Based on record review and staff interview, the facility failed (1) to provide a properly installed and tested fire alarm system in accordance with NFPA 101 9.6.1.4, and NFPA 72 Chapters 1 and 5 on installation and testing of transmission and receiving equipment to provide annunciation of trouble signals from phone line failure; and (2) to provide a Fire Alarm system that was installed to minimum standards of NFPA 72 in accordance with NFPA 9.6.1.4, 9.6.3.2. The deficient practice affects all patients, staff and visitors.

Findings include:

1. When interviewed during a review of fire alarm system testing and maintenance record on 8/29/2012 between 8 am and 10 am, Staff M1 (maintenance team leader) stated that audible and visible trouble signals caused by the phone line failure of the automatic dialer component of the fire alarm system were annunciated only at the dialer, and not at the man fire alarm control unit (FACP); and that the trouble signals were not annunciated at the extender panels located at various locations in the facility, where the staff is likely to be present and hear the trouble signals at all times. The room in the Ground Floor where the control unit is located was not a continuously occupied location. This did not meet the requirement of NFPA 101 9.6.1.4, NFPA 72 1-5.4.6.

2. Surveyor 12316 observed at 4:14 pm that the Staff Room 1B330 across the Patient Room 102 on the 1st Floor did not have a visual notification appliance for occupant notification.

The above deficiency was confirmed at the time of interview with the maintenance team leader and with the director of facilities services, maintenance team leader, and safety coordinator at the exit conference on 8/30/2012 at 9 pm.

References:
NFPA 72, Section 1-5.4.6
"......The trouble signal(s) shall be located in an area where it is likely to be heard."

NFPA 72, Section 1-5.4.4
"Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated."

NFPA 72, Section 1-5.4.6.1
"Visible and audible trouble signals, and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Control unit ....
(2) Building fire command center ...
(3) Central Station ... "

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with non-sprinkled rooms that met permitted exceptions , and unobstructed water distribution. This deficiency occurred in 2 of the 22 smoke compartments, and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 8/30/2012 at 9:35 am, observation revealed on the 2nd floor in the electric room, that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided. The electrical room had equipment other than electrical power equipment. There were 2 building automatic 'computers' in the room. This observed situation was not compliant with NFPA 101 (2000 ed.) 19.3.5.1 (exception).

2. On 8/30/2012 at 9:09 am, observation revealed on the 2nd floor in the all of the patient bathrooms, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a solid shower curtain This observed situation was not compliant with NFPA 13 (1999 ed.) 5-6.5.

3. On 8/30/2012 at 9:25 am, observation revealed on the 2nd floor in the Storage Room 2B370 that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a column. This observed situation was not compliant with NFPA 13 (1999 ed.) 5-6.5.

4. On 8/30/2012 at 9:55 am, observation revealed on the 2nd floor in the corridor alcove across from room 2B290 and 2B270 (rooms 221 &222), that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included walls of the alcove. This observed situation was not compliant with NFPA 13 (1999 ed.) 5-6.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).

Based on observation and staff interview, the facility failed to properly maintain the automatic supervised sprinkler system in accordance with NFPA 101 9.7.5 and NFPA 25 2-2.1.1. This deficient practice affected 3 of 22 smoke compartments in the facility.

Findings include:

During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator), Surveyor 12316 observed between 8/27 and 8/30/12 in the following 4 locations that the sprinkler heads were dirty and not free of foreign material, or without escutcheon plates.

1. On 8/28/12 at 2:27 pm, one sprinkler head in the Corridor GE055 adjacent to the electrical closet GD170 in the Radiology area was dirty;

2. On 8/29/12 at 1:24 pm, one sprinkler head in the Staff Room 1C520 of the OB unit was dirty;

3. On 8/29/12 at 3:40 pm, one sprinkler head in the ICU Patient Room 6 (1B120) was dirty;

4. On 8/30/12 at 6:12 pm, one sprinkler head above east end of Tray line, one sprinkler above the Dishwasher, one head above the 3-compartment sink, and one head on ceiling adjacent to speakers in the Kitchen were dirty. The lint/dust deposited on sprinkler heads causes the insulating effect which may delay the sprinkler heads to operate properly as intended and designed by manufacturer.

The above deficiencies were confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader, and safety coordinator, and also at the exit conference with the above staff on 8/30/2012 at 9 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to (i) lack of smoke isolation dampers in 3 air-handling units (AHU) in accordance with NFPA 90A 2-3.9.2; and (ii) lack of fire dampers in HVAC duct openings in the occupancy separation wall in accordance with NFPA 101 19.5.2.1 and NFPA 90A 3-3.1.1. This deficient practice had a potential of affecting 50% of patients, staff and undetermined number of visitors in the facility.

Findings include

1. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), Staff M2 (safety coordinator) ), and Staff M3 (maintenance mechanic) on 8/28/2012 between 10:30 am and 11:20 am that AHU #5 and AHU #1 did not have smoke isolation dampers in the supply and return sides of the unit, and AHU #3 did not have smoke isolation damper in the supply side of the unit to isolate the air-handling unit. All 3 Air Handling units had fan capacities of more than 15000 cfm.

The installation of isolation smoke dampers for air-handling units of greater than 15000 cfm capacity was also a requirement in the 1985 edition of NFPA 90A. The Building 01 was constructed in 2000.

2. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), Staff M2 (safety coordinator), and Staff M3 (maintenance mechanic), Surveyor 12316 observed on 8/30/12 between 3 pm and 3:30 pm that there were no fire dampers protecting several HVAC supply and return duct openings in the 2-hr fire resistance-rated occupancy separation wall between the hospital Building 06 and the Creekside outpatient clinic building of business occupancy.

The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader, and safety coordinator, and also at the exit conference with the above staff on 8/30/2012 at 9 pm.

Reference:
NFPA 90A (1999) 2-3.9.2
"Smoke dampers shall be installed in systems with a capacity greater than 15000 ft3/min (7080 L/sec) to isolate the air-handling equipment, including filters, from the remainder of the system in order to restrict the circulation of smoke."

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This deficiency occurred in 3 of the 22 smoke compartments, and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 8/30/2012 at 6:00 pm, observation revealed on the 1st floor in the OR 6, 11 and C-section rooms, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. This observed situation was not compliant with NFPA 101 (2000 ed.) 19.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Director of facilities service).


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2. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator) on 8/29/12, Surveyor 12316 observed at 1:26 pm that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There were three approximately 20 gallon trash/soiled linen containers next to each other in the Nursery 1C400 of the OB unit on the 1st Floor. This observed situation was not compliant with NFPA 101 (2000 edition) 19.7.5.5. The above condition was confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader and safety coordinator, and confirmed with the director of facilities services at the exit conference on 8/30/12 at 9 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients due to lack of remote emergency manual stop for the emergency generator of the essential electrical system. This deficient practice affected the entire facility.

Findings include:

1. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator) between 8/27 - 8/30/12, Surveyor 12316 observed on 8/29/2012 that there was no remote emergency stop for the emergency generator as required by NFPA 110 3-5.5.6, Table 3-5.5.2(d). When interviewed on 8/30/12 between 9 and 11:30 am, the maintenance team leader stated that there was no remote emergency stop located outside of the generator room.

The above deficiency was confirmed with the director of facilities services, the maintenance team leader, and the safety coordinator at the exit conference on 8/30/2012 at 9 pm.

Based on observation, interview and record review, the facility did not provide a code compliant environment with miscellaneous deficiencies, including proper smoke removal system from anesthetizing locations. This deficiency could affect 1 of the 22 smoke compartments and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 08/30/2012 at 2:45 PM, surveyor 12187 on the 1st floor OR area, observed that one smoke detector at the air handle return, closed the return air damper to operate the smoke removal system for anesthetizing location. The smoke detector was not sensitive enough to detect smoke in the operating room. The operating room had 1950 CFM of air being exhausted, but the smoke detector at the air handler was viewing 40,000 CFM of air.

This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.3 and NFPA 99 (1999 edition) 5.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff B (director of facilities services).

Based on observation and staff interview, the facility failed to (i) identify the critical branch electrical outlets of the essential electrical power system in PACU patient bed locations in accordance with NFPA 99 3-3.2.1.2(a)1, NFPA 70 517-19(a); and (ii) maintain working clear space in front of electrical panel in one location. This deficiency practice affected 1 of 22 smoke compartments in the facility.

Findings include

1. During a tour of the facility with Staff B (director of facilities services), Staff M1 (maintenance team leader), and Staff M2 (safety coordinator) on 8/29/12, Surveyor 12316 observed at 1:45 pm that the red-color, critical branch electrical wall outlets in all 11 PACU patient bed locations on the 1st Floor were not identified as to which electrical panel and branch circuit the power is supplied from.

2. On 08/29/12 at 1:49 pm, Surveyor #12316 observed on the 3rd floor in the corridor 1F010 in the PACU that access to electrical panel was less than 3'-0" clearance due to one computer work station and one table stored/used in the corridor. This observed situation was not compliant with NFPA 70 (1999 edition) 110-26.

The above deficiency items were was confirmed at the time of discovery by a concurrent observation and interview with the director of facilities services, maintenance team leader, and safety coordinator, and with the director of facilities at the exit conference on 8/30/2012 at 9 pm.

References:
NFPA 70 517-19(a)
"Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panelboard. Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them."

NFPA 70 110-26.
" Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment ... "

NFPA 70 110-26(b) Clear Spaces.
" Working space required by this section shall not be used for storage ... "