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Based on observation and interview the facility failed to maintain a 2 hour fire barrier between two different occupancies. This deficient practice has the potential to affect all patients, staff and visitors of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observation on 6/22/10, at 9:33 am revealed a 2 hour fire barrier that separated the industrial occupancy Energy Plant from the health care occupancy Hospital Maintenance Tunnel. The facility failed to install positive latching hardware in the 90 minute fire door. This observation was confirmed by interview with Safety Specialist C on the same date and time.




27394

Findings are:

Observation on 06/23/10 at 2:15 p.m. revealed no 2 hour fire separation between the sprinklered corridors of the Conference Center and the non sprinklered exit corridor leading into the hospital.
During an interview on 06/23/10 at 2:15 p.m. Specialist B confirmed that there was no 2 hour fire separation.


NPFA 101, 2000ed. 19.1.2 Mixed Occupancies.
19.1.2.1*
Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours.

Based on observation and interview, the facility failed to maintain the building construction type of the facility by not providing fire resistant insulation to cover the steel beams that support the steel deck assembly. The deficient practice affected the integrity of the structure, all residents and staff. The facility has a capacity of 356 beds and at the time of the survey the census was 165.

Findings Are:

Observation on June 22, 2010 at 10:35 a.m. revealed there were exposed steel beams that supported the steel deck assembly on the 4th floor in the ICU next to room 447 above the non-rated ceiling tile assembly. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 22, 2010 at 2:45 p.m. revealed there were exposed steel beams that supported the steel deck assembly in the corridor next to room 2731 above the non-rated ceiling tile assembly. Observations were acknowledged and verified by Bio Med A on the same date and time.



13879

Findings are:

Observations on 6-22-10 from 10:16 am to 1:23 pm on third floor revealed:
1. Visible structural beam members above Air Handler #2 and #3 where the fire-proofing had been removed and not replaced.
2. Visible structural beam members above the caged Bio-med area and on south column above Gardener Denver pure air machine, where the fire-proofing had been removed and not replaced.
3. Visible structural beam members throughout where new hangers were added on beams, where the fire-proofing had been removed and not replaced.
4. Visible structural beam members above the third floor landing into north tower leading into mechanical area where yellow foam had been sprayed on the beams.
Observations on 6-23-10 from 10:50 am to 11:03 am on basement level revealed:
5. Visible structural beam members in carpenters shop above door where yellow foam had been sprayed on the beams.
6. Visible structural beam members in locksmith area at top of stairs where yellow foam had been sprayed on the beams and fire-proofing had been removed and not replaced.

During an interview on both dates and times, Engineering D confirmed the lack of fire-proofing and yellow foam on the beams. No documentation was provided for the yellow foam product.



27395

Findings are:

Observation on 6/21/10, at 12:50 pm revealed missing spray-on fire proofing in the East Elevator Penthouse:
1. An 8 inch space failed to be sprayed on the wall beam to the left hand side of the East Elevator Penthouse Door.
2. An area failed to be sprayed on the ceiling structural beam.
This observation was confirmed by interview with Safety Specialist C on the same date and time.

Based on observation and interview the facility failed to provide documentation to verify interior finishes for rooms and spaces not used for corridors or exit ways that have a flame spread rating of Class A or Class B or C. These deficient practices affect patients, visitors, and staff the use the third and fourth floors. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-22-10 from 9:36 pm to 10:36 am on third floor revealed:
1. Wood floor in the transfer station area, with no listing stamped into the wood.
2. Wood floor above medical gas equipment, with no listing stamped not the wood.

During an interview on 6-22-10 at times of observations, Engineering D confirmed the findings.



27394

Findings are:

Observation on 06/21/10 at 12:53 p.m. revealed wood lining the walls of the Data Room #22176.
During an interview on 06/21/10 at 12:53 p.m. Specialist B confirmed the wood on the walls.

Observation on 06/21/10 at 3:23 p.m. revealed wood lining the walls of the Switch Gear Rooms, in the New Cancer Center.
During an interview on 06/21/10 at 3:23 p.m. Specialist B confirmed the wood on the walls.

Observation on 06/22/10 at 9:30 a.m. revealed wood lining the walls of the Data Room #IH2GA.
During an interview on 06/22/10 at 9:30 a.m. Specialist B confirmed the wood on the walls.

Observation on 06/22/10 at 9:41 a.m. revealed carpet lining the walls of the Multi Purpose Room #2642, in the Old Rehab Administration.
During an interview on 06/22/10 at 9:41 a.m. Specialist B confirmed the carpet on the walls.

Observation on 06/22/10 at 10:18 a.m. revealed wood on the walls of the Data Room #22753 in the New Rehab.
During an interview on 06/22/10 at 10:18 a.m. Specialist B confirmed the wood on the walls.

Observation on 06/22/10 at 10:55 a.m. revealed wood on the walls of the Electrical Room #22785.
During an interview on 06/22/10 at 10:55 a.m. Specialist B confirmed the wood on the walls.

Based on observation and interview, the facility failed to maintain the corridor walls with a fire resistance rating or smoke resisting above the ceiling tiles. The deficient practice affected all compartments in the building, all residents and staff. The facility has a capacity of 356 beds and at the time of the survey the census was 165.

Findings Are:

Observation on June 21, 2010 at 8:57am revealed there were two ceiling tiles in the corridor next to room 867 that were broken and would allow the passage of smoke through the ceiling. The wall above the ceiling tile was not maintained as a smoke partition. Observation was acknowledged and verified by Bio Med A on the same date and time.

Observation on June 21, 2010 at 2:39 p.m. revealed there was an electrical conduit that penetrated a 1 hour rated fire wall above the ceiling on the seventh floor next to the west fire doors. The wall above the ceiling tile is not maintained as a fire rated separation. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 21, 2010 at 2:53 p.m. revealed the 1 hour fire rating wall was not sealed at the top between the wall and the roof deck assembly on the seventh floor in the tunnel to IPC above fire door. The wall above the ceiling tile was not maintained as a fire rated separation. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 21, 2010 at 3:10 p.m. revealed the 1 hour fire rated wall above the ceiling tile was not sealed to prevent the passage of smoke and fire that separated the construction site on the 6th floor. The wall above the ceiling was not maintained as a fire rated separation. Observation were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 22, 2010 at 9:11 a.m. revealed the 2 hour fire rated wall was not sealed above the ceiling in Room # 4506A and would allow the passage of smoke and fire through the wall. The wall was not maintained as a fire rated separation. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 22, 2010 at 10:35 a.m. revealed the corridor walls above the ceiling tile were not smoke resistant on the 4th floor ICU. The tops of the corridor walls throughout the floor were not sealed at the top between the wall and the roof deck assembly. The wall above the ceiling was not maintained as a smoke rated separation. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 22, 2010 at 1:35 p.m. revealed that the cable train penetrated a 1 hour fire rated wall above the ceiling tile in the north tower on the third floor next to door 339. The wall above the ceiling tile was not maintained as a fire rated separation. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 22, 2010 at 1:43 p.m. revealed some insulation between the1 hour fire rated wall the roof deck in room #3352. Bio Med A personal was unaware if the insulation had a fire rating. The facility failed to provide documentation on the insulation. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 22, 2010 at 1:55 p.m. revealed the smoke resistant wall above the ceiling tile in room #3355 was not sealed to prevent the passage of smoke. The wall above ceiling was not maintained as smoke separation. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 22, 2010 at 2:15 p.m. revealed that along the north side of the 1 hour rated fire wall above the ceiling tile assembly there were multiple penetrations and the drywall was not sealed to prevent the passage of smoke and fire throughout the clinic. The wall above the ceiling tile was not maintained as a fire rated separation. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 22, 2010 at 2:25 p.m. revealed that above the ceiling tile a conduit penetrated a 1 hour fire rated wall allowing the passage of smoke and fire in room # 2748. The wall above ceiling tiles was not maintained as a 1 hour fire separation. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 22, 2010 at 2:35 p.m. revealed that above the ceiling tiles there were multiple penetrations in a 1 hour fire rated wall allowing the passage of smoke and fire in room # 2748. The wall above ceiling tiles was not maintained as a 1 hour fire separation. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 22, 2010 at 3:00 p.m. revealed that above the ceiling tile there were multiple penetrations in a 1 hour fire rated wall allowing the passage of smoke and fire in room # EC2369. The wall above ceiling tile was not maintained as a 1 hour fire separation. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 22, 2010 at 3:30 p.m. revealed that a 1 hour rated fire wall stopped at the unrated ceiling tile assembly in room 2367. The corridor walls are required by NFPA 101 to extend from the floor to the roof. Observations were acknowledged and verified by Bio Med A on the same date and time.

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-21-10 from 12:54 pm to 2:11 pm on the fifth floor revealed:
1. Patient room 509 nurse server's closet door failed to latch when closed. These doors are located in corridors, linen and supplies are stored inside for patient use.
2. Patient room 503 nurse server's closet door failed to latch when closed. These doors are located in corridors, linen and supplies are stored inside for patient use.
3. Patient room 502 nurse server's closet door failed to latch when closed. These doors are located in corridors, linen and supplies are stored inside for patient use.
4. Patient room 551 nurse server's closet door failed to latch when closed. These doors are located in corridors, linen and supplies are stored inside for patient use.
5. Patient room 552 nurse server's closet door failed to latch when closed. These doors are located in corridors, linen and supplies are stored inside for patient use.
6. Patient room 553 nurse server's closet door failed to latch when closed. These doors are located in corridors, linen and supplies are stored inside for patient use.
7. Patient room 556 nurse server's closet door failed to latch when closed. These doors are located in corridors, linen and supplies are stored inside for patient use.
Observations on 6-21-10 at 2:27 pm on the fourth floor revealed:
8. Care Management Office 4494 door held open with rubber chock.
Observations on 6-22-10 from 9:17 am to 9:35 am on the fourth floor ICU revealed:
9. Sliding glass patient door 442 failed to latch within doorframe when tested.
10. Sliding glass patient door 442 failed to latch within doorframe when tested.
11. Sliding glass patient door 443 failed to latch within doorframe when tested.
12. Sliding glass patient door 445 failed to latch within doorframe when tested.
13. Sliding glass patient door 446 failed to latch within doorframe when tested.
14. Sliding glass patient door 448 failed to latch within doorframe when tested.
15. Sliding glass patient door 449 failed to latch within doorframe when tested.
16. Sliding glass patient door 451 failed to latch within doorframe when tested.
17. Sliding glass patient door 452 failed to latch within doorframe when tested.
18. Sliding glass patient door 455 failed to latch within doorframe when tested.
19. Sliding glass patient door 457 failed to latch within doorframe when tested.
20. Sliding glass patient door 458 failed to latch within doorframe when tested.
21. Sliding glass patient door 459 failed to latch within doorframe when tested.
22. Small leaf of double glass patient room 440 failed to provide self-closing device and self-latching device.
23. Small leaf of double glass patient door 453 failed to provide self-closing device and self-latching device.
Observations on 6-22-10 at 9:52 am on the third floor revealed:
24. Reading Room 3335 door held open with a trash can to prevent to from closing shut.

During an interview on each date and time Engineering D confirmed all the findings.



27395

Findings are:

Observations on 6/21/10, 2:37 pm to 6/23/10, 1:32 pm revealed:

Observation on 7th Floor revealed the Room 7736 Door failed to latch when pulled shut.

Observations on the 6th Floor revealed:
1. The Room 638 Door failed to latch by the automatic closure.
2. The Room 639 Door failed to latch by the automatic closure.
3. The Room 644 Door failed to latch by the automatic closure.
4. The Room 645 Door failed to latch by the automatic closure.
5. The Room 674 Door failed to latch by the automatic closure.

Observations on the 1st Floor revealed:
1. The 1154 Quality Management Office Door failed to latch when pulled shut.
2. The Human Resources Office Door failed to latch when pulled shut.
3. The Health Information Medical Records Door failed to latch when pulled shut.
This observation was confirmed by interview with Safety Specialist C on the same date and time.



27394

Findings are:

Observation on 06/21/10 at 2:30 p.m. revealed the glass doors to Steir Pharmacy do not positive latch.
During an interview on 06/21/10 at 2:30 p.m. Specialist B confirmed the doors did not positive latch.

Observation on 06/22/10 at 9:00 a.m. revealed multiple patient rooms in Peri-Op were separated from the egress corridor by sliding curtains and not doors that positive latch.
During an interview on 06/22/10 at 9:00 a.m. Specialist B confirmed the lack of positive latching doors to the patient rooms.

Observation on 06/23/10 at 9:40 a.m. revealed the East exit door from the Cafeteria did not positive latch.
During an interview on 06/23/10 at 9:40 a.m. Specialist B confirmed that the exit door from the Cafeteria did not positive latch.

Observation on 06/23/10 at 1:15 p.m. revealed the door to Room #1333 Health Records did not positive latch.
During an interview on 06/23/10 at 1:15 p.m. Specialist B confirmed the door to Health Records did not positive latch.

Based on observation and interview, the facility failed to maintain the vertical opening which provides a minimum 2-hour fire rating. This deficient practice affected all patients, staff, and visitors of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-23-10 at 10:43 am revealed key pad door hardware on stair door leading into the basement, which failed to indicate a fire rating.

During an interview on 6-23-10 at 10:43 am, Engineering D confirmed the hardware on the door.



27395

Findings are:

Observation on 6/21/10, from 3:08 pm to 6/23/10, 9:30 am revealed:

Observations on the 8th Floor revealed:
1. The Center Stair Tower Panic Hardware failed to be UL Listed Fire Rated Hardware.
2. The East Stair Tower door handle assembly failed to be listed. Documentation to verify the specific listing failed to be provided.

Observations on the 7th Floor revealed:
1. The Center Stair Tower Door revealed a tag failed to be attached to the door to verify the fire resistance rating of the door.
2. The Center Stair Tower Panic Hardware failed to be UL Listed Fire Rated Hardware.

Observations on the 6th Floor revealed:
1. The Center Stair Tower Panic Hardware failed to be UL Listed Fire Rated Hardware.
2. The East Stair Tower door handle assembly failed to be listed. Documentation to verify the specific listing failed to be provided.
3. The East Patient Elevator Lobby Smoke Doors failed to close with a gap at the meeting edges less than 1/8 inch.

Observation on the 1st Floor revealed The Center Stair Tower Panic Hardware failed to be UL Listed Fire Rated Hardware.
This observation was confirmed by interview with Safety Specialist C on the same date and time.


27394

Findings are:

Observation on 06/21/10 at 12:55 p.m. revealed 3 " holes in the ceilings of the Emergency Room Nurse Servers.
During an interview on 06/21/10 at 12:55 p.m. Specialist B confirmed the holes in the ceilings of the Nurse Servers.

Based on observation and interview, the facility failed to ensure that smoke separation doors protecting corridor openings in a sprinklered building are capable of resisting the passage of smoke. This deficient practice affected all patients, staff and visitors, as the doors would not prevent the spread of smoke.
The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-28-10 at 9:55 am on the third floor revealed the smoke separation double doors failed to close.

During an interview on 6-28-10 at 9:55 am, Safety Specialist B confirmed the door hardware prevented the doors from closing.

Based on observations and interviews the facility failed to provide fire rated separations on 2 of 2 rooms formerly used for surgery and of 16 total surgery rooms. Not providing the rooms with approved one hour fire separations and openings protected with minimum 45 minute rated assemblies could allow a fire, in those rooms, to migrate to other portions of the surgery areas affecting all the patients in the surgery area. In addition the facility failed to provide a smoke barrier/fire separation between 1 of 1 large storage rooms in the main surgery area. Not providing the barriers as required by the National Fire Protection Association could cause smoke and fire from the rooms to migrate into corridors or areas of the surgery. The facility had a census of 165 and has a capacity of 356

Findings Are:

1. On June 22, 2010 at 2:44 P.M. it was observed that surgery rooms 1 and 2 were being used for storage. Safety Specialist A and Safety Specialist B confirmed the findings.

2. On June 22, 2010 at 2:51 P.M. it was observed that a space of approximately ¼ inch was observed between the leaves of newly installed doors of the large storage room, that opens into the corridor of the main surgery area. Safety Specialist A confirmed the gap/opening and said the doors had been newly installed but hadn ' t been finished by the contractor.



13879

Findings are:

Observations on 6-21-10 from 1:04 pm to 2:05 pm on fifth floor revealed:
1. Electrical closet room 521, door failed to close and latch. The self-closing device failed to be screwed into the door preventing it to operate.
2. Computer room 511, door stop installed on the lower portion of door.
3. PAR closet on east end of unit, double doors failed to close and latch when released from magnetic hold opens.
4. Storage room 570, door stop installed on the lower portion of door.
Observations on 6-21-10 from 2:21 pm to 3:19 pm on fourth floor revealed:
5. Laundry room 453, the gap between double doors was greater than 1/8 inch.
6. Laundry room 4485, doors failed to close and latch within door frame.
7. Laundry room 4485, the gap between double doors was greater than 1/8 inch.
8. Laundry room 487, door failed to provide self-closing device.
Observations on 6-22-10 from 10:16 am to 1:50 pm on third floor revealed:
9. Com. Room contained numerous ceiling tiles out of the grid and broken throughout the room.
10. Storage room 3339 in North tower failed to provide self-closing device on the door, the room calculated over 100 square feet in size.

During an interview on all dates and times, Engineering D confirmed all the findings.




27395

Findings are:

Observations on 6/22/10, from 11:08 am to 6/23/10, 1:53 pm revealed:

Observation on the 6th Floor in the construction area revealed the first door on the left when entering the construction area failed to have a tag attached to the door to verify the fire resistance rating of the door. All of the walls around this door did not extend to structure, therefore, this door was required as part of the construction separation.

Observations on the 1st Floor revealed:
1. The Maintenance Room Automatic Double Doors failed to latch when closed. The doors failed to close with a gap at the meeting edges less than 1/8 inch.
2. Both sets of the Dock Automatic Double Doors failed to latch when closed.
3. Both sets of the CS Supply Room Automatic Double Doors failed to latch when closed.
4. Storage was observed inside of the Steam Tunnel in the non-sprinkler protected area. Door 62608 failed to have a tag attached to the door to verify the fire resistance rating of the door.
This observation was confirmed by interview with Safety Specialist C on the same date and time.



27394

Findings are:

Observation on 06/21/10 at 12:54 p.m. revealed storage that was open to the corridor in the Emergency Department.
During an interview on 06/21/10 12:54 p.m. Specialist B confirmed the open storage in the corridor.

Observation on 06/21/10 at 1:06 p.m. revealed unsealed penetrations around pipes, above the suspended ceiling, in ER Storage #2139.
During an interview on 06/21/10 at 1:06 p.m. Specialist B confirmed the unsealed penetrations.

Observation on 06/21/10 at 1:10 p.m. revealed unsealed penetrations in the wall separating the squad bay from the Emergency Department.
During an interview on 06/21/10 at 1:10 p.m. Specialist B confirmed the penetrations.

Observation on 06/21/10 at 1:20 p.m. revealed unsealed penetrations in the North wall of the Electrical Close #2340.
During an interview on 06/21/10 at 1:20 p.m. Specialist B confirmed the penetrations.

Observation on 06/21/10 at 1:52 p.m. revealed the Storage Close #2305 was not provided with a self closing and latching door.
During an interview on 06/21/10 at 1:52 p.m. Specialist B confirmed the door was not self closing and latching.

Observation on 06/21/10 at 2:36 p.m. revealed the Bio-Hazard Room #2365 was not separated from the remainder of the building by smoke partitions.
During an interview on 06/21/10 at 2:36 p.m. Specialist B confirmed the room was not separated from the remainder of the building.

Observation on 06/21/10 at 2:36 p.m. revealed the Electrical Closet #2422, in the Surgery Lobby, had unsealed penetrations.
During an interview on 06/21/10 at 2:36 p.m. Specialist B confirmed the unsealed penetrations.

Observation on 06/21/10 at 3:00 p.m. revealed unsealed penetrations above the wire tray, in the North wall, of the shell space in the New Cancer Center.
During an interview on 06/21/10 at 3:00 p.m. Specialist B confirmed the unsealed penetrations.

Observation on 06/21/10 at 3:20 p.m. revealed unsealed penetrations in the Data Closet in the New Cancer Center.
During an interview on 06/21/10 at 3:20 p.m. Specialist B confirmed the unsealed penetrations in the Data Closet.

Observation on 06/21/10 at 3:23 p.m. revealed unsealed penetrations in the East wall of the Switch Gear Rooms, in the New Cancer Center.
During an interview on 06/21/10 at 3:23 p.m. Specialist B confirmed the unsealed penetrations.

Observation on 06/22/10 at 9:30 a.m. revealed room #2593 being used as storage with no self closing and latching door.
During an interview on 06/22/10 at 9:30 a.m. Specialist B confirmed the room did not have a self closing and latching door.

Observation on 06/22/10 at 9:45 a.m. revealed room #2671 in Rehab/Occupational Health was being used as a storage room and did not have a self closing and latching door.
During an interview on 06/22/10 at 9:45 a.m. Specialist B confirmed the room did not have a self closing and latching door.

Observation on 06/22/10 at 9:47 a.m. revealed room #2668 was being used as a storage room and did not have a self closing and latching door.
During an interview on 06/22/10 at 9:47 a.m. Specialist B confirmed that the door was not self closing and latching.

Observation on 06/22/10 at 9:57 a.m. revealed the Hydro Therapy Room #2695 was being used as storage and did not have self closing and latching doors.
During an interview on 06/22/10 at 9:57 a.m. Specialist B confirmed the doors were not self closing and latching.

Observation on 06/22/10 at 10:05 a.m. revealed the door to Storage Room #2698 was not self closing and latching.
During an interview on 06/22/10 at 10:05 a.m. Specialist B confirmed the door was not self closing and latching.

Observation on 06/22/10 at 10:10 a.m. revealed unsealed conduits and penetrations in the New Rehab shell space.
During an interview on 06/22/10 at 10:10 a.m. Specialist B confirmed the unsealed conduits and penetrations.

Observation on 06/23/10 at 9:36 a.m. revealed the door to Housekeeping, by the Cafeteria, was not latching.
During an interview on 06/23/10 at 9:36 a.m. Specialist B confirmed the door was not latching.

Observation on 06/23/10 at 9:57 a.m. revealed that an old cooler, in the Kitchen, was being used as a storage room and was not separated from the remainder of the building by smoke partitions and also did not have a self closing and latching door.
During an interview on 06/23/10 at 9:57 a.m. Specialist B confirmed that the cooler was being used as storage without separation and a self closing and latching door.

Observation on 06/23/10 at 10:02 a.m. revealed that the Kitchen Store Room door was not self closing and latching.
During an interview on 06/23/10 at 10:02 a.m. Specialist B confirmed the door was not self closing and latching.

Observation on 06/23/10 at 10:03 a.m. revealed the Kitchen Storage/Pantry was open to the rest of the kitchen with no separated from the remainder of the building by smoke partitions and self closing and latching doors.
During an interview on 06/23/10 at 10:03 a.m. Specialist B confirmed the Pantry was open to the kitchen with no separation.

Observation on 06/23/10 at 10:05 a.m. revealed the Electrical Closet in the Kitchen was not provided with a door that self closes and latches.
During an interview on 06/23/10 at 10:05 a.m. Specialist B confirmed that the door did not self close and latch.

Observation on 06/23/10 at 10:16 a.m. revealed that the Data Closet #1333A was not provided with a door that self closes and latches.
During an interview on 06/23/10 at 10:16 a.m. Specialist B confirmed the door did not self close and latch.

Observation on 06/23/10 at 11:00 a.m. revealed the automatic closing doors to Receiving #1137 were not functioning and were being held in the open position.
During an interview on 06/23/10 at 11:00 a.m. Specialist B confirmed that the doors were being held in the open position.

Observation on 06/23/10 at 1:33 p.m. revealed that one of the double doors leading into the Physicians Garage was not latching.
During an interview on 06/23/10 at 1:33 p.m. Specialist B confirmed that the door was not latching.

Observation on 06/23/10 at 1:56 p.m. revealed the Storage Room #1214 was not provided with 1 hour fire separation from the remainder of the building and was also not provided with a ¾ hour fire rated door that self closes and latches.
During in interview on 06/23/10 at 1:56 p.m. Specialist B confirmed the room was not 1 hour fire separated and the door was not ¾ hour fire rated and did not self close and latch.

Based on observation and interview, the facility failed to provide panic hardware on the required exit doors from the Cafeteria that has an occupant load of over 100 persons. This practice affects all patients, visitors and staff that use the Cafeteria. The facility capacity is 356 and the census was 165.

Findings are:

Observation on 06/23/10 at 9:40 a.m. revealed that the occupant load of the Cafeteria was over 100 persons and neither of the required exits from the Cafeteria were provided with panic hardware.
During an interview on 06/23/10 at 9:40 a.m. Specialist B confirmed that the exits were not provided with panic hardware.

Based on observation and interview, the facility failed to provide fire exit hardware on the fire rated exit doors for the exit stairwells. This practice affects all patients, visitors and staff of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observation on 06/22/10 at 9:35 a.m. revealed that the fire rated exit door #FD227 was provided with panic hardware and not fire exit hardware.
During an interview on 06/22/10 at 9:35 a.m. Specialist B confirmed that the door was not provided with fire exit hardware.

Observation on 06/22/10 at 10:07 a.m. revealed that the fire rated exit stairwell door, in the East hallway of Rehab, was provided with panic hardware and not fire exit hardware.
During an interview on 06/22/10 at 9:35 a.m. Specialist B confirmed the door was not provided with fire exit hardware.

Only approved panic hardware shall be used on doors that are not fire doors. Only approved fire exit hardware shall be used on fire doors. NFPA 101 2000 edition 7.2.1.7.2

Based on observation and interview the facility failed to provide two means of exiting for one of three smoke zones. The facility also provided staff to be posted at the nurse ' s station to monitor doors via camera to unlock the doors when someone approached the door to exit. One of two magnetically locked exits failed to have a means of notification for requesting unlocking of the doors. This deficient practice has the potential to affect all maternity patients, staff, and visitors of the fifth floor should there be an emergency. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-21-10 at 1:35 pm on the third floor revealed:
1. The double doors with exit signage in the south corridor on the sixth floor with magnetic locks and a phone to allow access to access on one side and a camera on the other side to allow access to exit of the double doors to allow egress.
2. No employee posted at front desk at double doors to visually see approaching visitors to the locked maternity area.
3. Nurses station located approximately 12 feet down the hall out of view of the locked entrance to the maternity unit with camera monitor and staff assigned to watch monitor.

During interview on 6-21-10 at 1:35 pm, Engineering D confirmed the locked doors with camera monitoring system.




27395

Findings are:

Observations on 6/22/10, from 2:40 pm to 6/23/10, 1:57 pm on the 1st Floor revealed:
1. The Northeast Emergency Exit Door from the Doctor ' s Parking Garage failed to open when pressure was applied to the door.
2. The Northwest Emergency Exit Door from the Doctor ' s Parking Garage failed to open when pressure was applied to the door.
3. The smoke door near the Conference Center Entrance by the Centennial Room failed to open when the door knob was turned.
This observation was confirmed by interview with Safety Specialist C on the same date and time.

Based on observation and interview, the facility failed to provide illumination of the exit discharge so that the failure of any single lighting fixture (bulb) will not leave the area in darkness. This deficient practice effects all patients, staff and visitors that use that exit. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-23-10 at 1:34 pm revealed:
1. Plaza west stair exit failed to provide a two-bulb light fixture.

During an interview on 6-23-10 at 1:34 pm, Engineering D confirmed the lack of exterior lights at the door.

Based on interviews and observations and tours of the surgery areas the facility failed to provided emergency battery powered lighting in 5 West Surgery room. Not providing the battery powered lighting could allow for total darkness during a switch from normal power to emergency power in the facility. This could cause confusion and panic and could affect the patients in the rooms. The facility had a census of 165 and has a capacity of 356.

Findings Are:

1. Based on interviews and observations on June 22, 2010 at random times and locations between 11:30 A.M and 5:00 P.M. it was determined that an emergency light had not been installed in the 5 West Surgery room. It was confirmed through observation and interview with Safety Specialist A.

Based on Record review and interview the facility failed to maintain the exit lighting of the facility by not conducting the required monthly inspections of the exit lights throughout the facility. Since exit signs are installed throughout the entire facility and are necessary to locate the nearest exit in the event of an emergency, this deficient practice has the potential to affect all residents, staff and visitors of the facility. The facility capacity is 356 and the census was 165.

Findings are:

A review of the exit and emergency light inspection reports on June 21, 2010 at 1:03pm revealed that the exit lights were being inspected on a quarterly basis.

An interview with Safety Specialist A on June 21, 2010 at 1:03pm revealed that previously the exit signs had been inspected on a monthly basis but that the report generated by the facility preventive maintenance program was accurate and that the inspections were only being conducted on a quarterly basis.




13879

Findings are:

Observations on 6-22-10 from 11:02 am to 11:15 am on the third floor revealed:
1. No exit signage to indicate second exit to east stair.
2. No exit signage provided in the east side mechanical area.
Observations on 6-23-10 at11:02 am in the basement level revealed:
3. No exit signage to indicate exit to escape ladder and hatch located near the carpenters shop.

During an interview on both dates and at times of observations, Engineering D confirmed the findings.



27394

Findings are:

Observation on 06/22/10 at 10:37 a.m. revealed the exit sign, in the New Rehab, across from the Courtyard, in the interior hallway that runs East and West, needs to be turned around so it does not lead down a dead end corridor.
During an interview on 06/22/10 at 10:37 a.m. Specialist B confirmed that the exit sign needs to be turned around to direct people to the exit corridor and not down the dead end corridor.

Observation on 06/23/10 at 9:12 a.m. revealed that the South exit, that leads through the double doors, by #1429 Facility Support, was not marked by an exit sign.
During an interview on 06/23/10 at 9:12 a.m. Specialist B confirmed that the exit path was not marked by an exit sign.


NFPA 101, 2000ed.
7.10.9.1 Inspection.
Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing.
Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Based on interviews and records review on June 22, 2010 the facility failed to provide posted information in the 5 West Surgery room outlining procedures in the event of a fire emergency in the room. Not providing the written direction could cause staff to not be familiar with their responsibilities during an emergency. The facility also failed to provide documented training to new surgical room personnel including physicians and surgeons. Not providing the training could cause personnel to not be able to respond to an emergency. This could affect all patients in the surgery areas. The facility had a census of 165 and has a capacity of 356.

1. On June 21, 2010 at 1:20 P.M. it was determined that no plan had been posted in the 5 West Surgery room and that the plan had not been practiced periodically. It was confirmed by Safety Specialist A.

2. On June 21, 2010 at 2:20 P.M. it could not be determined, through records review, that new operating room surgical personnel including physicians and surgeons had been taught general safety practices for the equipment and procedures they will use. It was confirmed by Safety Officer A.






27394

Findings are:

Observation on 06/23/10 at 9:35 a.m. revealed that the Emergency Department did not respond or follow the written emergency procedures for fire alarm activation when the fire alarm system was sounded for a broken sprinkler head in the building.
During an interview on 06/23/10 at 9:35 a.m. Specialist B confirmed that the Emergency Department did not take any action during the fire alarm.


NFPA 99
12-4.1.1.4 Rules and Regulations.

(a) Hospital authorities and professional staff shall jointly consider and agree upon necessary rules and regulations for the control of personnel concerned with anesthetizing locations. Upon adoption, rules and regulations shall be prominently posted in the operating room suite.
(d) Orientation and Training.
1. New operating room/surgical suite personnel, including physicians and surgeons, shall be taught general safety practices for the area and specific safety practices for the equipment and procedures they will use.
2. Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures shall be reviewed annually.
3. Fire exit drills shall be conducted periodically.

Based on record review and interview the facility failed to conduct fire drills for each shift in each quarter. This deficient practice affected all residents, staff and visitors of the facility.

Findings are:

Record review on 6/28/10 of fire drills revealed the facility failed to conduct fire drills for:
1. The 1st shift in the 1st quarter.
2. The 3rd shift in the 1st quarter.
3. The 3rd shift in the 2nd quarter.
4. The 2nd shift in the 3rd quarter.
5. The 2nd shift in the 4th quarter.
6. The 3rd shift in the 4th quarter.
This record review was confirmed by interview with Safety Specialist A on the same date and time.

Based on observation and interview the facility failed to have a fire alarm system installed in accordance with NFPA 72. Because the fire alarm system is used to notify personnel throughout the facility in case of fire, this deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observation during testing of the fire alarm system on June 24, 2010 between 9:30am and 12:00pm revealed that audible level in the two rooftop mechanical rooms of the new rehab area was not 85db minimum. This observation was confirmed at the same date and time by Engineering F.

Observation during testing of the fire alarm system on June 24, 2010 between 9:30am and 12:00pm revealed that the manual pull stations in the two rooftop mechanical rooms of the new rehab area were not installed with the activation handle located between 42 inches and 48 inches above the finished floor as they are front approach only. This observation was confirmed at the same date and time by Engineering F.

Observation on June 23, 2010 at 9:57 a.m. revealed that the fire alarm system in the corridors failed to operate properly during test on 6th floor. The fire alarm system ' s visual strobe was not synchronized with the other visual strobes in the corridor. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observation on June 23, 2010 at approximately from 9:30 a.m. to 11:30 a.m. revealed the fire alarm system failed to operate properly during the test on the 5th and 6th floor. The fire alarm system did not activate correctly giving the correct audible noise requirements. Without a fire alarm system staff, visitors, and residents would not be notified of an emergency. Observations were acknowledged and verified by Bio Med A on the same date and time.

Observations on June 23, 2010 from 9:30 am to 11:30 am revealed that the fire alarm notification devices on the first floor level and basement level were not flashing consistently or sounding an adequate audible alarm. This observation was confirmed by interview with Safety Specialist G on the same date and time.





13879

Findings are:

Observations on 6-22-10 at 2:15 pm on the third floor North Tower revealed:
1. The facility failed to provide an audible and visual fire alarm device in all exam rooms of the heart clinic.
Observations on 6-22-10 from 10:30 am to 11:30 am during fire alarm testing revealed:
2. Third floor Com-room notification fire alarm device failed to operate.
3. Third floor RAD area failed to provide notification fire alarm device.
4. Third floor medical gas area failed to hear the fire alarm notification over the noise in that area.
5. Five notification fire alarm devices in the third floor North Tower east corridor failed to be synchronized.
6. Visual notification fire alarm devices in the third floor North Tower in Billing area failed to be synchronized.
7. The notification fire alarm sound failed to continue after the alarm started, throughout third and fourth floors.
8. Second floor east surgical corridor notification fire alarm devices failed to be synchronized.
9. Two separate sounds could be heard in the PeriOp area during the fire alarm testing.

During an interview on 6-22-10 during the time of testing, Engineering D confirmed all the finding.


27395

Findings are:

Observations on 6/24/10, from 10:46 am to 11:19 am revealed:

Observations on the 8th and 7th Floor revealed the audible fire alarm devices sounded sporadically for approximately two minutes and stopped.

Observations on the 4th Floor East, North Side and in the Special Care Area revealed visual fire alarm devices failed to be synced together. The audible fire alarm devices sounded sporadically for approximately two minutes and stopped.
This observation was confirmed by interview with Safety Specialist C on the same date and time.



27394

Findings are:

Observation on 06/23/10 at 10:40 a.m. revealed six (6) fire alarm devices not working in the New Rehab.
During an interview on 06/23/10 at 10:40 a.m. Specialist D confirmed that the devices were not working.

Observation on 06/23/10 at 10:40 a.m. revealed that the fire alarm system was not providing the required audible levels in the Lobby, Gym, Lobby Hallway in Rehab and the Dr. Offices.
During an interview on 06/23/10 at 10:40 a.m. Specialist D confirmed the audible levels were not being reached.

Observation on 06/23/10 at 10:47 a.m. revealed the fire alarm devices in the Old Rehab area did not provide the required audible levels.
During an interview on 06/23/10 at 10:47 a.m. Specialist D confirmed that the audible levels were not being obtained.

Observation on 06/23/10 at 11:03 a.m. revealed the fire alarm devices in the Lobby did not provide the required audible levels.
During an interview on 06/23/10 at 11:03 a.m. Specialist D confirmed the audible levels are not being obtained.

Observation on 06/23/10 at 11:04 a.m. revealed that there was no fire alarm device within 15 ' of the corridor fire doors that separate the main Lobby from the New Cancer Center.
During an interview on 06/23/10 at 11:04 a.m. Specialist D confirmed that there was no fire alarm device within 15 ' of the corridor fire doors.

Observation on 06/23/10 at 11:05 a.m. revealed the fire alarm devices in the New Cancer Center did not provide the required audible levels.
During an interview on 06/23/10 at 11:05 a.m. Specialist D confirmed the devices were not providing the required audible levels.

Observation on 06/23/10 at 11:21 a.m. revealed the fire alarm devices in the Emergency Department did not provide the required audible levels.
During an interview on 06/23/10 at 11:21 a.m. Specialist D confirmed the audible levels were not reached.

Observation on 06/23/10 at 11:23 a.m. revealed that there was no visual fire alarm device in Triage 2 in the Emergency Department.
During an interview on 06/23/10 at 11:21 a.m. Specialist D confirmed that there was no fire alarm device in Triage 2.

Observation on 06/23/10 at 11:26 a.m. revealed that the required audible levels were not obtained in the PEC area.
During an interview on 06/23/10 at 11:26 a.m. Specialist D confirmed that the required audible levels were not obtained.

Based on observation and interview the facility failed to have a fire alarm system installed in accordance with NFPA 72. Because the fire alarm system is used to notify personnel throughout the facility in case of fire, this deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observation during testing of the fire alarm system on June 24, 2010 between 9:30am and 12:00pm revealed that audible level in the two rooftop mechanical rooms of the new rehab area was not 85db minimum. This observation was confirmed at the same date and time by Engineering F.

Observation during testing of the fire alarm system on June 24, 2010 between 9:30am and 12:00pm revealed that the manual pull stations in the two rooftop mechanical rooms of the new rehab area were not installed with the activation handle located between 42 inches and 48 inches above the finished floor as they are front approach only. This observation was confirmed at the same date and time by Engineering F.



27394

Findings are:

Observation on 06/21/10 at 1:30 p.m. revealed a smoke detector head that was located next to an air vent that may prevent the detector head from functioning properly.
During an interview on 06/21/10 at 1:30 p.m. Specialist B confirmed that the detector head was located right next to an air vent.

Observation on 06/22/10 at 10:55 a.m. revealed a smoke detector head in Electrical Room #22785, in the New Rehab area, that had the plastic protective cover on it.
During an interview on 06/22/10 at 10:55 a.m. Specialist B confirmed the plastic cover over the detector head preventing it from operating.

Based on observation and interview, the facility failed to install the automatic sprinkler system to provide complete coverage for all portions of the building in accordance with NFPA 13. This deficient practice affected all patients, visitors and staff that are in the area of those areas without sprinkler protection. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 5-23-10 at 10:45 am on the basement level revealed HVAC office failed to provide sprinkler protection.

During an interview on 5-23-10 at 10:45 am Engineering D confirmed the lack of sprinkler protection in that room.



27395

Findings are:

Observations on 6/21/10, from 12:59 pm to 6/23/10, 10:15 am revealed:

Observation on the Penthouse Level revealed the East Elevator Penthouse failed to be sprinkler protected.

Observation on the 1st Floor revealed a glycol loop for the sprinkler system inside of the closet in Maintenance Area 1153A. The expansion tank installed on the sprinkler system failed to be a listed component for a sprinkler system; only carrying a listing of 150 psi.
This observation was confirmed by interview with Safety Specialist C on the same date and time.

Observation on 6/23/10 at 9:50 am outside of the Cancer Center revealed a PIV and a FDC. The facility failed to provide information at the sprinkler system components as to what areas of the facility they serve.
This observation was confirmed by interview with Safety Specialist C on the same date and time.



27394

Findings are:

Observation on 06/23/10 at 10:10 a.m. revealed an area by the Cafeteria entrance, on the East side of the double corridor fire doors, that was not protected by the sprinkler system.
During an interview on 06/23/10 at 10:10 a.m. Specialist B confirmed the missing sprinkler system coverage.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 Edition of NFPA 25, by ensuring that sprinkler heads are installed as required. Failed to provide protection and monitoring of Post Indicator Valves (PIV). This deficient practice affects all residents, visitors and staff that use those areas. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-28-10 at 10:49 am revealed the PIV located in the front parking lot near street failed to provide protections against mechanical damage. The PIV failed to be monitored by the fire alarm panel for water flow.

During an interview on 6-28-10 at 10:49 am, Safety Specialist B confirmed the findings.

NFPA Standard
Post indicator valves shall be protected against mechanical damage where needed. 2002 NFPA 24, 6.3.2

Based on observation and interview, the facility failed to conduct monthly inspection of fire extinguishers throughout the building. This deficient practice affects all patients, visitors and staff that are in the area. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-28-10 from 9:30 am to 10:46 am revealed all the fire extinguisher throughout the building failed to have a current monthly inspection. The last inspection on card was 5-13-10.

During an interview on 6-28-10 at 9:30 am, Safety Specialist B confirmed the findings.

Based on record review and interview the facility failed to maintain the fire and smoke dampers of the facility by not performing the required maintenance. Because the fire and smoke dampers are installed throughout the facility for the protection of smoke barriers, hazardous areas, and other protection measures to limit the spread of smoke and fire, this deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 356 and the census was 165.

Findings are:

A review of the fire and smoke damper maintenance reports from an outside contractor on June 21, 2010 at 1:18pm revealed that there were several fire and smoke dampers throughout the facility that they were not able to perform the required maintenance on because there was no access panel installed to allow for the inspection and testing of the dampers.

An interview with Safety Specialist A on June 21, 2010 at 1:18pm revealed that reports were accurate and complete and that several dampers had not been inspected and tested because there was no access to the dampers.

Based on observation, interview and record review, the facility failed to have cooking facilities protected and maintained in accordance with NFPA 96. This practice affects all patients, visitors and staff of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observation on 06/23/10 at 1:46 p.m. revealed two (2) manual pull stations for the kitchen hood suppression systems were mounted to high.
During an interview on 06/23/10 at 1:46 p.m. Specialist B confirmed the manual pull stations were mounted to high.

Record review on 06/28/10 at 10:30 a.m. revealed that on the inspection report dated 01/13/10, the kitchen suppression system did not have the gas valve operation checked to verify that it is in working condition.

A readily accessible means for manual activation shall be located between 1067 mm and 1219 mm (42 in. and 48 in.) above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected. NFPA 96 10.5.1

All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer ' s listed procedures. NFPA 96 11.2.2

Based on observation, interview the facility failed to maintain the facility free of heat producing devices in all areas of the building. This deficient practice affected all patients, staff and visitors in the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-21-10 at 2:54 pm on fourth floor revealed:
1. Portable space heater in care management office 4406.
Observations on 6-22-10 at 10:10 am and 1:59 pm on third floor revealed:
2. Portable space heater in Bio-Med room.
3. Portable space heater in the third floor billing area of the North Tower, in the first cubical north east corner.

During an interview on both dates and times, Engineering D confirmed the space heaters, and no documentation was provided to verify temperature requirement.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice affected all patients, staff and visitors in the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-21-10 at 3:10 pm on the third floor revealed:
1. Two chairs and housekeeping cart stored in the east corridor between the special care unit and the east adult unit.
Observations on 6-23-10 at 10:50 am in the basement level revealed:
2. A maintenance cart and equipment stored in front of access ladder to the escape hatch. Blocking the signage that states " NO Storage " .

During an interview on both dates and times, Engineering D confirmed the findings.

Based on observation and interview the facility failed to maintain the protection of recycling containers that exceed 32 gallons capacity in areas protected as hazardous areas throughout the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-28-10 at 9:43 am on the third floor revealed:
1. Paper recycling barrel over 32 gallons in Suite 305, room 316 in a room without a door providing a self-closing device.
Observations on 6-28-10 at 10:13 am and 10:19 am on the second floor revealed:
2. Paper recycling barrel over 32 gallons in Suite 203, room D224 in a room without a door providing a self-closing device.
3. Paper recycling barrel over 32 gallons in Suite 202, room C207 in a room without a door providing a self-closing device.
Observations on 6-28-10 at 10:33 am on the first floor revealed:
4. Paper recycling barrel over 32 gallons in Suite 101 in Nursing area, where there was opening in corridor wall with a manual closure on window shutter.

During an interview on 6-28-10 at times of observations, Safety Specialist B confirmed all the findings.

Based on observation and interview, the facility failed to have medical gas cylinders stored and adequately secured in accordance with NFPA 99. Failure to restrain oxygen cylinders increases the potential for the cylinder to fall over, break, and become a projectile that could injure anyone in the path of the cylinder. The facility capacity is 356 and the census was 165.

Findings are:

Observation on 6-22-10 at 2:11 pm on third floor North Tower revealed:
1. Room 3308 contained one E-sized oxygen cylinder unrestrained.

During an interview on 6-22-10 at 2:11 pm, Engineering D confirmed the oxygen tank failed to be secured.


NFPA Standard:
Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. 1999 NFPA 99, 4-3.5.2.1 (27).

Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4-3.1.1.2

Based on observations and interviews the facility failed to provide approved color code labeling for Level 1 Gas and Vacuum Systems at 2 of 2 locations in the 5 West Surgery area and Main Surgery area including 16 of 16 locations. Not providing the correct color labeling of a particular gas when applied and as determined by the Compressed Gas Association Pamphlet C-9 and National Fire Protection Association could cause confusion of what valve to shut off in a fire emergency. In addition the facility failed to provide turn off handles connected to the valves at 1 of 2 valve box locations in the 5 West Surgery area. Not being able to indentify and then to shut off gasses when needed could affect all the patients in the surgery area by allowing a fire to be augmented by medical gasses. Thirdly the facility failed to provide documented information on the minimum vacuum operating range for vacuum pump system. Not providing the correct vacuum could allow Waste Anesthetic Gases and other scavenged gases to become part of the atmosphere of the surgery areas. The facility had a census of 165 and has a capacity of 356.
Findings Are:

1. On June 22, 2010 at 1:12 P.M. it was observed that air was color coded green, vacuum yellow and oxygen yellow at the shut off cabinet locations at 5 West obstetrics surgery area. Safety Officer 1 and Engineer I confirmed the findings.

2. On June 22, 2010 at 1:12 P.M. it was observed that handles for turning off valves had been taken off and left in the cabinet. Safety Officer A and Engineer I confirmed the findings.

3. On June 22, 2010 at 2:20 P.M. it was observed that color coded labeling was incorrect for medical gas piping in shut off boxes outside of surgery rooms. Oxygen was labeled yellow and vacuum was labeled yellow. Safety Officer A and Engineer I confirmed the findings.

4. On June 22, 2010 at 4:10 P.M it was determined through interviews with Engineer I that no information could be obtained indicating levels of medical gas vacuum at a minimum of 12 inches of Mercury. (Hg).



27394

Findings are:

Observation on 06/23/10 at 10:15 a.m. revealed the gas valves were not labeled with the correct color coding in the medical gas cabinet by #1327.
During an interview on 06/23/10 at 10:15 a.m. Specialist B confirmed that the medical gasses were not color coded correctly.

Based on records review as provided on June 21, 2010 and interviews the facility failed to provide information verifying that all surgery rooms met the minimum humidity requirements of 35 per cent as determined by the National Fire Protection Association and Pamphlet 99. Not providing correct and approved humidity levels could be a major concern for nonflammable anesthetizing locations and reducing the hazard of electrostatic spark discharges under many conditions. This could affect all the patients in surgery areas.
The facility had a census of 165 and has a capacity of 356.

1. On June 21, 2010 it was determined through records review as supplied by the facility that humidity level information was not available for rooms 1, 2 & 7 and the 5 West to determine minimum percentages of humidity. Safety Specialist A confirmed records submitted to surveyors; however records left out the rooms in question.

Based on observation and interview the facility failed to provide a Type I Essential Electrical System (EES) by not having the emergency generator monitored at a continuously occupied location and by not having a generator feeder installed to the Life Safety Transfer Switch ATS1. This Life Safety system also does not transfer in less than the required 10 seconds. Because this emergency generator system supplies emergency power to the entire facility, this deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observation on June 22, 2010 at 9:00am revealed that there was a generator battery warning light illuminated on the generator emergency switchgear in the Energy Plant and there was no one around and no remote notification of this alarm at a continuously attended location.

An interview with Engineer E on June 22, 2010 at 9:00am revealed that this alarm was not activated at a continuously attended location and there was no disarrangement signal anywhere around the facility. They also stated that there is no remote monitoring for the generators at any point other than the energy plant and that no one was generally in the room where the monitor panel was.

Observation on June 22, 2010 at 9:49am revealed that the two sources of power to the Life Safety Transfer Switch ATS 1 were coming from the normal electrical service and that there was no direct connection of the EES to this transfer switch. Thus the load from this transfer switch would not be re-energized in the required 10 second interval following the loss of normal power. This observation was confirmed at the same date and time by Engineering E.


NFPA 99, 199ed.
3-4.1.1.2
Essential electrical systems shall have a minimum of two independent sources of power: a normal source generally supplying the entire electrical system and one or more alternate sources for use when the normal source is interrupted.
3-4.1.1.3
The alternate source of power shall be a generator(s) driven by some form of prime mover(s) and located on the premises.
3-4.1.1.8 + Load Pickup.
The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
3-4.1.1.15 + Alarm Annunciator.
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

Based on observation and interview the facility failed to restrain compressed gas cylinder, refrigerant cylinders and a Freon cylinder. This deficient practice affected all staff and visitors of the facility that use basement level. The facility capacity is 356 and the census was 165.

Findings are:

Observation on 6-23-10 at 10:50 am in basement level revealed:
1. Six refrigerant bottles stacked on top of other storage and not secured in the HVAC office.
2. One unrestrained unidentified compressed gas container in the HVAC office.
3. One unrestrained 125 pound Freon cylinder in the HVAC office.

During an interview on 6-23-10 at 10:50 am, Engineering D confirmed the unrestrained cylinders.

NFPA Standard:
Compressed gas containers, cylinders, and tanks in use or in storage shall be secured to prevent them from falling or being knocked over by corralling them and securing them to a cart, framework, or a fixed object by use of a restraint, unless otherwise permitted by the following. 2003, NFPA 1, 63.3.1.3.4



27395

Based on observation and interview the facility failed to post " no smoking " signage around the bulk oxygen tank so that persons from all directions were aware to keep sources of ignition away from the area. This deficient practice has the potential to affect all patients, staff and visitors of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observation on 6/22/10, at 1:14 pm of the bulk oxygen tank revealed " no smoking " signage failed to be visible when approaching the west side of the tank.
This observation was confirmed by interview with Safety Specialist C on the same date and time.

NFPA 50, 3.5.8 The bulk oxygen storage location shall be permanently placarded to indicate " OXYGEN - NO SMOKING - NO OPEN FLAMES. "


Based on observation and interview the facility failed to post " no smoking " signs at the heliport. This deficient practice has the potential to affect all patients, staff and visitors of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observation on 6/22/10 at 8:52 am revealed both entrances to the heliport failed to have " no smoking " signage installed
This observation was confirmed by interview with Safety Specialist C on the same date and time.

NFPA 418, 2.5 No Smoking. No smoking shall be permitted within 50 ft (15.2 m) of the landing pad edge. No smoking signs shall be erected at access/egress points to the heliport.


Based on observation and staff interview the facility failed to install battery backup illumination for the facility generators. This deficient practice has the potential to affect all patients, staff and visitors of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observation on 6/22/10, from 9:44 am to 9:52 am in the Energy Plant revealed:
1. The Generator Room failed to have battery backup illumination installed in the room.
2. The North Generator Room failed to have battery backup illumination installed in the room.
This observation was confirmed by interview with Safety Specialist C on the same date and time.

NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.



27394

Based on observation, interview and record review, the facility failed to have the FM 200 fire suppression system maintained in a working, reliable condition. This practice affects all patients, visitors and staff of the 1st Floor. The facility capacity is 356 and the census was 165.

Findings are:

Observation on 06/23/10 at 9:09 a.m. revealed an obstructed nozzle for the FM 200 system in the Computer Room, on the West side of the Cafeteria.
Record review on 06/23/10 at 9:09 a.m. revealed that the inspection report for the FM 200 system noted that the nozzle was being obstructed.
During an interview on 06/23/10 at 9:09 a.m. Specialist B confirmed the nozzle being obstructed and also confirmed the inspection report stating the nozzle was being obstructed.

The discharge nozzle shall be oriented in such a manner that optimum agent dispersal can be effected. NFPA 2001 4-7.2.2.5

Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observation on June 22, 2010 at 9:05am revealed that there were non-life safety loads for receptacles in the Energy Plant #14 and #16 connected to the Life Safety branch panel E1L in the generator switchgear room. This observation was confirmed at the same date and time by Engineering E.

Observation on June 22, 2010 at 10:19am revealed that there were Life Safety loads for the Fire Alarm system and Elevator Shaft dampers connected to the Equipment System branch panel 1EQ. This observation was confirmed at the same date and time by Engineering E.

Observation on June 22, 2010 at 10:56am revealed that there were two non-life safety loads for Siemens HVAC controls connected to the Life Safety branch panel 2E. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 10:59am revealed that there were non-critical loads for a water heater connected to the Critical Branch panel 2CH. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 11:04am revealed that there were the following non-critical loads connected to the Critical Branch panel 3C. #23 Siemens Control, and #7 Fire Dampers. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 11:04am revealed that there were the following Life Safety loads connected to the Critical Branch panel 3C. #21 Med Gas alarm Room 3449 and #24 Fire Alarm panel. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 11:10am revealed that there were the following non-life safety loads connected to the Life Safety branch panel 4E. #4 Security Door Room 4461, #5 Security Door Room 4470, #8 Security Door Room 4470A, #10 Siemens Controls 4th Floor, #12 AHU 4 Controls, #16 Data / Comm Rack 4428A, and #17 AHU 5 Controls. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 1:08pm revealed that there were the following non-critical loads connected to the Critical Branch panel 8C2. #11 Water Circ Pump South Corridor, and #12 Outlet Siemens Panel. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 1:20pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 7E2. #1 Tube Messenger, #6 Rec 6 flr EC671, #8 Rec Rm 780, #9, Rec 8th flr EC8, #14 Siemens Alarm Panel, #15 and17 A/C Condensor Elevator Machine. This observation was confirmed at the same date and time by Engineering F.


Observation on June 22, 2010 at 1:22pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 7E1. #6 8th Flr Rec, #9 Pneumatic Tube System, and #16 HVAC Controls. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 1:35pm revealed that there were non-critical loads for HVAC Controls connected to the Critical Branch panel 6C2 while these loads are connected to the equipment system and normal power in other areas of the facility. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 1:42pm revealed that there were non-critical loads for HVAC Controls connected to the Critical Branch panel 5C2 while these loads are connected to the equipment system and normal power in other areas of the facility. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 1:45pm revealed that there were 4 non-critical loads for power operated doors connected to the Critical Branch panel 5C1. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 1:50pm revealed that there were non-critical loads for HVAC Controls connected to the Critical Branch panel 4C2 while these loads are connected to the equipment system and normal power in other areas of the facility. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 1:51pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 4E2. #6 Outlet 4th Floor EC4512, and #8 Outlet 6th Floor EC580. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 1:54pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 4E1. #6 Outlet EC462B, #13 Security Cameras, and #14,15, 16 5th Floor. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 1:56pm revealed that there were the following non-critical loads connected to the Critical Branch panel 4C1. #1 Johnson Control, and #5 Johnson Control. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 2:05pm revealed that there were the following Life Safety loads connected to the Equipment System panel EQ2. #3, Fire Alarm Panel Accel and #5 Fire Alarm Panel Air Comp. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 2:07pm revealed that there were the following Life Safety loads connected to the Equipment System panel EQ3. #13 Elevator Shaft Dampers. This observation was confirmed at the same date and time by Engineering F.
Observation on June 22, 2010 at 2:13pm revealed that there were the following non-life safety loads connected to the Life Safety Branch panel 2E2. #6 Outlet Electrical Room, #12 Siemens Panel, #13 Outlet Sec. Cam. Staff Elevator, #14 Pager Interface, and #18 Outlets Conference Room. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 2:16pm revealed that there were the following non-life safety loads connected to the Life Safety Branch panel 2E3. #5 Outlets Electrical Closet, #6 UH 3rd Floor, #7 Spine Pampers, #9, Spine Lights, #11 Spine Doors North, #13 Spine Doors South, #15 Temp Lights Med Records, and #18 Fire Campers Surgery Waiting Room. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 2:17pm revealed that there were the following Life Safety loads connected to the Critical Branch panel 2C3. #11 Auto Doors NE Corridor, #13 Auto Doors East Corridor, #27 Won Door East Corridor, #29 SW Auto Door, East Entry, and #31 Won Door West Corridor. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 2:21pm revealed that there were the following non-critical loads connected to the Critical Branch panel 2C5-A. #19 Johnson Controls, and #27 Siemens Control Panel 2384. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 2:25pm revealed that there were the following non-critical loads connected to the Critical Branch panel 2C5. #1 Damper motors Diagnostic, #9 Auto doors SE Ultrasound, #13, Outlet Security Camera Radiology, and #18 Door operator Radiology. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 2:37pm revealed that there were the following non-life safety loads connected to the Life Safety Branch panel LS-2. #2 Lights Room 209, #4 Lights Room 201, #6 Lights Room 203, #8 Lights Room 101, #10 Lights Room 103, #14 Lights Room108, #18 Outlets-Hyperth, #20 Oultet Above Panel, #41 Johnson Controls, and #38, 40,42 Elevator. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 2:42pm revealed that there were the following non-critical loads connected to the Critical Branch panel CR21. #67 Auto Door Room 223, #69 Sliding Auto Door Room 225, and #81 Outlets Outside. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 2:42pm revealed that there were the following Life Safety loads connected to the Critical Branch panel CR21. #63 Fire Alarm Panel, and #64 Fire Alarm Panel. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 2:52pm revealed that there were non-critical loads for HVAC Controls connected to the Critical Branch panel 2C4 while these loads are connected to the equipment system and normal power in other areas of the facility. This observation was confirmed at the same date and time by Engineering F.

Observation on June 22, 2010 at 2:55pm revealed that there were the following non-life safety loads connected to the Life Safety Branch panel 2E1. #1 Lights NW oncology, #3 Lights NE Oncology, #5 Outlets Phone room & EC2424, #7 Lights South Oncology, #8 Fire & Security Room 2424, and #9 Nurse call Oncology. Observation on June 22, 2010 at 1:35pm revealed that there were non-critical loads for HVAC Controls connected to the Critical Branch panel 6C2 while these loads are connected to the equipment system and normal power in other areas of the facility. This observation was confirmed at the same date and time by Engineering F.

Observation on June 23, 2010 at 9:07am revealed that there were the following non-life safety loads connected to the Life Safety Branch panel 1E3. #7 Clock Controls, #8 Outlet Room 1303, #10 Outlet Room 1303, #11 Lights & Plugs Pipe Acc. Tunnel, and #13 Siemens Equipment. This observation was confirmed at the same date and time by Engineering F.

Observation on June 23, 2010 at 9:13am revealed that there were the following non-life safety loads connected to the Life Safety Branch panel 1E5. #2 Outlet Data, #3 Lights linen storage, #4 Lights New Mechanical Room, and #8 Dock Auto Doors. This observation was confirmed at the same date and time by Engineering F.

Observation on June 23, 2010 at 9:17am revealed that there was a non-life safety load for the cooler timers connected to the Life Safety Branch panel 1E4. This observation was confirmed at the same date and time by Engineering F.

Observation on June 23, 2010 at 9:27am revealed that there were the following non-life safety loads connected to the Life Safety Branch panel BE2. #3 Outlets West Wall, #13 Outlets Elevator Pit, and #15 Lights Elevator Pit. This observation was confirmed at the same date and time by Engineering F.

Observation on June 23, 2010 at 9:29am revealed that there were the following Life Safety loads connected to the Equipment System panel BQ2. #2 Lights Conv. Elevator Car, #3 Car Lights Elevator 2, #8 Elevator Fire Alarm Shunt Trip, #11 Elevator 1 Car Lights, #17 Elevator #9 Car Lights, #19 Elevator #10 Car Lights, #22 Elevator #4 Car Lights, and #24 Elevator #5 Car Lights. This observation was confirmed at the same date and time by Engineering F.

Observation on June 23, 2010 at 9:36am revealed that there were the following non-life safety loads connected to the Life Safety Branch panel BE3. #5, 7 A/C condenser NE corner Mech. Room, and #9 Water Treatment. This observation was confirmed at the same date and time by Engineering F.

Observation on June 23, 2010 at 10:10am revealed that there were the following non-critical loads connected to the Critical Branch panel 3C1. #1 Mechanical Penthouse, #2 Mechanical Penthouse Unit Heaters, #3 Mechanical Penthouse, #5 Penthouse Receptacles, #7 Penthouse Receptacles, and #8 Unit Heater East Penthouse. This observation was confirmed at the same date and time by Engineering F.

Observation on July 23, 2010 at 10:42am revealed that there was a Life Safety Load for Elevator Shaft smoke dampers connected to the Equipment System panel 3Q3. This observation was confirmed at the same date and time by Engineering F.

Record Review of the panel schedule for the Life Safety Branch panel 2E6 on June 23, 2010 between 1:00pm and 4:00pm revealed that that there were the following non-life safety loads connected to that Life Safety Branch panel. #1 Outlet Electrical Closet and #8 Outlet OR#4 TV. This record was confirmed at the same date and time by Engineering F.

Record Review of the panel schedule for the Life Safety Branch panel 2E7 on June 23, 2010 between 1:00pm and 4:00pm revealed that that there were the following non-life safety loads connected to that Life Safety Branch panel. #4 Recpt-Lobby, Hold, Pool, #9 Nurse Call Panel, and #18 Recpt-Code Blue. This record was confirmed at the same date and time by Engineering F.

Record Review of the panel schedule for the Equipment System panel 1EQ on June 23, 2010 between 1:00pm and 4:00pm revealed that that there were the following Life Safety loads connected to that Equipment System panel. #12 East Won Door Corridor 4469, #14 Elevator Smoke Shutters 3rd Floor, #16 Elevator Smoke Shutters 4th Floor, #20 West Won Door Corridor 4458, #22 Elevator 17 Car Lights, #24 Elevator 18 Car Lights, and #27 Fire Alarm Panel Mechanical Room. This record was confirmed at the same date and time by Engineering F.

Record Review of the panel schedule for the Critical Branch panel 2CX-1 on June 23, 2010 between 1:00pm and 4:00pm revealed that that there were the following Life Safety loads connected to that Critical Branch panel. #11 Med Gas Col OR Room 1, #12 Med Gas Col OR Room2, #23 Med Gas Col OR Room 3, #24 Med Gad Col OR Room 4, #35 Med Gas Col OR Room 5, #36 Med Gas Col OR Room 6, and #42 Med Gas Col OR Room7 . This record was confirmed at the same date and time by Engineering F.

Record Review of the panel schedule for the Critical Branch panel 2CX-2 on June 23, 2010 between 1:00pm and 4:00pm revealed that that there were the following Life Safety loads connected to that Critical Branch panel. #53 Med Gas Col OR Room 9, #54 Med Gas Col OR Room 8, #72 Med Gas OR 7 North, #74 Med Gad OR 7 North, #76 Med Gas OR 7 East #2, and #80 Med Gas OR 7 East #1 . This record was confirmed at the same date and time by Engineering F.



NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on staff interview and observation, the facility failed to ensure all electrical is installed in accordance with National Fire Protection Association 70 (electrical code). These deficient practices affected all patients, visitors and staff that are in there of three floors. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-28-10 at 9:38 am and 9:46 am on the third floor revealed:
1. Contractor ' s cart, trashcan stored in front of the panel box in housekeeping storage.
2. Refrigerator plugged into an extension cord in E312.
Observations on 6-28-10 at 9:48 am on the second floor revealed:
3. Vacuum, trashcan and boxes stored in front of the panel box in housekeeping storage.
Observations on 6-28-10 from 10:24 am to 10:38 am on the first floor revealed:
4. Cover plate cover missing on light switch next to group room in A117 Gym.
5. Non hospital grade power strip in patient game room A121 on TV cart.
6. Stored items in front of the panel box in housekeeping storage.

During an interview on 6-28-10 at times of observations, Safety Specialist B confirmed all the findings.

Based on observation and interview the facility failed to have Alcohol Based Hand Rub (ABHR) dispensers installed so that they are not above or immediately adjacent to an electrical ignition source. This deficient practice affected all residents, staff, and visitors of the facility. The facility capacity is 356 and the census was 165.

Findings are:

Observations on 6-21-10 at 12:58 pm and 1:47 pm on the fifth floor revealed:
1. Room 520 an ABHR dispenser installed adjacent to light switch.
2. Room 536 an ABHR dispenser installed adjacent to light switch.
Observations on 6-22-10 at 9:13 am and 9:17 am on the fourth floor revealed:
3. Pod A 4-North ICU nurses station an ABHR dispenser installed adjacent to light switch.
4. Pharmacy 4518 an ABHR dispenser installed adjacent to an outlet.
Observations on 6-22-10 at 1:47 pm on the third floor North Tower revealed:
5. Room 3333 an ABHR dispenser installed adjacent to light switch.

During an interview on 6-21-10 and 6-22-10 at times of observations, Engineering D confirmed the ABHR dispensers were installed immediately adjacent to electrical sources.



27395

Findings are:

Observation on 6/22/10, at 9:41 am in the Decontamination South Entrance revealed an alcohol based hand sanitizer installed immediately adjacent to a light switch.
This observation was confirmed by interview with Safety Specialist C on the same date and time.



27394

Findings are:

Observation on 06/21/10 at 1:40 p.m. revealed a hand sanitizer dispenser, in Ultrasound #2, that was located approximately 2 ' above an electrical outlet.
During an interview on 06/21/10 at 1:40 p.m. Specialist B confirmed the dispenser being located above an ignition source.