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Based on documentation review and staff interview, the facility failed to provide an essential electrical system capable of supplying service within 10 seconds. This deficient practice did not ensure the emergency generator would provide the essential life safety power supply in the event of a power loss, affecting all building occupants of all campus buildings. Facility census was 109 and licensed for 423 at the time of the survey.

Findings are:

Observations on 11-14-2019 at 9:25 AM revealed the following:

Documentation shown that emergency generators 4, 5 and 6 supplying the life safety branch took 15 seconds to transfer power during the October 2019 monthly load test.

During an interview on 11-14-2019 at 9:25, Facility Staff A confirmed the findings.

Based on observation and interview, the facility failed to provide a self-closing device on the door separating construction from an occupied area. This deficient practice would allow fire, gasses and smoke to migrate between the areas on the 3rd Floor. The facility has the capacity for 137 beds with a census of 105 on the day of survey.

Findings are:
Observations on 11-18-19 at 9:34 am revealed, the door separating the construction area near the 3rd floor elevator lobby failed to provide a self-closing device.

During an interview on 11-18-19 at 9:34 am, Facility Staff D confirmed the lack of a self-closing device.

Based on observation and interview, the facility failed to maintain a 3-hour fire separation doors. This deficient practice would allow smoke and fire to migrate between the occupancies on the second floor. The facility has the capacity for 137 beds with a census of 105 on the day of survey.

Findings are:
Observation on 11-18-19 at 11:02 am revealed:
2nd Floor
1. The 3-hour fire door in the "wedge" had an undercut greater than ¾ inch.

During an interview on 11-18-19 at 11:02 am, Facility Staff D confirmed the findings.

Based on observation, record review and interview, the facility failed to provide fire sprinkler protection or provide fire resistance documentation of the fabric canopy attached to the exterior of the North Tower near Compactor. The facility has the capacity for 423 beds with a census of 109 on the day of survey.

Findings are:
Observations on 11-13-19 at 1:45 PM revealed, a fabric awning approximately 10 feet by 27 feet attached to the building near the trash compactor, was in excess of four feet wide and failed to provide sprinkler protection or documentation of fire resistance.

During an interview on 11-13-19 at 1:45 PM, Facility Staff D confirmed the canopy with the lack of sprinkler protection and failed to provide documentation.

NFPA Standard:
2010, NFPA 13, 8.15.7.1
Unless the requirements of 8.15.7.2, 8.15.7.3, or 8.15.7.4 are met, sprinklers shall be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding 4 ft (1.2 m) in width.
8.15.7.2*
Sprinklers shall be permitted to be omitted where the canopies, roofs, porte-cocheres, balconies, decks, or similar projections are constructed with materials that are noncombustible, limited-combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant- Treated Wood and Fire-Retardant Coatings for Building Materials.
8.15.7.3
Sprinklers shall be permitted to be omitted from below the canopies, roofs, porte-cocheres, balconies, decks, or similar projections of combustible construction, provided the exposed finish material on the roofs, canopies, or porte-cocheres are noncombustible, limited-combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials, and the roofs, canopies, or porte-cocheres contain only sprinklered concealed spaces or any of the following unsprinklered combustible concealed spaces:

Based on observation and interview, the facility allowed the use of "NOT AN EXIT" signage on doors in a means of egress. The deficient practice would cause confusion and delay egress on the second floor. The facility has the capacity for 137 beds with a census of 105 on the day of survey.

Findings are:
Observation on 11-18-19 at 1:52 PM revealed:
1. Exit doors 066852/062537 next to Electrical Room 2551 had "Not an Exit" signage on the door.

During an interview on 11-18-19 at 1:52 PM, Maintenance Staff D confirmed the findings.

Based on observation and interview, the facility failed to maintain clear and unobstructed exit corridors. This deficient practice would impede the full use of the exit corridor and delay exiting during an emergency on the 3rd Floor. The facility has the capacity for 137 beds with a census of 105 on the day of survey.

Findings are:
Observation on 11-18-19 at 11:02 am revealed:
3rd Floor
1. Medical equipment stored in the NICU corridors near rooms 3311 and 3301.

During an interview on 11-18-19 at 11:02 am, Facility Staff D confirmed the equipment in corridor and stated this area was not a Suite.

Observation on 11-19-19 at 9:32 am revealed:
2nd Floor IVF
1. Medical equipment and cardboard boxes stored in the IVF corridor.

During an interview on 11-19-19 at 9:32 am, Facility Staff D confirmed the findings.

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2012 NFPA 101, 7.1.10.1

Based on observation and interview, the facility failed to post signage to operate delayed egress locks on magnetically locked exit doors and failed to provide signage on break away doors in the North Tower on the 1st and 4th floors. This deficient practice would delay egress during an emergency. The facility has the capacity for 423 beds with a census of 109 on the day of survey.

Findings are:
Observations on 11-13-19 between 10:42 am and 3:08 PM revealed:
4th Floor
1. The magnetically locked exit door from PICU south failed to activate unlocking signal after pressure was applied for three seconds.
2. The delayed egress operating instructions signage installed on the south PICU exit door failed to be installed near the hardware.
3. The delayed egress operating instructions signage on the magnetically locked door in PICU failed to be installed at hardware height.
4. The delayed egress operating instructions signage on the magnetically locked door in PICU failed to release in the time posted on the door.
5. West stair tower door failed to provide delayed egress operating instructions signage on the magnetically locked door.
6. The delayed egress operating instructions signage installed on the smoke doors next to room 490 failed to be installed near the hardware.
7. The smoke door into PICU south installed with delayed egress hardware failed to open.
1st Floor
8. 3 of 3 sliding exit doors at the Emergency Department failed to break open when the power was turned off.

During an interview on 11-13-19 between 10:42 am and 3:08 PM, Facility Staff D confirmed the findings.

NFPA Standard:
NFPA 101, 2012, 7.2.1.6.1 Delayed-Egress Locking Systems.
7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected
throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section
9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met:
(4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on observation and interview, the facility failed to assure that there were no dead-end corridors on the sixth floor. This deficient practice would delay egress and cause confusion in the North Tower. The facility has a capacity of 423 and a census of 109 patients at the time of survey.

Findings are:
Observations on 11-12-19 at 3:10 PM revealed:
6th Floor
1. The facility failed to post an exit sign above the smoke doors leading to a construction area and failed to provide a directional exit sign, which created a 68 foot long dead end in the north corridor.
2. The facility created a 36 foot long dead end on the south corridor by construction barrier.

During interview on 11-12-19 at 3:10 PM, Facility Staff D confirmed the distance of the dead end and confirmed the construction barrier had created a dead end.

Based on observation and interview, the facility failed to provide a second required exit from the IVF area without passing through any intervening rooms or spaces other than an approved corridor to get to an exit. The facility has the capacity for 137 beds with a census of 105 on the day of survey.

Findings are:
Observations on 11-19-19 at 9:20 am revealed, the IVF area provided only one exit from OR 8 which lead through a corridor into the "wedge" corridor.

During an interview on 11-19-19 at 9:20 am, Facility Staff D confirmed that the facility provided only one exit in the corridor outside OR 8 in the IVF area, and stated that it was classified as a business suite.

NFPA Standard:
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4

Based on document review and staff interview, the facility failed to provide documentation that all battery operated emergency light fixtures were functionally tested monthly or within a 3-5 week timeframe. The deficient practice would not ensure the battery operated emergency light would activate to illuminate the means of egress in the event of a power loss affecting all occupants of the building. The facility has a licensed capacity of 423.

Findings are:

Documentation review on 11-14-2019 at 9:40 AM revealed the following:

1) Emergency light #081568 was not tested between 4-29-2018 and 6-11-2018.

2) Emergency light #081568 was not tested between 8-28-2018 and 10-23-2018.

3) Emergency light #081568 was not tested between 10-23-2018 and 12-20-2018.

During an interview on 11-14-2019 at 9:40 AM, Facility Staff J confirmed the finding.

Based on observation and staff interview, the facility failed to ensure proper exit signage in the North Tower. This deficient practice would prevent occupants from identifying a set of doors within a required means of egress as an exit on the 4th and 5th floors. The facility had a capacity of for 423 beds with a census of 109 on the day of survey.

Findings are:
Observation on 11-13-19 between 9:43 am to 10:58 am revealed:
5th Floor
1. Standing in the corridor outside 5N-120 looking East, no exit sign was provided over the smoke doors.
2. Standing in the south corridor outside elevator lobby looking east, no exit sign was provided to indicate a second required exit.
4th Floor
3. Standing in the south corridor looking east outside the service elevator no exit sign was provided to indicate a second required exit.
4. Chevrons pointing left and right on the exit sign above the south smoke doors inside PICU across from room 496.
5. Standing at the south smoke doors outside PICU no exit sign was provided to indicate a second required exit.
6. No exit sign was provided about the double doors 4N118 to indicate a second required exit.

During an interview on 11-13-19 between 9:43 am to 10:58 am, Facility Staff D confirmed exit signage was not installed above the doors and that the dual chevrons could cause confusion of exit travel.

Based on observation and staff interview, the facility failed to ensure a stair door would positively latch. This condition would allow smoke or fire to enter the stair tower. The facility census was 109 with a capacity of 423.

Findings are:
Observation on 11/13/19, at 11:30 am revealed the 2nd Floor Locker Room Stair Tower Door did not positively latch when self-closed.

In an interview on 11/13/19, at 11:30 am, Facility Staff H confirmed the findings.

Based on observation and interview, the facility failed to assure the doors to hazardous areas would close and latch within the doorframe, failed to assure doors were not held open and that hazard rooms were constructed to resist the passage of smoke. These deficient practices would allow fire, smoke and gases to migrate into the exit corridor in the North Tower in the basement, 1st, 2nd, 3rd 5th and 6th floors. The facility has the capacity for 423 beds with a census of 109 on the day of survey.

Findings are:
Observation on 11-12-19 at 3:16 PM revealed:
6th Floor
1. Staff Development Nurse Office door equipped with self-closing device failed to close and latch within the doorframe. A coat hook over top of door prevented the door from latching.

During an interview on 11-12-19 at 3:16 PM, Facility Staff D confirmed findings.

Observation on 11-13-19 between 9:56 am and 3:33 PM revealed:
5th Floor
2. Recovery Room used as a storage room and failed to provide a self-closing device on the door.
3rd Floor
3. Sleep Room 10 used as storage room over 50 square feet in area failed to provide a self-closing device on the
door.
4. Hospitalist Office equipped with a self-closing device failed to latch within the doorframe, and appeared to have tape covering the latching hardware.

2nd Floor
5. Old Bio-hazard Room failed to provide a self-closing device on the door.
6. 2 hour fire rated doors 072752 into the dock had excessive gap between doors.
7. Pallet jack obstructing the 1 ½ hour rated fire doors at the Compactor area.
8. Excessive gap between the 1-hour fire rated doors to the Cage Storage Room.

1st Floor
9. Dialysis Storage Room used for storage provided a sliding door, which failed to provide a self-closing device and latch within the doorframe.
10. The ¾ hour fire rated door equipped with a self-closing device at the Social Worker Office near ambulance failed to close and latch within the doorframe.
11. Office door 038914 equipped with a self-closing device was obstructed by an office chair.

Basement
12. 2 hour fire rated doors to the Old Bed Storage room had excessive gap between the doors.

During an interview on 11-13-19 between 9:56 am and 3:33 PM, Facility Staff D confirmed findings.

Based on observation and staff interview, the facility failed to identify missing kitchen exhaust hood fire-extinguishing system nozzle caps during monthly inspections. This condition did not ensure that all system components were intact, and increased the potential that the fire-extinguishing system would not operate as designed during a cooking fire. The facility census was 105 with a capacity of 137.

Findings are:
Observation on 11/18/19 at 11:38 am revealed an exhaust hood fire-extinguishing system nozzle cap was missing above the 1st Floor Cafeteria Griddle.

In an interview on 11/18/19 at 11:38 am, Facilities Staff J confirmed the missing cap.

NFPA 17A, 2009, 4.3.1.5 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping.

Based on observation, interview and documentation review, the facility failed to use materials in accordance with the interior finish requirements. This deficient practice has the potential to allow smoke and fire to spread in the North Tower on the 7th, 8th and 9th floors. The facility has the capacity for 423 beds with a census of 104 on the day of survey.

Findings are:
Observations on 11-12-19 between 1:43 pm and 2:37 pm revealed:
9th Floor
1. Wood on the east wall of the Communications room.
2. Wood on the north wall of the West Electrical room.
8th Floor
3. Wood on the wall of the East Electrical room.
7th Floor
4. Wood on the wall of the East Electrical Room.
5. Wood on the wall of the West Electrical Room.

During an interview on 11-12-19 between 1:43 pm and 2:37 pm, Facility Staff D confirmed the wood on the walls and stated that there was no stamp to indicate it had been fire treated.

During documentation review on 11-12-19 at 2:45 pm, Administration Staff D failed to provide documentation for the wood.

Based on observation and staff interview, the facility failed to ensure the fire alarm system audible and visual notification devices were synchronized. This deficient practice could lead to confusion during a fire alarm notification event affecting all occupants. The facility census was 109 with a capacity of 423.

Findings are:

Observations on 11-14-2019 between 10:03 AM and 10:30 AM revealed the Cancer Center fire alarm notification devices in the Basement did not have synchronized visual notification.

During an interview on 11-14-2019 between 10:03 AM and 10:30 AM, Facility Staff A confirmed the finding.

Based on observation and interview the facility failed to assure that fire alarm activated in the IVF area, that magnetically locked exit doors dropped on activation of the fire alarm and that visual fire alarm devices operated and were synchronized on the second floor. The facility has the capacity for 137 beds with a census of 105 on the day of survey.

Findings are:
Observations during a fire alarm activation on 11-19-18 at 12:22 PM revealed:
2nd Floor
1. The south exit from Labor and Delivery which was magnetically locked, failed to release upon activation of the
fire alarm system.
2. Visual fire alarm devices were not synchronized in the Labor and Delivery corridor outside Soiled Linen 2361.
3. Facility failed to assure that the rolling shutter in the OR corridor wall closed upon fire alarm system activation or local smoke detection.
4. The fire alarm failed to operate within the IVF area and corridor outside the area.
5. The magnetically locked exit door in the "wedge" leading from the exit corridor in the hospital to the medical
office building failed to release upon activation of the fire alarm.

During an interview on 11-19-19 at 12:40 PM, Facility Staff D confirmed the findings, and failed to verify if the rolling shutter in the OR corridor was activated by a local smoke detector, also stated that the IVF area failed to be connected to the hospital fire alarm system.

NFPA Standard:
2010, NFPA 72, 18.5.4.3.2
Visible notification appliances shall be installed in accordance with Table 18.5.4.3.1(a) or Table 18.5.4.3.1(b) using one of the following:
(1) A single visible notification appliance
(2) Two visible notification appliances located on opposite walls
(3)*Two groups of visible notification appliances, where visual appliances of each group are synchronized, in the same room or adjacent space within the field of view. This shall include synchronization of strobes operated by separate systems
(4) More than two visible notification appliances or groups of synchronized appliances in the same room or adjacent space within the field of view that flash in synchronization

Based on observation and interview, the facility failed to provide a smoke detector in sleeping rooms and allowed smoke detectors to be covered in the North Tower. This deficient would not alert occupants of smoke within the room and would allow smoke to enter the exit corridor on the 5th and 6th floors. The facility has the capacity for 423 beds with a census of 109 on the day of survey.

Findings are:
Observations on 11-12-19 at 3:06 pm revealed:
6th Floor
1. Three smoke detectors in the construction area were covered with plastic dust shields.

During an interview on 11-12-19 at 3:06 pm, Facility Staff D confirmed the smoke detectors were covered, and stated that Contractors should not have used them.

Observations on 11-13-19 at 9:30 am and 9:36 am revealed:
5th Floor
2. The sleeping room in the Office area failed to provide a smoke detector.
3. The sleeping room across from 5N-120 failed to provide a smoke detector.

During an interview on 11-13-19 at 9:30 am and 9:36 am, Facility Staff D confirmed the lack of a smoke detector.

Based on observation and staff interview, the facility failed to protect an opening in a 1-hour fire barrier with a 45-minute fire door. This condition would allow fire to penetrate the room that contained the fire pump. The facility census was 105 with a capacity of 137.

Findings are:
Observation on 11/18/19, at 10:50 am revealed the manufacture fire resistance rating tag on the door to the Basement Fire Pump Room was rated 20-minutes. The door was inspected by a fire door inspection company that re-labeled the door in excess of the manufacture at 45-minutes.

In an interview on 11/18/19, at 10:50 am, Facilities Staff J confirmed the inspection company attempted to re-label the door with a higher fire resistance than the manufacture.

NFPA 20, 2010, 4.12.1.1.2 Indoor fire pump rooms in non-high-rise buildings
or in separate fire pump buildings shall be physically
separated or protected by fire-rated construction in accordance
with Table 4.12.1.1.2. Fully Sprinkled: 1-hour fire rated.

Based on observation and interview, the facility failed to maintain sprinkler components in the North Tower. This deficient practice increased the potential for damage to the sprinkler and could delay the response of the sprinkler heads resulting in a larger fire that could spread outside of the room of origin on the 1st, 2nd 7th, 8th, 9th and 10th floors. The facility has the capacity for 423 beds with a census of 109 on the day of survey.

Findings are:
Observation on 11-12-19 between 1:31 pm to 2:34 pm revealed:
10th Floor
1. Unsealed penetration around the sprinkler escutcheon above elevator #13.
9th Floor
2. Paint covering the sprinkler in Janitor Closet across from room 957.
8th Floor
3. Missing sprinkler escutcheon in the Staff Lounge.
7th Floor
4. Missing ceiling tile in the North Staff Lounge.
5. Obstruction to the sprinkler in the closet of the Staff Lounge.

During an interview 11-12-19 between 1:31 pm to 2:34 pm, Facility Staff D confirmed the findings.

Observation on 11-13-19 between 1:21 pm to 2:54 pm revealed:

2nd Floor
6. Missing sprinkler escutcheon in the Duplicating Room above the sliding door.
7. Missing sprinkler escutcheon near the Clinical Offices.
8. Wires attached to the sprinkler pipe in the North Cage Storage.
9. Wires attached to the sprinkler pipe in the walkway in the Cage Storage Room.
10. Wires attached to the sprinkler pipe in the South Cage Storage.
1st Floor
11. Foreign matter on the sprinkler in Dialysis.
12. Missing ceiling tile in the janitor closet across from the north elevators.
13. Missing ceiling in the fire sprinkler control vale closet, of Social Workers office.

During an interview on 11-13-19 between 1:21 pm to 2:54 pm, Facility Staff D confirmed the findings.

Based on observation and interview, the facility failed to ensure that the corridor room doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire and smoke within the exit corridors in the North Tower on the 1st, 2nd, 4th, 5th, 6th, 7th, 8th and 9th floors. The facility has the capacity for 423 beds with a census of 109 on the day of survey.

Findings are:
Observation on 11-12-19 between 1:38 pm and 3:22 pm revealed:
9th Floor
1. 9 of 18 Patient room doors had excessive gaps between the leafs of the doors.
8th Floor
2. Patient Room door 844 was obstructed by a wheel chair and failed to close.
3. The undercut of door 862 was greater than 1 inch.
4. Patient Room door 853 was obstructed by a housekeeping cart.
7th Floor
5. Patient Room doors 740, 745, 748, 746 and 749 had excessive gaps between the leafs fo the doors.
6th Floor
6. Patient Room door 650 was obstructed by medical cart and failed to close.
7. Patient Room door 647 failed to latch within the doorframe.

During an interview on 11-12-19 between 1:38 pm and 3:22 pm Facility Staff D confirmed the findings.

Observation on 11-13-19 between 9:38 am and 3:02 pm revealed:
5th Floor
8. OR B door failed to latch within the doorframe.
9. Reception/042285 door was obstructed by a trashcan and failed to latch when tested.
4th Floor
10. A trashcan obstructed Patient Room door 498.
11. Patient Room pass-through door was obstructed by clean linen and failed be smoke tight.
2nd Floor
12. A trashcan obstructed Office door P2A017.
1st Floor
13. X-ray Room #3/038908 door equipped with a self-closing device failed to close and latch within the doorframe.

During an interview on 11-13-19 between 9:38 am and 3:02 pm, Facility Staff D confirmed the findings.

Based on observation and interview, the facility failed to ensure smoke separation doors were capable of resisting the passage of smoke. The deficient practice would allow smoke and gases to spread between smoke compartments in the North Tower on 1st, 4th, 8th and 9th floors. The facility had a capacity of for 423 beds with a census of 109 on the day of survey.

Findings are:
Observations on 11-12-19 between 2:00 pm and 2:23 pm revealed the following:
9th Floor
1. An excessive gap between smoke doors 058966 near room 949.
8th Floor
2. An excessive gap between smoke doors 042394.

During an interview on 11-12-19 between 2:00 pm and 2:23 pm Facility Staff D confirmed the findings.

Observations on 11-12-19 between 10:29 am and 2:57 pm revealed the following:
4th Floor
3. An excessive gap between smoke doors 072745.
4. The undercut of smoke doors 072745 was greater than ¾ inches.
1st Floor
5. An excessive gap between smoke doors 054220 in Dialysis.
6. Smoke doors 017824 entering Radiology failed to latch.

During an interview on 11-13-19 between 10:29 am and 2:57 pm, Facility Staff D confirmed the findings.

Based on observation and interview, the facility failed to provide an approved cover for an open circuit breaker slot in electrical circuit breaker panel in the North Tower. The deficient practice increased the potential of an electrical shock or fire from unintended contact with live electrical wiring. The facility capacity is 423 with a census of 109 on the day of survey.

Findings are:
Observation on 11-13-19 at 11:12 am revealed an open circuit breaker slot #33 in panel 4L1 in the west Electrical Closet across from room 492.

During an interview on 11-13-19 at 11:12 am, Facility Staff D confirmed the findings.

Based on observation and staff interview, the facility failed to ensure a direct vent gas fireplace was installed so it would not cause a burn or fire, or to provide notification of the presence of carbon monoxide. This condition had the potential to cause a burn or fire, or carbon monoxide hazard. The facility census was 105 with a capacity of 137.

Findings are:
Observation on 11/18/19, at 11:43 am revealed:
1. A wire mesh panel or screen was not installed in front of the Cafeteria fire place.
2. A carbon monoxide detector connected to the fire alarm was not installed in the Cafeteria for the fire place.

In an interview on 11/18/19, at 11:43 am Facilities Staff J acknowledged the findings.

NFPA 101, 2012, 19.5.2.3 The requirements of 19.5.2.2 shall not apply where
otherwise permitted by the following:
(2) Direct-vent gas fireplaces, as defined in NFPA 54, National
Fuel Gas Code, shall be permitted inside of smoke compartments
containing patient sleeping areas, provided that all
of the following criteria are met:
(a) All such devices shall be installed, maintained, and
used in accordance with 9.2.2.
(b) No such device shall be located inside of a patient
sleeping room.
(c) The smoke compartment in which the direct-vent gas
fireplace is located shall be protected throughout by
an approved, supervised automatic sprinkler system
in accordance with 9.7.1.1(1) with listed quick response
or listed residential sprinklers.
(d)*The direct-vent fireplace shall include a sealed glass
front with a wire mesh panel or screen.
(e)*The controls for the direct-vent gas fireplace shall be
locked or located in a restricted location.
(f) Electrically supervised carbon monoxide detection in
accordance with Section 9.8 shall be provided in the
room where the fireplace is located.

Based on observation and staff interview, the facility failed to provide a laundry chute door that self-closed and positively latched. This condition would allow smoke from a fire to migrate between floors. The facility census was 109 with a capacity of 423.

Findings are:
Observation on 11/13/19, at 1:36 PM revealed the 1st Floor Soiled Linen Chute did not self-close or positively latch.

In an interview on 11/13/19, at 1:36 PM, Facility Staff H acknowledged the findings.

Based on observation and interviews, the facility failed to store mobile recycling collection receptacles with capacities greater than 32 gallons in a room protected as a hazardous area when not attended. This deficient practice would allow fire and smoke to enter the exit corridors on the 3rd floor. The facility had a capacity of for 137 beds with a census of 105 on the day of survey.

Findings are:
Observation on 11-18-19 at 11:02 am, revealed an unattended recycling container with a capacity of greater than 32 gallons in the exiting corridor near Stair 3098D.

In an interview on 11-18-19 at 11:02 am, Facility Staff D confirmed the observation.

NFPA Standard:
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended. Containers used solely for recycling are permitted to be excluded from the above requirements where each container is ? 96 gal. unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent. 18.7.5.7, 19.7.5.7

Based on observation and interview, the facility allowed the use of portable electric space heaters and failed to provide documentation the heating element of the device did not exceed 212 degrees Fahrenheit. This deficient practice increased the potential of a fire in the North Tower. The facility has the capacity for 423 beds with a census of 109 on the day of survey.

Findings are:
Observations on 11-13-19 at 1:19 PM revealed a portable heating device in central supply, Inventory Coordinator office.

During an interview on 11-13-19 at 1:19 am, Facility Staff D stated that the facility did not have the manufactures specification for the heater and could not confirm the heating element of the device did not exceed 212 degrees Fahrenheit and that the heater was brought into the facility by staff, the facility policy is to forbid space heaters.

NFPA Standard:
2012 NFPA 101, 19.7.8
Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

Based on documentation review and staff interview, the facility failed to provide documentation of monthly testing starting batteries for the emergency generators. This deficient practice did not ensure the emergency generators would start, providing the essential critical and life safety power supply in the event of a power loss. This deficient practice affects all building occupants of all campus buildings. Facility census was 109 and licensed for 423 at the time of the survey.

Findings are:
Observations on 11-14-2019 at 9:45 AM revealed the following:

Documentation failed to show the maintenance-free batteries used to start the generators were tested monthly.

During an interview on 11-14-2019 at 9:45 AM, Facility Staff A confirmed the findings.

Code reference: NFPA 110, 8.3.7.1 2010 edition.
Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

Based on observation and interview, the facility did not document an individualized assessment for non-hospital grade receptacles at patient bed locations, which include the physical integrity, continuity of the grounding circuit, and polarity. This deficient practice could create electrical injury and fire hazards on the fourth floor in the North Tower. The facility has the capacity for 423 beds with a census of 109 on the day of survey.

Findings are:
Observation on 11-13-19 at 11:09 am revealed, a 30-amp specialized type non-hospital grade receptacle in Patient room 490.

During an interview on 11-13-19 at 11:09 am, Facility Staff D confirmed the receptacle and stated that the facility was not aware of any non-hospital grade outlets in patient rooms and indicated that it had not been tested.

NFPA Standard:
2012, 99 NFPA
6.3.3.2.1
The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2
The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3
Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4
The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on observation and interview, the facility failed to conduct monthly testing of the maintenance-free battery for the emergency generator. This deficient practice could cause the emergency generator to fail to start when needed and not supply emergency power to the facility in the North Tower. The facility has the capacity for 423 beds with a census of 109 on the day of survey.

Findings are:
Observations on 11-14-19 at 11:17 am revealed that specific gravity or battery conductance testing of the maintenance-free battery for the emergency generator was not conducted.

During an interview on 11-14-19 at 11:17 am, Facility Staff A confirmed the maintenance-free batteries and was not aware of the testing requirements.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in a way that would not create a fire, or prevent electricity from being shut off. This condition had the potential to cause a fire, or prevent response to a fire. The facility census was 105 with a capacity of 137.
Findings are:

Observation on 11/18/19, from 11:15 am to 11:34 am revealed:
1. Two electrical disconnects were blocked by storage in the 1st Floor MRI Equipment Room.
2. Power cord plugs were bent from a freezer pushed up against the plugs in the 1st Floor Kitchen Room Service Line.

In an interview on 11/18/19, from 11:15 am to 11:34 am, Facility Staff J acknowledged the findings.

NFPA 70, 2011, 110.26 Spaces About Electrical Equipment. Access and
working space shall be provided and maintained about all
electrical equipment to permit ready and safe operation and
maintenance of such equipment.
(A) Working Space. Working space for equipment operating
at 600 volts, nominal, or less to ground and likely to
require examination, adjustment, servicing, or maintenance
while energized shall comply with the dimensions of
110.26(A)(1), (A)(2), and (A)(3) or as required or permitted
elsewhere in this Code.


41670

Based on observations and staff interview, the facility failed to ensure electrical junction boxes were equipped with cover plates. This deficient practice could cause electrical injury and fire, affecting all occupants in 1 of 2 smoke compartments on fourth floor. Facility census was 105 and licensed for 137 at the time of the survey.

Finding are:
Observation and staff interview on 11-18-2019 at 10:30 AM revealed the following:

An open low voltage junction box was located above the corridor ceiling outside of room 4201.

During interview on 11-18-2019 at 10:30 AM, Staff E confirmed the open junction box.

Code reference: NFPA 70-314.28.C

Based on observation and interview, the facility failed to prohibit the use of extension cords as a substitute for adequate wiring. This deficient practice would create electrical injury and increase the probability of a fire on the second floor. The facility had a capacity of for 137 beds with a census of 105 on the day of survey.

Findings are:
Observations on 11-18-19 at 10:42 am revealed:
2nd Floor
1. Extension cord used for permanent wiring for a refrigerator in Sleep Room 2.

During an interview on 11-18-19 at 10:42 am, Facility Staff D confirmed the extension cord.