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Based on facility tour and staff interview and verification, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In sprinkler buildings, waiting areas may be open to the corridor under certain conditions specified in the Code. The facility had a capacity of 224 patient beds with a census of 111 patients at the time of the survey completed on 01/30/14.

Findings include:

On 01/28/14 between 3:40 P.M. and 5:00 P.M., tour of the first floor was conducted with Staff Y and W. Observation of an outpatient therapy waiting area revealed the area was provided with automatic sprinkler protection only. The narrow waiting area, was noted to be approximately seven feet wide and approximately 13 feet deep. There was no smoke detector observed in the waiting area.

Staff Y present on the tour verified the observation.

Based on tour and staff verification the facility failed to have a visible exit sign in the intensive care unit and the critical care step down unit. The facility had a capacity of 224 patient beds with a census of 111 patients.

Findings include:

Tour of the Intensive Care Unit on the third floor completed 01/28/18 at 4:18 PM revealed upon entering the suite from the suite adjacent, no sign was visible to show the means of egress through the Intensive care unit. No exit sign was visible to show the means of egress from Room 6 of the Intensive Care Unit. This was verified by Staff W on 01/28/14 at 4:10 P.M.


Tour of the Critical Care Stepdown on the 3rd floor completed on 01/29/14 revealed the exit signs were not visible from Room 6. This was verified by Staff Y on 01/29/14 at 9:00 A.M.

Based on review of facility schematics, facility tour and staff interview and verification, the facility failed to ensure that smoke barriers were constructed to provide the noted fire resistance rating in accordance with 8.3. The number of penetrations were 53 and were found on all floors of the facility. The facility had a capacity of 224 patient beds with a census of 111 patients at the time of the survey completed on 01/30/14.

Findings include:

On 01/27 through 01/29/14 between 8:45 A.M. and 5:00 P.M., tour of the facility was conducted with Staff W, Z and Y. The following observations were noted in one, two and three hour fire rated walls in the following areas of the facility:

Fourth floor

1. On 01/27 through 01/29/14 between 8:45 A.M. and 5:00 P.M., tour of the facility was conducted with Staff W, Z and Y. Observation above the ceiling tiles at room 4E-020, a clean utility room, revealed a penetration approximately four inches by six inches and an area surrounding two conduit in a one hour fire rated wall.

2. On 01/27 through 01/29/14 between 8:45 A.M. and 5:00 P.M., tour of the facility was conducted with Staff W, Z and Y. Observation of a two hour fire rated wall above the ceiling tiles at room 4E026 revealed a penetration approximately two inches by two and one half inches.

3. On 01/27/14 at 1:45 P.M. a tour was conducted with Staff Z of the fourth floor. At 2:05 P.M. in a medical director ' s office rated wall (perpendicular to the outside wall), conduits from said wall lead to an open junction box. On 01/27/14 at 1:45 P.M. in an interview, Staff Z confirmed the finding.

4. At 3:05 P.M. in office 4A-431 in the corner near the double doors an approximate five inch hole was observed in the two hour wall running across the A building. On 01/27/14 at 3:05 P.M. in an interview, Staff Z confirmed the finding.

5. On 01/27/14 at 3:15 P.M. an open junction box was observed from the two hour wall that separates the core building from the C building in rehab 4C.

6. On 01/28/14 at 3:17 PM observation was made above the ceiling of room 4E-018 which was documented to have a one hour fire rated wall as per the building drawings, penetrations were noted: 3 inch pipe with 1 inch gap between the wall and pipe, and 3 inch pipe with 1/2 inch gap between the wall and the pipe. Verified by Staff Y on 01/28/14 at 3:17 PM.

7. On 01/28/14 at 3:35 PM observation was made above door 4E-026 in the corridor a 2 inch round whole with a white cable passing through a one hour wall as per the building drawings, was noted. This was verified by Staff Y on 01/28/14 at 3:35 PM.


Third Floor

8. On 01/27 through 01/29/14 between 8:45 A.M. and 5:00 P.M., tour of the facility was conducted with Staff W, Z and Y. Above the ceiling of room LKW3-319D the mechanical room a 4 x 4 box with out a cover and a conduit opening that passes through the smoke partition wall as per the building drawings, to the corridor.

9. On 01/27 through 01/29/14 between 8:45 A.M. and 5:00 P.M., tour of the facility was conducted with Staff W, Z and Y. Above the ceiling of room LKW3-315 a 6 inch x 2.5 inch penetration through the drywall of a 1 hour wall as per the building drawings, and a .25 inch gag around a section of dry wall. This was verified by Staff Y on 1/28/14.


Second Floor

10. On 01/27 through 01/29/14 between 8:45 A.M. and 5:00 P.M., tour of the facility was conducted with Staff W, Z and Y. Observation above the ceiling tiles of a one hour fire rated wall located in the ambulatory surgery center (ASC) recovery area, revealed the open space at the floor decking above. The above findings were observed and verified by Staff Y present during tour.

11. On 01/27 through 01/29/14 between 8:45 A.M. and 5:00 P.M., tour of the facility was conducted with Staff W, Z and Y. Observation above the ceiling tiles of a one hour fire rated wall , located in the emergency department, at the sprinkler control room, revealed unsealed areas in the wall at the floor decking above. The above findings were observed and verified by Staff Y present during tour.

12. On 01/27 through 01/29/14 between 8:45 A.M. and 5:00 P.M., tour of the facility was conducted with Staff W, Z and Y. Observation above the ceiling tiles of a two hour fire rated wall, located in the Stair 8 corridor near the emergency department revealed the wall was not sealed at the floor decking above. The above findings were observed and verified by Staff Y present during tour.

13. On 01/27 through 01/29/14 between 8:45 A.M. and 5:00 P.M., tour of the facility was conducted with Staff W, Z and Y. Observation above the ceiling tiles of a two hour fire rated wall near the MRI computer room, revealed the wall was not sealed at the floor decking above. Also observed was a penetration surrounding pipe that went through the wall. The above findings were observed and verified by Staff Y present during tour.


14. On 01/28/14 at 11:00 A.M. a tour was conducted of the second floor with Staff Z. At 11:00 A.M. on the north side of the three hour wall near the single door near the western exit, an open one inch conduit was observed. On 01/28/14 at 11:00 A.M. in an interview, Staff Z confirmed the finding.

15. On 01/28/14 at 12:02 P.M. observation revealed annular spaces around plumbing lines in the coding room. On 01/28/14 at 12:02 P.M. in an interview, Staff Z confirmed the finding.

16. On 01/28/14 at 1:45 P.M. observation above the drop down ceiling of the one hour rated wall on the south entrance to the laboratory revealed a one inch conduit with a blue wire, and around the conduit an annular space was present. On 01/28/14 at 1:45 P.M. in an interview, Staff Z confirmed the finding.

17. At 2:04 P.M. in the one hour rated wall in the transport office (LA2-242), an open one inch flex conduit was observed. On 01/28/14 at 2:04 P.M. in an interview, Staff Z confirmed the finding.

18. On 01/28/14 at 2:12 P.M., proceeding south along the one hour wall, across the hallway, into the room, a two by one foot penetration was observed in the corner, left of the door. On 01/28/14 at 2:12 P.M. in an interview, Staff Z confirmed the finding.

19. On 01/28/14 at 2:26 P.M. observation of the laboratory ' s west one hour wall revealed two blue and two gray wires and one copper line with annular spaces. On 01/28/14 at 2:26 P.M. in an interview, Staff Z confirmed the finding.

20. On 01/28/14 at 2:31 P.M. a one inch metal conduit with one blue wire was unstopped and observed in the one hour wall in the laboratory conference room/copier room. On 01/28/14 at 2:31 P.M. in an interview, Staff Z confirmed the finding.

21. In the Mechanical room on the Second floor by the B elevators had two 8 inch round penetration through the floor deck above. This was Verified by Staff Y on 1/28/14 at 10:15 AM.

22. In the Nurse Managers Office of the ambulatory surgery center area of a 3 hour wall as per the building drawings, a 12 inch X 12 inch penetration, 1 inch conduit with 0.25 inch gap around, 2 inch gap between the deck and the drywall, 3 inch penetration with 1 inch gap around 2 inch conduit, and 3 inch X 3 inch whole which appeared to be filled on the other side of wall.

23. South corridor wall by the Radiology door a 2 foot X 1 foot section of drywall cut out of a 2 hour wall as per the building drawings. This was verified by Staff Y on 1/28/14 at 1:05 PM.

24. East wall of ED waiting area which was shown to be a 2 hour wall as per the building drawings, a 0.5 inch conduit sleeve with white cable open on the end, 4 inch round penetration with 2 inch pipe and open around pipe, 0.5 penetration with 2 red cables, 0.5 inch penetration with red ring on end and 2 blue cables passing through open on the end, 0.5 inch penetration with white ring open on the end. This was verified by Staff Y 01/28/14 at 1:45 PM.

25. Bathroom in ED located on the east wall by the ED waiting area which was shown to be a 2 hour wall as per the building drawings, a 0.75 inch conduit with on the West wall an open end.

26. In the Coding Room a penetration of a 3 hour wall as per the building drawings, was noted of unknown size with multiple pipes. Viewed the same penetration from the Lab in room LA2-138A was able to visibly see light from the Coding Room. This was verified by Staff Y on 01/28/14.

Ground Floor

27. On 01/27 through 01/29/14 between 8:45 A.M. and 5:00 P.M., tour of the facility was conducted with Staff W, Z and Y. Observation above the ceiling tiles at the fire doors located near the administration office, revealed penetrations in a three hour fire rated wall. The penetrations consisted of a four inch sleeve with a one half inch cable through the sleeve. Another penetration was noted to be approximately two inches by one and one-half inch with a Greenfield cable through it and the final area was a penetrations approximately seven inches with multiple cables through the opening.

28. On 01/27 through 01/29/14 between 8:45 A.M. and 5:00 P.M., tour of the facility was conducted with Staff W, Z and Y. Observed in a two hour fire rated wall, a penetration approximately six inches wide and approximately 18 inches in length. The penetration located where an air duct went through an EVS storage room wall, near the double doors.

29. On 01/29/14 at 11:36 A.M. a tour was conducted of the ground floor with Staff Z. At 3:20 P.M. observation above the drop down ceiling above double doors leading from the atrium to the E building revealed two one inch, unstopped conduits. On 01/29/14 at 11:36 A.M. in an interview, Staff Z confirmed the finding.
30. During the tour of the ground floor of the facility on 01/29/14 at 11:42 AM a penetration through the two hour was observed on the south side above the double doors in the corridor next to Central Service Supplies office. Staff Z confirmed the finding at 11:42 AM on 01/29/14.

31. During the tour of the ground floor of the facility on 01/29/14 at 2:08 PM a penetration through the two hour rated wall above the double doors in the hallway outside the Clean Sterile Supplies office. The conduit pipe was open without fire stop material and the bundle of wire just below the conduit had the fire stop material pulled away from the wall leaving a open penetration visible. Staff Z confirmed the findings at 2:08 PM on 01/29/14.

32. During the tour of the ground floor of the facility on 01/29/14 at 3:07 PM a penetration of the two hour rated wall was observed. The area above the ceiling locate by the key pad to enter the administration offices hallway from the atrium side there was found to be an open junction box. Staff Z confirmed the finding at 3:08 PM on 01/29/14.

33. During the tour of the ground floor of the facility on 01/29/14 at 3:16 PM outside the administration offices on the atrium side the wall above the pictures had failed and left the conduit open without fire stop present. Staff Z confirmed the finding at 3:16 PM on 01/29/14.

34. During the tour of the ground floor of the facility on 01/29/14 at 3:33 PM a conduit passing through the three hour rated wall failed to be closed by fire stop material. The penetration was located over the double doors near Stair 9 doorway. Staff Z confirmed the finding at 3:34 PM on 01/29/14.

35. During the tour of the ground floor of the facility on 01/29/14 at 4:20 PM the conduit, passing wire through the two hour rated wall, above the double doors, located across from the two atrium elevators, failed to be closed by fire stop. Staff Z confirmed the finding at 4:20 PM.

36. On 01/28/14 at 3:07 P.M. a tour of the first floor was conducted with Staff Z. At 3:23 P.M. in the one hour wall in the room to the right of the double doors entering onto building B, had a one by one foot penetration in the west side of said room. The room is a soiled utility room. On 01/28/14 at 3:23 P.M. in an interview, Staff Z verified the finding.

37. On 01/28/14 at 4:00 P.M., just south of the admitting office, a one hour rated wall was observed to have a section 6 feet long by 1 foot high with drywall thickness of only about 1 inch. On 01/28/14 at 4:00 P.M. in an interview, Staff Z verified the finding.

38. On 01/29/14 at 8:50 A.M. a tour was conducted of the first floor with Staff Z. Observation above the double doors perpendicular to the east, one hour wall surrounding admin offices (designated area one on the schematic) revealed a penetration to the barrier. On 01/29/14 at 8:50 A.M. in an interview, Staff Z confirmed the finding.

39. On 01/29/14 at 9:35 A.M. in the bathroom of the lobby conference room, observation above the drop down ceiling revealed a penetration in the east/west 3 hour fire wall. On 01/29/14 at 9:35 A.M. in an interview, Staff Z confirmed the finding.

40. On 01/29/14 at 10:56 A.M. in the three hour barrier in the kitchen, above the drop down ceiling near the cooking battery, a six inch square penetration and a pipe with "carey" written on its white covering, was revealed to be an unsealed penetration. On 01/29/14 at 10:56 A.M., in an interview, Staff Z confirmed the finding.

41. During the tour of the first floor of the facility on 01/29/14 at 9:56 AM a penetration through the three hour rated wall was observed. The penetration was located above the ducting over the doorway in the Medical office leading into the EKG reading room. Staff Z confirmed the finding at 9:57 AM on 01/29/14.

42. During the tour of the first floor of the facility on 01/29/14 at 10:24 AM a penetration through the three hour rated wall was observed. The penetration was located above the roller door on the dinning room side of the cafeteria passing through to the food service side. Staff V confirmed the finding at 10:24 AM on 01/29/14.

43. During the tour of the first floor of the facility on 01/29/14 at 10:44 AM a penetration through the three hour rated wall was observed. The penetration was located in the kitchen area where the serving carts were stored. The area above the sign showing NICU on the wall were two rectangular penetrations passing through the wall the one on the left had fire protection "pillow" stuffed into the opening where the penetration to the right failed to have fire stop material in place. Staff V confirmed the finding at 10:45 AM on 01/29/14.


44. Room LKW1-300 a 2 inch penetration with gray cables and 0.5 conduit passing through a 3 hour north wall as per the building drawings. This was verified by Staff W on 01/28/14 at 4:00 PM.

45. Room LKW1-315 a 1 inch conduit with blue and gray cables passing through with open on the end of the 1 hour wall as per the building drawings, 3 inch X 4 inch penetration with blue and white cables in East 3 foot section, and 4 inch round penetration with multiple cables in East 3 foot section of 1 hour wall as per the building drawings. This was verified by Staff W on 01/28/14 at 4:10 PM.

46. In the North wall of the Cafeteria by the Kitchen corridor two 2 foot X 6 inch section of Concrete block with multiple conduits going through both penetrations of a 2 hour wall, as per the building drawings, going to the electrical room location in the storage room for the cafeteria. This was verified by Staff W on 01/28/14 at 4:30 PM.

47. In the men's locker room beside the Kitchen entrance between the Cafeteria and Kitchen a 8 inch X 12 inch square duct penetrating the 3 hour wall, as per the building drawings, with 1.5 inch gap between the duct and the concrete block. This was verified by Staff W on 01/28/14 at 4:40 PM.

48. In the corridor above Rehab Services/Occupational Services door a 1 inch X 3 inch section at the roof deck, and a 2 inch X 3 inch section by the roof deck on the 2 hour South wall of the Corridor, as per the building drawings. This was verified by Staff Y on 01/29/14 at 8:45 AM.


Basement Floor

49. Above door with barcode label FED 026323B located at the end of the corridor by the supply room a 4 inch sleeve with multiple cables passing through a 3 hour wall, as per the building drawings, having an open end. This was verified by Staff Y on 01/29/14 at 9:30 AM.

50. Above the administration kitchen door in the corridor in the 3 hour west wall, as per the building drawings, a 0.5 inch conduit penetration with no fire stop in the end.

51. Basement mechanical room an 9 inch penetration with an 8 inch pipe passing through of the 2 hour south wall as the drawings show with gap around pipe, 12 inch open duct in the east 2 hour wall as per the building drawings, a 4 inch pipe extending into the room approximately 10 feet open on the end was noted. This was verified by Staff Y at 1:30 PM.

52. The east wall in the computer room of Medical records by the E elevators a 2 foot X 6 foot penetrating the 2 hour wall, as per the building drawings, with a gap of 1 foot on the right side of duct and 2 inch gap at the bottom of the duct. This was verified by Staff Y on 01/29/14 at 2:00 PM.

53. Medical records office area South 2 hour wall, as per the building drawings, a 5 inch X 5 inch penetration and 5 inch X 16 inch penetration with 5 conduits side by side passing through. This was verified by Staff Y on 01/29/14 at 2:20 PM.












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Based on building drawings, facility tour and staff verification the facility failed to have the proper fire rated door in a fire wall or smoke barrier and have properly working positive latching hardware as per 19.3.6.3.2 of the 2001 edition of NFPA 101. The facility had a capacity of 224 patient beds with a census of 111 patients at the time of the survey completed on 01/30/14.


Findings include:


1. Tour of the basement level completed on 01/29/14 revealed a 20 minute rated fire door in a 2 hour wall between the corridor and the far east side of medical records. This was verified by Staff Y on 01/29/14 at 1:35 PM.

2. Between the corridor by medical records and the atrium by administration a 3 hour fire rated door located in a 3 hour wall would not properly latch without being pushed/pulled shut by staff. This was verified by Staff Y on 01/29/14.


3.Observation on 01/27/14 at 3:30 P.M. with Staff Y of a two hour fire rated wall, revealed that at room 4E026, a door located in the two hour fire rated wall had a 45 minute fire resistance rating.


4. Observation on 01/29/14 at 3:00 P.M. with Staff Y, of the medical records area on the ground floor revealed a door to the medical record room was located in a two hour fire resistance wall which separated the medical record room. The wood door to the room was noted to have a 20 minute fire resistance rating.



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5. On 01/27/14 at 1:45 P.M. a tour was conducted with Staff Z of the fourth floor. At 2:14 P.M. the double doors in the three rated wall that led to the B building were observed not to close upon testing. On 01/27/13 at 2:14 P.M. in an interview, Staff Z confirmed the finding.



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6. During the tour of the ground floor of the facility on 01/29/14 at 2:47 PM the door to the Office of Financial Director was part of a two hour rated wall. The door was open and did not have a self-closing device attached. Staff Z confirmed the finding on 01/29/14 at 2:48 PM.





31007

Based on facility tour and staff interview and verification, the facility failed to ensure that when the automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing. The facility had a capacity of 224 patient beds with a census of 111 patients at the time of the survey completed on 01/30/14.

Findings included:

1. On 01/28/14 between 3:40 P.M. and 5:00 P.M. observation of the first floor was conducted with Staff Y and W. Observation of a soiled utility room in the respiratory department revealed the door to the sprinklered room had a device on the door that held the door in the open position. The door was not self closing.

2. On 01/29/14 between 9:50 A.M. and 11:45 A. M., tour of the facility was conducted with Staff Y present. Observation of the ground floor revealed the presence of a medical record storage room. Observation of the room revealed the presence of a significant amount of combustibles in the form of paper medical records. The large amount of patient medical records dated from 1967 to more recent years.

Observation of the storage area revealed the presence of two doors that separated the medical records area from the offices where staff worked. One door was observed to be connected to the fire alarm system so that upon activation, the door would close. Observation of the other door revealed the magnetic hold device was no longer connected and the door remained in the open position. The door was open with no functioning self closing device. Staff Y confirmed the observation on 01/29/14 at 11:45 AM.

Based on observation during a tour of facility and staff interview it was determined that the facility failed to maintain the EXIT signs in working condition. The facility had a capacity of 224 patient beds with a census of 111 patients at the time of the survey completed on 01/30/14.

Findings include:



On 01/29/14 during the tour of the first floor of the facility, at 8:42 AM, it was noted the EXIT sign above the doorway exiting the nurse manager's office was not illuminated.

On 01/29/13 Staff Z confirmed the findings at 8:43 AM.

Based on observation and interview, the facility failed to maintain its automatic sprinkler system in reliable operating condition such that sprinkler bulbs are kept clean, items are 18 inches or greater from the sprinkler heads, escutcheons were in place, and spare sprinkler heads of each type in place were available. The facility had a capacity of 224 patient beds with a census of 111 patients at the time of the survey completed on 01/30/14.

Findings include:

1. On 01/27/14 at 1:45 P.M. a tour was conducted with Staff Z of the fourth floor. At 2:35 P.M. in the medication room an escutcheon was observed to have slid down to the sprinkler leaving a gap between it and the wall. At 2:35 P.M. in an interview, Staff Z confirmed the finding.

2. On 01/27/14 at 2:35 P.M. in room B05 an escutcheon was observed taped to the ceiling with medical tape. At 2:35 P.M. in an interview, Staff Z confirmed the finding.

3. On 01/28/14 at 2:58 P.M. observation of the laboratory's file room revealed four shelving units extending to the center of the room that held items that were not 18 inches clear from the sprinkler heads. On 01/28/14 at 2:58 P.M. in an interview, Staff Z confirmed the finding.

4. On 01/28/14 at 3:25 P.M. tour of the second floor, in room 116, revealed an escutcheon dropped down from the sprinkler and a dirty sprinkler head in room 107. On 01/28/14 at 3:25 P.M. in an interview, Staff Z confirmed the findings.

5. On 01/29/14 at 11:36 A.M. a tour was conducted of the ground floor with Staff Z. At 11:52 A.M. a sprinkler head with corrosion on the bulb was observed in the case management office area, at 11:55 A.M. in the clinical engineering office a sprinkler was observed with a dropped escutcheon, and at 1:55 P.M. a missing escutcheon was observed over the sprinkler over the reception to the long term care unit. On 01/29/14 in interviews at 11:52 A.M., at 11:55 A.M., and at 1:55 P.M. Staff Z confirmed the findings.

6. On 01/29/14 at 2:00 P.M. observation of the spare sprinkler heads did not reveal spare flush pendent heads of the type used in the facility's behavioral health unit. On 01/29/14 at 2:00 P.M. in an interview, Staff Z confirmed the finding.

Based on observation and interview, the facility failed to provide sufficient means to indicate the location of each portable fire extinguisher. The facility had a capacity of 224 patient beds with a census of 111 patients at the time of the survey completed on 01/30/14.

Findings include

On 01/27/14 at 1:45 P.M. a tour was conducted with Staff Z of the fourth floor. The fire extinguisher was observed at the nurse's station on a wall immediately next to a red cart, and was therefore not readily visible.

On 01/27/14 at 2:44 P.M. in an interview Staff U was asked at the nursing station where the nearest fire extinguisher was. Staff U walked past said extinguisher several times without seeing it.

On 01/27/14 at 2:44 P.M. in an interview, Staff Z witnessed the finding.

Based on facility observation and staff interview and verification, the facility failed to ensure that trash and linen chute discharges into a trash collection rooms were protected in accordance with 8.4 and NFPA 82. The facility had a capacity of 224 patient beds with a census of 111 patients at the time of the survey completed on 01/30/14.

Findings included:

1. On 01/29/14 at 10:30 A.M. observation of trash and linen chutes was made with Staff Y present. Operational testing of the linen chute discharge door revealed the presence of a "S" hook and wire, which held the door open unless the wire was manually removed. The chute discharge door had no fusible link. Staff Y verified the chute door was to have a fusible link for proper function.

2. On 01/29/14 at 2:00 P.M. observation was made of a trash/ line chute discharge room located near Stair 8. Observation of the chutes revealed both discharge doors of the chutes were in the closed position with the fusible links disconnected. Staff Y could not address why the door were in the closed position.

Staff Y opened each chute door to reveal one bag of soiled linen present in the soiled linen chute and two bags of trash present in the trash chute. Staff Y reconnected the fusible links at the time of the observation so the doors were in the open position.

3. On 01/29/14 at 2:15 P.M. observation of the chute room near Stair 3 revealed the door to the chute was latched closed. The observation revealed that the door did not close completely, and bags of material could be seen in the crack between the door and the opening of the chute.

On 01/29/14 at 2:14 P.M. Staff Z explained the door was always kept shut because the carts brought into the room to empty the chute were getting caught on the wire attached to a fusible link to hold the door open.





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Based on interview and observation, the facility failed to ensure its medical gas system complied with NFPA 99. The facility had a capacity of 224 patient beds with a census of 111 patients at the time of the survey completed on 01/30/14.

Findings include:

On 01/27/14 at 1:45 P.M. a tour was conducted with Staff Z of the fourth floor. On 01/27/14 at 2:44 P.M. in an interview Staff T was asked where the nearest medical gas shut off valve was located. Staff T gave erroneous direction to one, and said there was a second valve, when there was no second valve.

On 01/27/14 at 1:45 P.M. in an interview, Staff Z witnessed the finding.

On 01/28/14 at 9:35 A.M. a tour was conducted of floor 3C with Staff Z. At 9:55 A.M. the medication gas shut off valves were observed to be labeled for room 324 to 343; however, the rooms were not numbered with three numerical digits.

On 01/28/14 at 9:35 A.M. in an interview, Staff Z confirmed the label on the rooms did not correspond to the label on the medical gas shut off valve.

Based on facility observation and staff interview and verification, the facility failed to ensure that oxygen storage was in accordance with NFPA 99, Chapter 4, with regards to protection and storage of oxygen cylinders from excessive heat or freezing temperatures.


Findings included:

On 01/29/14, between 3:00 P.M. and 3:40 P.M., observation with Staff Y was conducted of an outside dock area. Observation of the area revealed the presence of two meshed wire areas where cylinders of oxygen, nitrogen and medical air were stored. The cylinders varied in size from an E size to the larger H size cylinders.

Observation of the cylinders revealed there were at least 18 E size cylinders of oxygen and eight E size medical air. This group of cylinders were observed to be snow covered. A second storage area, slightly more protected, was observed to have at least at least 64 E size cylinders, five H size cylinders of nitrogen and six H size cylinders of oxygen. Snow was observed to be in the second area but not on the cylinders. Outside temperatures during the week of the survey, 01/26 through 01/29/14 was zero to 18 degrees on 01/29/14 with chill factors earlier in the week of 20 degrees below zero.

Staff Y confirmed the observation.

Based on observation and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular with extension cords arranged in a daisy chain formation in several areas. The facility had a capacity of 224 patient beds with a census of 111 patients.

Findings include:

1. On 01/28/14 at 1:55 P.M. at a beverage vendor stand in the atrium on the second floor, a toaster and a microwave oven was observed plugged into a power strip.

On 01/28/14 at 1:55 P.M. in an interview, Staff Z confirmed the finding.

2. On 01/29/14 at 9:50 A.M. in the executive suite, three power strips were found plugged together in a daisy chain formation.

On 01/29/14 at 9:50 A.M. in an interview, Staff Z confirmed the finding.

3. On 01/29/14 at 10:25 A.M. observation of the pharmacy office was conducted with Staff Y. Observation of the office revealed a multiple outlet power strip plugged into the wall. Plugged into the power strip were two extension cords used to supply electric to a coffee maker and a phone charger. Staff Y verified use of more than one power cord was discouraged and removed the extension cords from the appliances immediately.

4. During the tour of the ground floor of the facility on 01/29/14 at 2:41 PM. In the office of Clean Linen, under a desk, it was observed that two power strips were plugged end to end.

Staff Z confirmed the finding at 2:42 PM on 01/29/14.



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