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Based on observation, the facility failed to maintain the corridor doors as evidenced by self-closing corridor doors that failed to latch. This could result in the spread of smoke and fire throughout the facility and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 5 of 10 smoke compartments.

Findings:

During the facility tour and fire alarm testing with the Director of Plant Operations and Support Services on July 12, 2011 through July 13, 2011, the corridor doors were observed.

1. At 1:30 p.m. on July 12, 2011, the corridor door failed to fully close and positive latch when released from the magnetic lock during fire alarm testing in the Respiratory Supply Room on the fourth floor.

2. At 1:45 p.m. on July 12, 2011, the corridor door failed to fully close and positive latch when released from the magnetic lock during fire alarm testing in the Occupational Therapy Room on the third floor.

3. At 2:05 p.m. on July 12, 2011, the corridor double door, both leafs failed to fully close and positive latch when released from the magnetic locks during fire alarm testing in the Modalities Room on the second floor.

4. At 2:25 p.m. on July 12, 2011, the corridor double door P231, the right leaf failed to fully close and positive latch when released from the magnetic locks during fire alarm testing on the P2 floor.

5. At 9:08 a.m. on July 13, 2011, the self-closing corridor door failed to fully close and positive latch in the Anti-Room to Patient Room 322 on the third floor.

6. At 9:22 a.m. on July 13, 2011, the self-closing corridor door failed to fully close and positive latch in the Tub Room EM-NPC-20 on the third floor.

Based on observation, the facility failed to maintain the floor to floor separations as evidenced by unsealed vertical openings through the floors located in the telephone rooms. This could could result in smoke and fire spreading from one floor to the next floor and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 4 of 10 smoke compartments.

Findings:

During the facility tour with the Director of Plant Operations and Support Services on July 13, 2011, the building construction was observed.

1. At 9:27 a.m., there was a 1 and 1/2 inch circular unsealed penetration surrounding a new cable through the concrete in the Telephone Closet Em-Mech-04 on the third floor.

2. At 9:40 a.m., there was a 1 and 1/2 inch circular unsealed penetration at the top and the bottom surrounding a new cable through the concrete in the Telephone Closet Em-Mech-04 on the second floor.

3. At 9:45 a.m., there was a 1 and 1/2 inch circular unsealed penetration surrounding a new cable at the top and the bottom through the concrete in the Telephone Closet Em-Mech-04 on the first floor.

Based on observation, the facility failed to maintain the integrity of a smoke barrier wall as evidenced by an unsealed penetration in a smoke barrier wall. This could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 10 smoke compartments.

Findings:

During the facility tour with the Director of Plant Operations and Support Services on July 12, 2011, the smoke barrier walls were observed.

At 2:00 p.m., there was an approximately 1 inch circular unsealed penetration above the dropped ceiling surrounding a cable in the center of the smoke barrier wall over the smoke barrier door 2060 on the second floor.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed to fully close and positive latch upon closure. These could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 10 smoke compartments.

Findings:

During fire alarm testing with the Director of Plant Operations and Support Services on July 12, 2011, the smoke barrier doors were observed.

1. At 2:15 p.m., the left leaf of the smoke barrier double door 1013 in the first floor failed to positive latch. The Director of Plant Operations and Support Services confirmed that the smoke barrier double door 1013 failed to positive latch.

2. At 2:20 p.m., the smoke barrier double door 1086 in the first floor, both leafs failed to fully close and positive latch. The Director of Plant Operations and Support Services confirmed that the smoke barrier double door 1086 failed to fully close and positive latch.

Based on record review and interview, the facility failed to conduct fire drills quarterly as evidenced by no documentation of a second shift fire drill for the third quarter of 2010. This could result in the failure of any one facility staff member accomplishing all of the tasks expected of him or her in the event of a fire and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 10 of 10 smoke compartments

Findings:

During record review and interview with the Director of Plant Operations and Support Services on July 12, 2011 through July 13, 2011, the fire drills were reviewed and staff interviewed.

1. At 10:00 p.m. on July 12, 2011, documetation of the fire drills for one year were requested.

2. At 2:45 p.m. on July 13, 2011, the facility failed to provide a 7 p.m. to 7 a.m. fire drill record for the third quarter of 2010. The Director of Plant Operations and Support Services stated that there were two 7 a.m.to 7 p.m. fire drills but not a 7 p.m. to 7 a.m. fire drill for the third quarter of 2010.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by sprinkler heads with no escutcheon rings. These could prevent the fire sprinkler system from operating as designed and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 4 of 10 smoke compartments.

Findings:

During the facility tour with the Director of Plant Operations and Support Services on July 12, 2011 through July 13, 2011, the sprinkler system was observed.

1. On July 12, 2011 at 2:35 p.m., 1 of 3 sprinklers was missing an escutcheon ring in the Kitchen Dish Room.

2. On July 13, 2011 at 8:15 a.m., 2 of 2 sprinklers were missing an escutcheon ring in Patient Room 423.

3. On July 13, 2011 at 8:25 a.m., 1 of 2 sprinklers was missing an escutcheon ring in Patient Room 427.

4. On July 13, 2011 at 8:56 a.m., 1 of 3 sprinklers was missing an escutcheon ring in Patient Room 428.

5. On July 13, 2011 at 9:00 a.m., 1 of 2 sprinklers was missing an escutcheon ring in Patient Room 323.

6. On July 13, 2011 at 9:20 a.m., 2 of 2 sprinklers were missing an escutcheon ring in the third floor Clean Wheel Chair Room.

7. On July 13, 2011 at 9:30 a.m., 1 of 1 sprinklers was missing an escutcheon ring in the Third Floor Janitor Room EM-NPC-04.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers in accordance with NFPA 10 as evidenced by fire extinguishers that were obstructed from immediate access. This could result in delayed response to a fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 10 smoke compartments.


NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition
1.6 General Requirements
1.6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal paths of travel, including exits from areas.
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.

Findings:

During the facility tour with the Director of Plant Operations and Support Services on July 12, 2011, the fire extinguishers were observed.

1. At 9:15 a.m., the fire extinguisher was blocked from access by a linen cart by Patient Room 422 on the fourth floor.

2. At 9:25 a.m., the fire extinguisher was blocked from access by bio-hazard barrels stacked in front in the corridor by Radiology on the first floor.

Based on observation, the facility failed to maintain the smoking areas as evidenced by the use of an open container for the disposal of cigarette butts. This finding could result in a fire and increase the risk of injury to patients, visitors and staff.

Findings:

During the facility tour with the Director of Plant Operations and Support Services on July 13, 2011, the smoking areas were observed.

At 9:50 a.m., there was an open container with approximately 12 cigarette butts in the Patio Smoking Area. The Director of Plant Operations and Support Services confirmed the open container with cigarette butts.

Based on observation, the facility failed to maintain the path of egress free of all obstructions and impediments to full instant use in case of evacuation during fire or other emergency. This was evidenced by an egress path where the floor had an indentation. This could delay evacuation in the event of an emergency and increase the risk of injury to patients, visitors and staff. This affected 1 of 10 smoke compartments.

Findings:

During the facility tour with the Director of Plant Operations and Support Services on July 13, 2011, the egress paths were observed.

At 10:10 a.m., there were two 4 inch square by 1/2 inch deep indentations in the floor creating a trip hazard at the Back Exit to the Kitchen.

Based on observation, the facility failed to ensure that their compressed gas cylinders were secured. This was evidenced by an unsecured E-oxygen tank. This finding could result in a fire and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 1 of 10 smoke compartments.

NFPA 99 (1999 Edition
8-3.1.11.2 (h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
4-3.5.2.1(b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During the facility tour with the Director of Plant Operations and Support Services on July 13, 2011, the facility storage areas were observed.

At 9:15 a.m., there was an E-oxygen cylinder standing unsecured in the Respiratory Clean Linen Room on the third floor. The Director of Plant Operations and Support Services confirmed that the E-oxygen tank was not secured.