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Based on observation, and staff interview, the facility failed to maintain their self closing doors. This was evidenced by self-closing doors that failed to fully close and positively latch. This affected three of four floors. and could result in the passage of smoke in the event of a fire.

Findings:

During a tour of the facility with a staff member on 7/17/17, the facility doors were observed.

1. At 9:53 a.m., on the 4th floor, in the ICU, the self closing door to the Staff Lounge, was not held open with a device tied into the fire alarm system. The self-closing door was held open by a chair placed up against the door.

2. At 11:18 a.m., on the 4th floor, the self-closing corridor door to Room 412, was tested. The door released, and failed to positively latch when closed.

3. At 11:21 a.m., on the 4th floor, across from Room 406, the self-closing door to the Soiled Utility Room, was tested. The door released, and failed to positively latch when closed.

4. At 1:04 p.m., on the 2nd floor, the self-closing door to the Dietary Storage Room, was tested. The door released, and failed to positively latch when closed.

5. At 11:21 a.m., on the 2nd floor, across from Room 206, the self-closing door to the Utility Room, was tested. The door released, and failed to positively latch when closed.

Based on observation, and staff interview, the facility failed to maintain their battery operated lights in the operating rooms. This was evidenced by no battery back up lights found in the operating rooms. This affected two of two operating rooms on the first floor. This could result in lack of light in the event of a power outage.


NFPA 101 Life Safety Code, 2012 Edition
6.3.2.2.11 Battery-Powered Lighting Units.
6.3.2.2.11.1 One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.
6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room.
6.3.2.2.11.3 The sensor for units shall be wired to the branch circuit(s) serving general lighting within the room.
6.3.2.2.11.4 Units shall be capable of providing lighting for 11.2 hours.
6.3.2.2.11.5 Units shall be tested monthly for 30 seconds, and annually for 30 minutes.

Findings:

During a tour of the facility, and interview with a staff member on 7/17/17, the operating rooms were observed.

1. At 10:51 a.m., in Operating Room 2, no battery back up light was observed in the room. During an interview staff stated, that there were no battery back up lights in the operating rooms.

2. At 10:53 a.m., in Operating Room 1, no battery back up light was observed in the room. During an interview staff stated, that no battery back up lights were in the operating rooms.

Based on observation, and staff interview, the facility failed to maintain the fire alarm system. This was evidenced by several chime/strobe devices that failed to emit an audible sound when activated. This affected four of four floors, and could result in failure of the fire alarm system to notify occupants in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3 unless otherwise modified by the following:
(1)*In lieu of audible alarm signals, visible alarm-indicating appliances shall be permitted to be used in critical care areas.
(2) Where visual devices have been installed in patient sleeping areas in place of an audible alarm, they shall be permitted where approved by the authority having jurisdiction.
9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall be provided to alert occupants of a fire or other emergency where required by other sections of this Code.

Findings:

During fire alarm testing, and interview with a staff member on 7/17/17, the facility fire alarm was tested.

1. At 9:40 a.m., on the 4th floor in the Administration wing, the chime/strobe combo device by Wound Care, was not audible. Staff confirmed that no audible sound came from the fire alarm device. The strobe did function as designed.

2. At 10:01 a.m., on the 2nd floor near Room 209, the chime/strobe combo #4-2 EOC device failed to function. Staff confirmed that no audible sound could be heard, and no strobe light came on from the fire alarm device.

3. At 10:03 a.m., on the 2nd floor outside of the Cafeteria, the chime/strobe combo device, was not audible. Staff confirmed that no audible sound came from the fire alarm device. The strobe did function as designed.

4. At 10:07 a.m., on the 2nd floor in the Cafeteria, two of two chime/strobe combo devices were not audible. Staff confirmed that no audible sound came from the fire alarm devices. The strobes on both devices did function as designed.

5. At 10:09 a.m., on the 2nd floor in the Loading Dock Area, the chime/strobe combo device was not audible. Staff confirmed that no audible sound came from the fire alarm device. The strobe did function as designed.

6. At 10:22 a.m., on the 1st floor in the Lobby Area, three of three chime/strobe combo devices were not audible. Staff confirmed that no audible sounds came from the three fire alarm devices. The strobes on all three devices did function as designed.

7. At 10:24 a.m., on the 1st floor in the Radiology Department, the chime/strobe combo device was not audible. Staff confirmed that no audible sound came from the fire alarm device. The strobe did function as designed.

Based on observation, document review, and staff interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by not conducting the five year inspection and test of automatic sprinkler system. This affected four of four floors, and could result in failure of the sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
9.7.7 Documentation. All required documentation regarding the design of the fire protection system and the procedures for maintenance, inspection, and testing of the fire protection system shall be maintained at an approved, secured location for the life of the fire protection system.
9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.
13.4.1.2* Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
13.4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate correctly, move freely, and are in good condition.
14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
14.3.1* An obstruction investigation shall be conducted for system or yard main piping wherever any of the following conditions exist:
(1) Defective intake for fire pumps taking suction from open bodies of water
(2) The discharge of obstructive material during routine water tests
(3) Foreign materials in fire pumps, in dry pipe valves, or in check valves
(4)*Foreign material in water during drain tests or plugging of inspector's test connection(s)
(5) Plugged sprinklers
(6) Plugged piping in sprinkler systems dismantled during building alterations
(7) Failure to flush yard piping or surrounding public mains following new installations or repairs
(8) A record of broken public mains in the vicinity
(9) Abnormally frequent false tripping of a dry pipe valve(s)
(10) A system that is returned to service after an extended shutdown (greater than 1 year)
(11) There is reason to believe that the sprinkler system contains sodium silicate or highly corrosive fluxes in copper systems
(12) A system has been supplied with raw water via the fire department connection
(13) Pinhole leaks
(14) A 50 percent increase in the time it takes water to travel to the inspector's test connection from the time the valve trips during a full flow trip test of a dry pipe sprinkler system when compared to the original system acceptance test.

Findings:

During document review with staff members on 7/18/17, the maintenance records for the automatic sprinkler system were requested.

1. At 2:34 p.m., the documentation for the 5 year sprinkler certification was provided. The document was dated 2007, and failed box was checked. Staff was asked to provided documentation with a correct date and corrections to the deficiencies found. No additional documents were provided.

2. On 7/19/17, at 11:30 a.m., no sticker for the current 5 year certification of the sprinkler system could be located. A partial 5 year sticker was found on the riser and was dated 2007.
The facility had quarterly and annual inspections for their sprinkler system.

Based on observation, and staff interview, the facility failed to maintain the facility fire doors. This was evidenced by doors that failed to fully close and latch. This affected three of three smoke compartments on the 1st floor, and could result in the in the passage of smoke and fire in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.7.6 Openings in smoke barriers shall be protected using one of the following methods:
(1) Fire-rated glazing
(2) Wired glass panels in steel frames
(3) Doors, such as 13/4 in. (44 mm) thick, solid-bonded woodcore doors
(4) Construction that resists fire for a minimum of 20 minutes.
19.3.7.8* Doors in smoke barriers shall comply with 8.5.4 and all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel.
8.5.4 Opening Protectives.
8.5.4.1* Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of 3/4 in. (19 mm).
8.5.4.2 Where required by Chapters 11 through 43, doors in smoke barriers that are required to be smoke leakage-rated shall comply with the requirements of 8.2.2.4.
8.5.4.3 Latching hardware shall be required on doors in smoke barriers, unless specifically exempted by Chapters 11 through 43.
8.5.4.4* Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.
8.5.4.5 Fire window assemblies shall comply with 8.3.3.

Findings:

During a tour of the facility with staff members on 7/17/17, the facility fire doors were observed.

1. At 10:15 a.m., on the 1st floor, the left hand fire door by Respiratory Therapy released and closed upon activation of the fire alarm system. The left hand door failed to positively latch when closed.

2. At 10:15 a.m., on the 1st floor, the left hand fire door by Physical Therapy released and closed upon activation of the fire alarm system. The left hand door failed to positively latch when closed.

Based on document review, and staff interview, the facility failed to maintain the facility elevators. This was evidenced by not conducting the monthly tests of the Fire Fighter Emergency operations. This affected four of four patient floors, and could result in the failure of the emergency recall of the elevators in the event of an emergency.

NFPA 101 Life Safety Code, 2012 Edition
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.
9.4.3.2 All existing elevators having a travel distance of 25 ft (7620 mm) or more above or below the level that best serves the needs of emergency personnel for fire-fighting or rescue purposes shall conform to the fire fighters ' emergency operations requirements of ASME A17.3, Safety Code for Existing Elevators and Escalators.
9.4.6 Elevator Testing.
9.4.6.1 Elevators shall be subject to periodic inspections and tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators and Escalators.
9.4.6.2 All elevators equipped with fire fighters ' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1/CSA B44, Safety Code for Elevators and Escalators.

Findings:

During document review, and interview with a staff member on 7/18/17, the documents for the monthly tests of the two elevators were requested.

At 2:18 p.m., no documents were provided for the monthly tests of the fire fighters emergency operations. During an interview, staff stated, that the elevators were recalled monthly during the generator full load test. No documentation was maintained for the monthly testing of the elevators.

Based on observation, the facility failed to maintain their electrical system. This was evidenced by the use of unapproved extension cords. This affected one of nine smoke compartments, and could result in the ignition of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage
590.3 Time Constraints.
(A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities.
(B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes.
(D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed.

Findings:

During a tour of the facility with a staff member on 7/17/17, the facility electrical wiring was observed.

1. At 11:02 a.m., on the 4th floor in the Chief Financial Officer's Office, an air conditioning unit was plugged into a surge protected power strip instead of directly into the wall outlet.

2. At 11:05 a.m., on the 4th floor in the Copy Room, a fax machine was plugged into an extension cord instead of directly into the wall outlet.

Based on document review, and staff interview, the facility failed to maintain the electrical outlets. This was evidenced by not conducting the annual tension and polarity test of the electrical outlets. This affected four of four floors, and could result in the ignition of an electrical fire.

NFPA 99, Health Care Facilities Code, 2012 Edition
6.3.3.2 Receptacle Testing in Patient Care Rooms.
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).
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

Findings:

During document review, with a staff member on 7/18/17, the records for the testing of the electrical outlets were requested.

At 2:06 p.m., no documents for the annual testing of the receptacle outlets were provided. During an interview, staff stated the receptacle outlets were tested regularly, but no records were maintained for the testing of the outlets.



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