HospitalInspections.org

Based on record review and interview, the facility failed to inspect the emergency generator circuit breaker(s) annually, and exercise the circuit breakers periodically. This deficient practice increased the potential that emergency power would not be supplied to the facility during an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

This deficiency applies to the following buildings: 8 (Clarkson Doctors North/South), 9 (Durham Outpatient), 10 (Lied Transplant Center), 11 (Munroe Meyer Institute), 14 (Specialty Services Pavilion), 15 (Hixson Lied Center), 16 (Clarkson Tower), 17 (University Tower), 18 (Buffet Cancer Center), 19 (Lauritzen Outpatient).

Findings are:
Record review on 9-18-19, at 11:14 am revealed, a preventative maintenance plan was not adopted to inspect annually, and exercise periodically the emergency generator circuit breaker(s).

During an interview on 9-18-19, at 11:14 am, Facility Staff X confirmed the inspection and testing was not implemented.

NFPA Standard:
2012, NFPA 99 , 6.6.4.1.2
Circuitry shall be maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2.1*
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.


27394





27395




41670

K100 A
Based on observation and staff interview, the facility failed to separate hazardous areas with smoke resistive doors. This condition would allow smoke to migrate into the exit corridors. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, from 9:31 am to 12:36 pm revealed:
4th Floor:
1. The open end of a conduit was not sealed in the Elevator Equipment Room 4.14.006.
2. The Elevator Equipment Room Door 4.14.011 was located in a 2-hour fire barrier, according to the facility floor plan. The door did not possess a fire resistance tag to verify the rating of the door.
3. The Mechanical Room Door 4.14.122 was located in a 1-hour fire barrier, according to the facility floor plan. The door did not possess a fire resistance tag to verify the rating of the door.
3rd Floor:
4. The Communication Door 3.14.106 Door did not close/positively latched when self-closed.
5. A 4 inch by 4 inch hole around a conduit in the back wall of the Electrical Room 3.14.107 was not sealed.
2nd Floor:
6. The 3.14.109 Door was located in a 1-hour fire wall, according to the facility floor plan. The door did not possess a fire resistance tag to verify the rating of the door.
1st Floor:
7. The Coffee Area Storage Room Door 1.14.07B was propped open to prevent the door from self-closing at the time of observation. The door did not positively latch when self-closed.

In an interview on 9/11/19, from 9:31 am to 12:36 pm, Facility Staff E acknowledged the findings.

K100 B
Based on observation and staff interview, the facility allowed a non-fire sprinkler related item to be attached to sprinkler piping. This condition had the potential to damage sprinkler components. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 11:59 am revealed a data cable was wrapped around a fire sprinkler pipe in the 2nd Floor Medical Gas 2.14.078 Room.

In an interview on 9/11/19, at 11:59 am, Facility Staff E acknowledged the findings.

NFPA 13, 2010, 9.1.1.7* Support of Non-System Components. Sprinkler piping
or hangers shall not be used to support non-system components.

K100 C
Based on observation and staff interview, the facility failed to use electrical wiring and equipment in a way that would not create a fire. This condition had the potential to cause a fire, or prevent response to a fire. The facility census was 728 with a capacity of 488.
Findings are:

Observation on 9/11/19, from 9:46 am to 12:45 pm revealed:
4th Floor:
1. A microwave was plugged into a power strip, and not directly into a hardwired outlet at the desks in the Ortho Lab.
2. A cart obstructed access to electrical panels in Mechanical Room 4.14.122.
3rd Floor:
3. A coffee maker was plugged into a power strip, and not directly into a hardwired outlet, which was daisy chained into a UPS by Exam Room 18, Door 3.14.068.
1st Floor:
4. The electrical disconnects were obstructed by storage in the MRI Equipment Room 1.14.104.

In an interview on 9/11/19, from 9:46 am to 12:45 pm, Facility Staff E 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.

NFPA 70, 2011, 210.23 Permissible Loads. In no case shall the load exceed
the branch-circuit ampere rating. An individual branch
circuit shall be permitted to supply any load for which it is
rated. A branch circuit supplying two or more outlets or
receptacles shall supply only the loads specified according
to its size specified in 210.23(A) through (D) and as summarized
in 210.24 and table 210.24.

K100 D
Based on observation and staff interview, the facility failed to provide fire sprinkler coverage to all areas of a room. This condition would prevent the suppression of a fire. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 12:40 pm revealed a wall partition was added in the southeast corner of Room 1.14.105 on the 1st Floor. A fire sprinkler was not installed inside this area, and a fire sprinkler was not within range to cover the area.

In an interview on 9/11/19, at 12:40 pm, Facility Staff E confirmed the findings.

NFPA 13, 2010, 4.1 Level of Protection. A building, where protected by an
automatic sprinkler system installation, shall be provided with
sprinklers in all areas except where specific sections of this
standard permit the omission of sprinklers.
8.5.5 Obstructions to Sprinkler Discharge.
8.5.5.1* Performance Objective. Sprinklers shall be located so
as to minimize obstructions to discharge as defined in 8.5.5.2
and 8.5.5.3, or additional sprinklers shall be provided to ensure
adequate coverage of the hazard. (See Figure A.8.5.5.1.)

K100 E
Based on observation, record review and staff interview, the facility failed to ensure a facility hot-work permit policy was in place for welding operations in a Business Occupancy. This condition increased the potential for the spread of a fire. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 9:50 am revealed a welder, with cylinders, was set up in the Ortho Lab on the 4th Floor.

Record review on 9/11/19, at 9:50 am revealed the facility did not have a hot-work permit policy in place for welding in the Ortho Lab.

In an interview on 9/11/19, at 9:50 am, Facility Staff E confirmed the findings.

NFPA 101, 2012, 4.6.1.2 Any requirements that are essential for the safety of
building occupants and that are not specifically provided for
by this Code shall be determined by the authority having jurisdiction.
Chapter 41 Welding, Cutting, and Other Hot WorkNFPA 1, 2012, 41.2.1* Management. Management or a designated agent shall be responsible for the safe operations of hot work activity.
[51B:4.1]
41.2.2 Permit Authorizing Individual (PAI). In conjunction
with management, the PAI shall be responsible for the safe
operation of hot work activities. [51B:4.2]
41.2.3 Hot Work Operator. The hot work operator shall
handle equipment safely and use it as follows so as not to endanger
lives and property:
(1) The operator shall have the PAI's approval before starting
hot work operations.
(2) All equipment shall be examined to ensure it is in a safe
operating condition, and, if found to be incapable of reliable
safe operation, the equipment shall be repaired by
qualified personnel prior to its next use or be withdrawn
from service.
(3) The operator shall cease hot work operations if unsafe conditions
develop and shall notify management, the area supervisor,
or the PAI for reassessment of the situation.
[51B:4.3]
41.3.2 Permissible Areas.
41.3.2.1 General. Hot work shall be permitted only in areas
that are or have been made fire safe. [51B:5.2.1]
41.3.2.2 Designated or Permit-Required Areas. Hot work shall
be performed in either designated areas or permit-required
areas. [51B:5.2.2]

K100 F
Based on observation and staff interview, the facility failed to ensure a stair door would remain shut in conditions. This condition would allow smoke or fire to enter the stair tower. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/11/19, at 12:17 pm revealed the 1st Floor Stair Door 1.14.98A did not positively latch when self-closed.

In an interview on 9/11/19, at 12:17 pm, Facility Staff E confirmed the findings.

NFPA 101, 2012, 8.3.3.1 Openings required to have a fire protection rating by
Table 8.3.4.2 shall be protected by approved, listed, labeled
fire door assemblies and fire window assemblies and their accompanying
hardware, including all frames, closing devices,
anchorage, and sills in accordance with the requirements of
NFPA 80, Standard for Fire Doors and Other Opening Protectives,
except as otherwise specified in this Code.

K100 G
Based on observation and staff interview, the facility failed to limit the quantity of propane cylinders indoors. This condition created the potential for a propane flash fire. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/12/19, at 9:09 am in the 1st Floor Receiving revealed two propane cylinders were labeled what appeared to be 30 pounds each, and were separated by 4 inches from each other. The propane cylinders were part of a supply system for Bunsen Burners on the 3rd Floor dental exam rooms and a work room.

In an interview, 9/12/19, at 9:09 am Facility Staff E confirmed the cylinders exceeded 20 pounds each, and were not separated by at least 20 feet.

NFPA 58, 2011, 6.19.7.2 Where cylinders are used in buildings housing educational
and institutional laboratory occupancies for research
and experimental purposes, the following shall apply:
(1) The maximum water capacity of individual cylinders used
shall be 50 lb (23 kg) [nominal 20 lb (9.1 kg) propane
capacity] if used in educational occupancies and 12 lb
(5.4 kg) [nominal 5 lb (2 kg) propane capacity] if used in
institutional occupancies.
(2) If more than one such cylinder is located in the same room,
the cylinders shall be separated by at least 20 ft (6.1 m).
(3) Cylinders not connected for use shall be stored in accordance
with Chapter 8.
(4) Cylinders shall not be stored in a laboratory room.

Based on observation and interview, the facility failed to maintain the two-hour fire barrier separation between buildings. This deficient practice would allow fire and smoke to migrate throughout the facility. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:

1. Observation on 9-12-19 at 10:05 am revealed the 90 minute door in the 2 hour firewall separation from corridor 5699S to corridor 5699E failed to close and latch.
2. Observation on 9-13-19 at 10:08 am revealed the 90 minute doors in the 2 hour firewall separation on 2nd floor between Durham Outpatient Center and the Buffet Cancer Center failed to close and latch.
3. Observation on 9-16-19 at 3:30 pm am revealed the 90 minute doors in the 2 hour firewall separation on 1st floor between Durham Outpatient Center and the Buffet Cancer Center failed to close and latch.
4. Observation on 9-17-19 at 2:01 pm revealed an unsealed 1-inch penetration above the door in the 2 hour separation from corridor 4699R to 4599E.


During interviews on 9-12-19 at 10:05 am, on 9-13-19 at 10:08 am, on 9-16-19 at 3:30 pm, and on 9-17-19 at 2:01 pm, Facility Staff F confirmed the findings.

Based on observation and interview, the facility failed to maintain a 2-hour fire rated separation doors. This deficient practice would allow smoke and fire to migrate between the occupancies. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-10-19 at 4:00 pm revealed:
4th Floor
1. The south 2-hour fire door 4.12.99F/C failed to latch within the doorframe.

During an interview on 9-10-19 at 4:00 pm, Facility Staff A confirmed the findings.

Ground Floor
Observations on 9-11-19 between 10:30 am and 12:16 pm revealed:
2. The undercut to the 2-hour fire rated door 0.12.99E was greater than ¾ inch.
1st Floor
3. The 2-hour fire rated door 1.12.05/99D had an excessive gap between the doors.
6th Floor
4. The 2-hour fire rated door between BCC and DOC failed to latch within the doorframe, the north door drug on the floor

During an interview on 9-11-19 between 10:30 am and 12:16 pm, Facility Staff A confirmed the findings.

Observations on 9-12-19 at 11:05 am:
4th Floor
5. The 2-hour fire rated wall in corridor 4.12.99B above the ceiling at fire door 4.12.99C/B, appeared to have an approximate 2-inch unsealed penetration around the top and sides.

During an interview on 9-12-19 at 11:05 am, Facility Staff A confirmed the findings.

Based on observations and interview, the facility failed to assure doors in the means of egress were not capable of locking. This deficient practice would delay egress and cause confusion and panic in the event of an emergency, facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-11-19 at 11:18 am revealed:
Ground Floor
1. 4 of 4 Main Entrance doors were equipped with keyed thumb locks.

During an interview on 9-11-19 at 11:18 am, Facility Staff A confirmed the findings.

Based on observation and interview, the facility failed to maintain means of egress free of obstructions for instant use in an emergency. This deficient practice could delay exiting or block the path of egress from the facility. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) Observations on 09/11/19 at 12:46 P.M. revealed the exit door at the bottom of west exit stairs in Clarkson Doctors North building had collection carts for combustibles obstructing the egress path to the exit door.

2) During an interview on 09/11/19 at approximately 12:46 P.M., Team # 4 Facility Staff A confirmed all the findings.

Based on observation and interview, the facility failed to post signage to operate delayed egress locks on a magnetically locked exit doors. This deficient practice would delay egress during an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-16-19 at 2:11 pm revealed:
4th Floor
1. The magnetically locked exit door 4899R/38203 did not have delayed egress operating instructions signage installed on the door.

During an interview on 9-16-19 at 2:11 pm, Facility Staff A confirmed the lack of delayed egress signage.

NFPA Standard:
2012 NFPA 101, 7.2.1.6.1.1
(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



27395

Based on observation and staff interview, the facility failed to post instructions to operate a delayed egress lock, and to remove components of an access control lock that were no longer in use. This condition would affect the evacuation of occupants during an emergency. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/16/19, from 3:48 pm to 3:58 pm revealed:
1. The magnetically locked 1st Floor 1899V Exit Doors did not have delayed egress operating instructions signage installed on the door.
2. The magnetically locked 1st Floor exit doors by Trauma in corridor 1839U/18291 had a motion sensor, and a push to exit button installed that were no longer in use.

In an interview on 9/16/19, at 3:48 pm, Facilities Staff E acknowledged the findings.

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 provide exit stairwells that were separated from the remainder of the building by self closing and latching doors. This deficient practice has the potential to allow smoke and heat spread to multiple floors of the building blocking off egress paths.

Findings are:
1. Observation on 9/13/19 at 9:25 a.m. revealed the 3rd Floor Stairwell door #3098A did not self close and latch.
2. Observation on 9/13/19 at 9:52 a.m. revealed the 2nd Floor Stairwell door #2098A did not self close and latch.

During an interview at the time of the findings, all three members from Team G confirmed the findings

Based on observation and interview, the facility failed to maintain an obstacle-free path of egress by allowing furniture to be stored in an exit stairwell. This deficient practice would delay the egress of occupants trying to use the stairwell in an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:

Observation of 9-17-19 at 9:58 am revealed 2 office chairs and an office table stored in stairwell number 0699C.

During an interview on 9-17-19 at 9:58 am, Facility Staff F confirmed the findings.

Based on observation, record review, and staff interview, the facility used the Emergency Department (ED) as a suite, but failed to designate/design the area as one. This condition would affect exiting and patient safety. The facility census was 728 with a capacity of 488.
Findings are:

Record review of facility floor plans on 9/16/19, at 3:30 pm revealed the ED was not designated/designed as a suite.
Observation on 9/16/19, at 3:30 pm of the ED revealed:
1. The sliding doors to Trauma 18256 did not have positive latching hardware installed in the corridor doors.
2. EMS 18223 was open to the exit corridor, and did not have smoke detection installed in the space.
3. Patients were stationed on wheeled beds throughout the exit corridors in the ED, due to lack of patient rooms, which obstructed the exit corridors.

In an interview on 9/16/19, at 3:30 pm, Facilities Staff E acknowledged the findings.

Based on observation and staff interview, the facility failed to provide emergency lighting of at least 1½-hour duration. This deficient practice would slow or prevent evacuation of occupants during an emergency under loss of normal power. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) The emergency lighting unit in the Clarkson Doctors North, third floor Surgery Room 31128 unit did not work when tested.

2) The emergency lighting unit in the Clarkson Doctors South, sixth floor room 61080 unit did not work when tested.

3) During an interview on 9-11-19 between 9:00 A.M. and 5:45 P.M., Team # 4 Facility Staff A confirmed all the findings.

Based on observation and interview, the facility failed to provide visible exit signs. This deficient practice had the potential for delay or to cause confusion during an emergency as occupants would be unable to locate exits. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-10-19 between 1:10 pm and 2:34 pm revealed:
8th Floor
1. While standing in south side corridor looking west, no exit sign was visible to direct occupants to the exit.
6th Floor
2. While standing in south side corridor looking west not exit sign was visible to direct occupants to the exit.

During an interview on 9-10-19 between 1:10 pm and 2:34 pm, Facility Staff A confirmed the lack of exit signage.

Observations on 9-11-19 at 12:03 pm and 1:33 pm revealed:
2nd Floor
3. While standing in corridor 2.12.99A looking south, no exit sign was visible to direct occupants to the exit.
1st Floor
4. While standing in corridor outside room 1.12.246 looking west the facility failed to provide an exit sign with a chevron to indicate direction of egress.

During an interview on 9-11-19 between 12:03 pm and 1:33 pm, Facility Staff A confirmed the lack of exit signage.

Based on observation and staff interview, the facility failed to ensure a door to a stair would positively latch. This condition would allow smoke or fire to enter the stair tower. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/16/19, at 3:10 pm revealed the 2898J Stair Door did not positively latch when self-closed.

In an interview on 9/16/19, at 3:10 pm, Facility Staff E confirmed the findings.

NFPA 101, 2012, 8.3.3.1 Openings required to have a fire protection rating by
Table 8.3.4.2 shall be protected by approved, listed, labeled
fire door assemblies and fire window assemblies and their accompanying
hardware, including all frames, closing devices,
anchorage, and sills in accordance with the requirements of
NFPA 80, Standard for Fire Doors and Other Opening Protectives,
except as otherwise specified in this Code.

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 smoke tight. These deficient practices would allow fire, smoke and gases to migrate into the exit corridor. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observation on 9-16-19 between 2:16 pm and 2:56 pm revealed:
4th Floor
1. 1-hour fire rated doors 48212 had an excessive gap between the doors.
2. 1-hour fire rated doors 4899P/4899N failed to provide latching devices.
3. 1-hour fire rated doors 4899AA/4899EE failed to provide latching devices.
4. 1-hour fire rated door 48275 equipped with self-closing device failed to close and latch within the doorframe.
5. 1-hour fire rated door 48272 equipped with self-closing device failed to close and latch within the doorframe.

During an interview on 9-16-19 between 2:16 pm and 2:56 pm, Facility Staff A confirmed findings.


27395

Based on observation and staff interview, the facility failed to separate hazardous areas with smoke resistive doors. This condition would allow smoke to migrate into the exit corridors. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/16/19, from 1:50 pm to 2:37 pm revealed:
1. The 1st Floor Soiled Utility Door 18309 did not positively latch when self-closed.
2. The 1st Floor OR 17/Clean Core door did not positively latch when self-closed.
3. The 2nd Floor Soiled Utility Door 28275 did not positively latch when self-closed.

In an interview on 9/16/19, from 1:50 pm to 2:37 pm, Facility Staff E acknowledged the findings.

Based on observation and interview, the facility failed to provide fire-extinguishing protection over a hamburger fryer. This deficient practice would allow a fire to spread and become uncontrollable. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) Observations on 09/11/19 at approximately 11:30 A.M. in the Clarkson Doctors North revealed the facility was using a Wolf Gang Puck fryer appliance in breakroom 11135 without the protection of a hood exhaust system and required fire-extinguishing system.

2) During an interview on 09/11/19 at approximately 11:30 A.M., Team # 4 Facility Staff A confirmed all the findings.

Based on observation and interview, the facility failed to provide complete fire alarm notification throughout the facility. This deficient practice has the potential to affect all staff using the conference room in the clinic.

Findings are:
1. Observation on 9/12/19 at 9:17 a.m. revealed that no fire alarm notification device was provided in the large conference room #1.0.17

During an interview at the time of the finding, all three members from Team G confirmed the findings.

Based on observation and interview, the facility failed to maintain a fire alarm initiating device. This deficient practice would not alert occupants of smoke within the room and would allow smoke to enter the exit corridor. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
5th Floor
Observations on 9-16-19 at 1:50 pm revealed, the heat detector in elevator room 58200 was hanging by its wires in the northeast corner near elevator SE3.

During an interview on 9-16-19 at 1:50 pm, Facility Staff A confirmed the finding.


27395

Based on record review and staff interview, the facility failed to test all duct detectors annually. This condition increased the potential of the devices failing to initiate during a fire. The facility census was 728 with a capacity of 488.

Findings are:
Record review on 9/17/19, at 2:42 pm revealed 8 duct detectors on the 2/25/19 and the 3/1/18 fire alarm inspection report failed testing, due to the devices being unreachable.

In an interview on 9/17/19, at 2:42 pm Facilities Staff E confirmed the findings.

Based on observation and staff interview, the facility failed to provide fire sprinkler coverage to all areas of a room. This condition would prevent the suppression of a fire. The facility census was 728 with a capacity of 488.

Findings are:
Observation on 9/16/19, from 1:48 pm to 2:25 pm revealed:
1. 1st Floor MRI 3 Equipment Room 18323 did not have sprinkler protection below an air duct that exceeded 4 feet in width, and no sprinkler coverage was installed below the obstructions to the upright fire sprinklers.
2. 2nd Floor IT Closet 28252 fire sprinkler was obstructed by a light fixture.

In an interview on 9/16/19, from 1:48 pm to 2:25 pm, Facility Staff E confirmed the findings.

NFPA 13, 2010, 4.1 Level of Protection. A building, where protected by an
automatic sprinkler system installation, shall be provided with
sprinklers in all areas except where specific sections of this
standard permit the omission of sprinklers.
8.5.5 Obstructions to Sprinkler Discharge.
8.5.5.1* Performance Objective. Sprinklers shall be located so
as to minimize obstructions to discharge as defined in 8.5.5.2
and 8.5.5.3, or additional sprinklers shall be provided to ensure
adequate coverage of the hazard. (See Figure A.8.5.5.1.)

Based on observation and interview, the facility failed to provide and maintain all required equipment and appurtenances for the fire sprinkler system. This deficient practice increased the potential that the fire sprinklers would not remain in the proper orientation upon activation of the sprinkler system and function as designed. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

Observations on 9/16/19 between the hours at 1:00 P.M. and 5:00 P.M., revealed the escutcheon rings on fire sprinklers for rooms 0626A, 0631, and 04073 were missing.

During an interview on 9/16/19 between the hours of 1:00 P.M. and 5:00 P.M. Team # 4 Facility Staff A confirmed the findings.


39858

Based on observation and interview, the facility failed to assure that fire sprinklers were not obstructed and allowed unsealed penetrations in the ceilings. This deficient practice would affect the operating temperature of the fire sprinklers and increased the potential that the sprinkler system would fail to activate as designed during a fire in the Durham Outpatient Center. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-12-19 between 9:27 am and 4:20 pm revealed:
1. A missing escutcheon for fire sprinklers in corridor by restroom 4626, and above the 4th floor window (second from north) on atrium 2697 side.
2. A majority of the sprinklers on floors 5 and 4 were covered with dust and lint.
3. Ceiling tile out of the grid in Room 4653.
4. Two holes in the ceiling tile of Room 4622.

Observations on 9-13-19 between 8:45 am and 11:30 am revealed:
1. A majority of the fire sprinklers on floors 3 and 2 were covered with dust and lint.

Observations on 9-16-19 between 1:35 pm and 3:55 pm revealed:
1. 2 missing escutcheons by the north wall in atrium 2697.
2. 2 missing escutcheons in the northeast corner of atrium 2697, by 3rd floor windows.
3. A majority of the sprinklers on floor 1 were covered with dust and lint.

During interviews on 9-12-19, 9-13-19, and 9-16-19 Facility Staff F confirmed the findings.

Based on record review and interview, the facility failed to assure that a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19 at 11:42 am, of the fire watch procedures revealed:
1. The fire watch policy failed to list insurance carrier, the alarm company, property owner or designated representative, supervisors and other authorities having jurisdiction (SFM, HHSS, OFD) have been notified.

During an interview on 9-18-19 at 11:42 am, Facility Staff A confirmed the lack of specific items were included in the fire watch policy.

NFPA Standard:
NFPA 25, 2011
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

Based on observation and interview, the facility failed to provide accessible portable fire extinguishers. This deficient practice would not assure the extinguisher was available when needed. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-10-19 at 3:12 pm and 5:00 pm revealed:
4th Floor
1. Chair in the elevator lobby 4.12.99A blocking the fire extinguisher cabinet.
1st Floor
2. A fire extinguisher on the floor in room 1.12.121.

During an interview on 9-10-19 at 3:12 pm and 5:00 pm, Facility Staff A confirmed the blocked and unsecured fire extinguisher.

Observations on 9-11-19 at 11:12 am revealed:
Ground Floor
3. The Class K fire extinguisher in 0.12.131 Kitchen was obstructed with trash cans, floor sweeper.

During an interview on 9-11-19, at 11:12 am, Facility Staff A confirmed the blocked fire extinguisher.

NFPA Standard:
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. 1998 NFPA 10, 1-6.3

Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location. 1998 NFPA 10, 1-6.7

Based on observation and staff interview, the facility failed to provide a separation between use areas and corridors by construction that would resist the passage of smoke. This practice would allow smoke to enter into the corridor during a fire emergency affecting all patients, staff, and visitors that use the facility. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) Observations on 09/11/19 at approximately 12:30 P.M. hours in the Clarkson Doctors North revealed a large hole unsealed in the corridor wall above the ceiling just above door 01108, which serves the basement corridor.

2) During an interview on 9/11/19 at approximately 12:30 P.M. Team # 4 Facility Staff A confirmed the findings.

Based on observation and interview the facility failed to maintain corridor doors to resist the passage of smoke. This deficient practice would allow smoke and fire gases to migrate throughout the smoke compartment. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

Observations on 9/16/19 at 2:00 P.M. revealed the doors to Supply Management failed to latch and one door had a 1 ½ inch in diameter hole through the door.

During an interview on 9/16/19 at 2:00 P.M. Team # 4 Facility Staff A confirmed the findings.

Based on observation and staff interview, the facility failed to ensure no items would obstruct the fire rated shutter in the lab for a corridor pass-through opening. This condition would allow smoke and fire to spread into the exit corridor. The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:

Observation on 9-13-19 at 9:41 am revealed:

3rd Floor
1. University Tower, Unit 3, Room 3312 items being stored on the counter under the 1 hour rated fire shutter would obstruct the shutter from closing.

In an interview on 9-13-19 at 9:41 am, Facility Staff C confirmed the items on the counter would obstruct the shutter from closing.

Based on observation and staff interview, the facility failed to maintain a smoke barrier that would resist the passage of smoke. This deficient practice would allow smoke to migrate between smoke compartments, which would allow smoke to spread. The facility has a capacity of 728 and a census of 488 residents at the time of the survey.

Findings are:
2nd Floor
Observation on 9-12-19, at 3:25 pm revealed, unsealed penetration in two cable trays in the smoke barrier wall above ceiling tiles at doors 2.12.99/F

In an interview on 9-12-19, at 3:25 pm, Facility Staff A confirmed the unsealed penetration.

Based on observation and interview, the facility did not ensure that fire rated doors in a smoke barrier would resist the passage of smoke from one compartment to another. This deficient practice would not prevent the spread of fire and smoke on the ground floor in the Durham Outpatient Center and the Buffet Cancer Center. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

Observation on 9/16/19 at 1:30 P.M., revealed the fire separation doors between the Durham Outpatient Center and the Buffet Cancer Center equipped with a latching device failed to latch properly.

During an interview on 9/16/19 at 1:30 P.M., Team # 4 Facility Staff A confirmed the findings.

Based on observation and interview, the facility allowed storage to obstruct access to electrical panel boxes. This deficient practice could cause a delay and injury when turning off the power during an electrical issue emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-10-19, at 2:08 pm revealed:
6th Floor
1. A ladder obstructed the electrical panel box in 6.12.79 Electrical Room.

During an interview on 9-10-19, at 2:08 pm, Facility Staff A confirmed the items stored in front of panel boxes.

NFPA Standard:
2011 NFPA 70, 110.26
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

Based on observation and interview the facility failed to assure that the rated soiled linen chute door was not obstructed. This deficient practice had the potential to spread smoke, gasses and fire into the chute to the floors above. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-10-19 at 4:50 pm revealed:
1st Floor
1. Numerous bags of soiled linen obstructed the rated chute door from closing in the discharge room 1.12.103.
2. The fire rated door to the soiled linen discharge room failed to close and latch 1.12.103.

During an interview on 9-10-19 at 4:50 pm, Facility Staff A confirmed the rated chute door was obstructed by soiled linen bags and that the door failed to latch.

Observations on 9-11-19 at 2:30 pm revealed:
2nd Floor
3. The fire rated door to the trash and soiled linen chute room 2.12.142 failed to close and latch within the doorframe.

During an interview on 9-11-19, at 2:30 pm, Facility Staff A confirmed the door to the chute room failed to latch.

Based on interview and record review, the facility failed to provide a complete fire plan. This deficient practice would delay evacuation and affected all smoke compartments and all occupants. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19, at 12:36 pm revealed, the fire evacuation plan failed to include the evacuation of the smoke compartments, failed to assure that staff do not cross the room where the fire originates and did not include the evacuation of the patient triangle and failed to assure the evacuation of the floors above and below the location of the fire.

During an interview on 9-18-19 at 12:26 pm, Facility Staff X confirmed the lack of specific evacuation.

Based on record review and staff interview, the facility failed to conduct fire drills quarterly under varying conditions. This practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels. The facility census was 728 with a capacity of 488.

Findings are:

Record review on 9/17/19 at 1:56 pm of fire drills revealed fire drills were conducted less than one hour apart between each quarter 3/23/18 at 2:00 pm and 11/19/18 at 1:49 pm.

In an interview on 9/17/19 at 1:56 pm, Facilities Staff E confirmed the fire drill times were not varied.

Based on observation and staff interview, the facility failed to label oxygen cylinders as empty or full. This deficient practice would create the possibility of an empty cylinder being exchanged when a full one was needed. This would affect all residents in Clarkson Tower. The facility had a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-16-2019 at 2:03 PM revealed the following:

1) Clarkson Tower Basement oxygen room #B899H had multiple oxygen cylinders that were not labeled and had no identification stating if they were full, in-use, or empty.

During an interview on 9-16-2019 at 2:03 PM, Facility Staff B confirmed the finding.

Based on observation and staff interview, the facility failed to maintain the building electrical system by allowing electrical junction boxes to remain open and energized electrical wires to be left exposed. This deficient practice increased the potential for an electrical fire or injury, affecting all occupants of Durham Outpatient Center. The facility has a licensed capacity of 728. Facility census was 488.

Findings are:

Observations on 9-17-2019 between 1:34 PM and 2:26 PM revealed the following:

1) There was an open electrical junction box above the ceiling by door #24114.
2) There were two open electrical junction boxes above the ceiling by door #1685.

During interviews on 9-17-2019 between 1:34 PM and 2:26 PM, Facility Staff B confirmed the findings.

Based on observation and interview, the facility failed to assure that electrical receptacles in areas were children were present were tamper proof. This deficient practice would have the potential for electrical shock. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Observations on 9-11-19, at 4:36 pm revealed, the electrical outlets in the Children's Playroom 2.12.106 failed to be tamper resistant.

During an interview on 9-11-19, at 4:36 pm, Facility Staff A confirmed the outlets in the playroom were not tamper proof.

Based on record review and interview, the facility failed to conduct an individualized assessment for non-hospital grade receptacles at patient bed locations, including the continuity of the grounding circuit, polarity and retention force. This deficient practice increased the risk of fire from an outlet. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19, at 11:01 am revealed, documentation of annual patient bed location receptacle testing was not provided for review.

During an interview on 9-18-19, at 11:01 am, Facility Staff X confirmed the testing documentation was not provided and testing was not implemented.

NFPA Standard:
NFPA 99, 2012, 6.3.4.1.1
Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
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.
6.3.3.2 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).

Based on record review and interview, the facility failed to inspect the emergency generator circuit breaker(s) annually, and exercise the circuit breakers periodically. This deficient practice increased the potential that emergency power would not be supplied to the facility during an emergency. The facility has the capacity for 728 beds with a census of 488 on the day of survey.

Findings are:
Record review on 9-18-19, at 11:14 am revealed, a preventative maintenance plan was not adopted to inspect annually, and exercise periodically the emergency generator circuit breaker(s).

During an interview on 9-18-19, at 11:14 am, Facility Staff X confirmed the inspection and testing was not implemented.

NFPA Standard:
2012, NFPA 99 , 6.6.4.1.2
Circuitry shall be maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2.1*
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

Based on observation and interview, the facility failed to assure that electrical junction boxes were covered. This deficient practice increased the potential for electrical fire on fourth floor. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) Observations on 9/17/19 at 2:30 P.M. revealed an open electrical junction box above the ceiling near 4498A on the fourth floor.

2) During an interview on 9/17/19 at 2:30 P.M., Team # 4 Facility Staff A confirmed the open junction box.


38543

Based on observation and staff interview the facility failed to provide approved cover plates for an electrical junction box. This deficient practice increased the potential of an electrocution injury or fire from unintended contact with live electrical equipment. The facility had a capacity of for 728 beds with a census of 488 on the day of survey.

Findings are:

Observations on 9-11-19 at 9:34 am revealed:

8th Floor
1. University Tower, Unit 4 Room 8400 an electrical junction box was missing a cover plate above Electrical Panel UT48Q1H4.

During an interview on 9-11-19 at 9:34 am, Facility Staff C confirmed the finding.

Based on observation and staff interview, the facility failed to maintain the electrical system of the facility in accordance with NFPA 70, 2011 ed. by having flexible cords installed as a substitute for permanent wiring. This practice has the potential of the wiring shorting out and causing a fire. The facility has the capacity for 728 beds with a census of 488 patients.

Findings are:

1) Observation on 09/11/19 at 09:23 A.M. revealed that in the Clarkson Doctors North pulmonary clinic patient corridor near 41154 had an extension cord plugged into a duplex receptacle behind the file cabinets along the north wall. The cord had a power strip plugged into another power strip which a copy machine had plugged into it. There was another cord plugged into the power strip going up above the drop ceiling.

2) During an Interview on 09/11/19 at 09:23 A.M. Team # 4 Facility Staff A confirmed the use of the extension cord and power strips to power the appliances.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 2011 NFPA 70, article 400-8

Based on observation and interview, the facility failed to ensure gas equipment was secured when not in use. This deficient practice could cause the potential for rapid fire growth within the room in the event of cylinder falling over, which would affect patients on 1 of 14 floors. Facility census was 488 and licensed for 728 at the time of the survey.

Finding are:
Observations on 9-12-2019 at 9:45 AM revealed the following:

5th Floor
One oxygen cylinder was not restrained or in a hand cart on 5th floor, in patient room 5831.

During interview on 9-12-2019 at 9:45 AM Facility Staff I confirmed that the cylinder was not restrained.