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Based on observation, interview and record review, the facility failed to ensure that corridors are seperated from use areas with walls appropriately fire rated.

Findings include:

1. Between 8/16/2010 and 8/23/2010 it was observed that the rated firestopping material that was sprayed onto the steel beams connected to floor/ceiling assembly to maintain the building's 332 rating was not present. Therefore, this invalidates the building's 332 rating, and makes the building non-compliant.

2.a. On 8/16/2010 at 11:30AM, it was observed that there was a gap above the smoke barrier door between the two I-Beams and the above floor deck located in the vicinity of rooms 722 and 725.

b. On 8/16/2010 at 12:00PM, it was observed that above the smoke barrier door in the vicinity of rooms 783 and 784, there was a 6" gap in which fiberglass material was inserted/stuffed up to the floor deck above.

c. On the afternoon of 8/16/2010, it was observed that above the smoke barrier door between rooms 683 and 641, a 12" x 6" piece of sheetrock had been cut out of barrier to accommodate piping.

d. On 8/16/2010 at 11:15AM, it was observed that two small circular holes were cut out of the smoke barrier in Room 482 to accommodate 110 V electrical wires.

3.a On the afternoon of 8/20/2010, it was observed that in the file room's 1 hour fire-rated wall there was a gap from the edge of the sheetrock to the steel beam of the floor above. This gap ran the whole length of the wall.

b. On 8/18/2010 at 3:30PM, it was observed that the penetrations around a 3 " tube and bunched voltage cables were not sealed in Room 145 (Soiled Holding Room) of the Cancer Center.

c. On 8/16/2010 at 3:00PM, it was observed that there was a duct that was not properly sealed in Room 583 (Soiled Utility Room) of the 5th Floor Wallace building. The rated firestopping material that was sprayed onto the steel beam was not present in some places and was in the process of falling off in other areas.

3.d. On 8/19/2010 at 11:00AM, it was observed that the HVAC tubing, which passes through both Room 038 (Soiled Utility Room) and Room 039 (Janitor's Closet), was not sealed properly.

4. On the morning of 8/18/2010, it was observed that the 2 hour fire barrier door entering G46 (Nutritional Care Services/Kitchen) had multiple cut-outs (for multiple pipes) which were not sealed. A concurrent observation of the other 2 hour fire barrier door entering the Kitchen revealed that the top of the barrier from the edge of the sheetrock to the steel beam was not sealed, with multiple small penetrations present.

5. All findings above were verified by Staff #2 at the time of the observations, except for the findings on 8/20/2010 which were verified by Staff #1.

6. On 8/19/10 at 3:55PM, three 2" conduits were noted penetrating the 2 hour separation between the general maintenance shop and construction on other side of the separation. The conduits lacked firestop material, thus compromising the integrity of the 2 hour separation.

Based on observations corridor doors were not constructed to resist the passage of smoke.
Findings include:
1. On 8/16/10 and 8/17/10, it was noted that janitor closet doors 466,566,666 & 766 located in the corridor and storing combustible supplies were provided with a louver for ventilation. Louvers are not permitted on corridor doors as they allow the passage of smoke.
2. On 8/17/10 at 11:25 AM, corridor doors 443 and 445 on the 4th floor medical surgical unit were not positive latching, as they were provided with a roller latch.

Based on observation and interview, the hospital's dumbwaiters were not enclosed with a fire resistance rating of at least 2 hours required for vertical shafts in a building greater than four stories in height.

Findings include:

1. Based on interview with Staff #2 on 8/20/10 at 10:30AM, the dumbwaiter is not used above the 3rd floor of the building. The dumbwaiter shaft openings on floors 4, 5, 6 & 7 were not sealed with the 2 hour resistive protection required when no longer in use.

2. On 8/23/10 at 10:30AM, it was noted that the dumbwaiter shaft doors used on the ground floor through the 3rd floor were not labeled to show that the required 11/2 hour fire resistance rating was provided.

Based on observation, record review, and interview the facility failed to ensure that doors were not held open by door stoppers.

Findings include:

1. On 8/18/2010 at 2:15PM, it was observed that the Gift Shop storage room door was held open by a door stopper.

2. On 8/23/2010 at 12:00PM, it was observed that both the Ambulatory Pantry and the Ambulatory Staff Lounge 1 ? hour rated doors were held open with door stoppers.

(Note: To ensure that the fire barrier maintains its rating these doors can only be held open by a Life Safety Code approved device. A fire-rated door which is held open improperly will not close automatically in case of an emergency. This can lead to the spread of smoke and fire.)

3. On 8/17/2010 at 11:30AM, it was observed that the 2 hr. fire barrier doors of Rooms 443 (Family Pantry) and 445 (Storage) did not positively latch. Later that afternoon it was also observed that the Mail Room fire barrier doors did not positively latch.

4. On the morning of 8/23/2010, it was observed that the Kitchen doors were kept open to a dirty hallway. There was a small readable sign on the door to keep it closed.

5. On 8/17/2010 at 12:30PM, it was observed that there was no Exit sign, for exiting purposes, out of the nursery (Room 307).

6. On the afternoon of 8/20/2010, it was observed that the Health Information Management/Billing Room door was fire rated at 45 minutes. For 2 hr fire barriers the doors are required to be rated for 1 ? hours.

7. All findings were verified by Staff #2 at the time of the observations, except for the findings on 8/20/2010 which were verified by Staff #1.

Based on observations, the hospital did not ensure that hazardous areas are protected as required.
Findings include:
1. On 8/17/2010 at 11:20AM, it was observed that patient rooms 711, 731, and 751 were converted into storage rooms. During a concurrent interview, Staff #2 stated that one patient room from each of the three compartments on the floor had been changed into a storage room to keep the corridors clear. He also stated that the smoke barriers on floors 4 through 7 were identical, and that 3 of the patient rooms on the 6th Floor and 4th Floor had been changed in a similar manner with one room per pod (corridor) being changed into a storage room. These rooms were neither provided with one hour fire rated construction, including a 3/4 hour rated self-closing door, nor were they sprinklered.

2. During tours of the 4th, 6th and 7th floor medical surgical units on 8/16 and 8/17/2010, it was noted that the sterile supply storage rooms adjacent to the staff lounge were not fully separated. An open doorway was noted between the two areas. This is also an infection control issue as cross contamination of clean supplies can occur.
3. On 8/17/10 at 11:05AM, the tub room (rm 440) was noted converted to a storage room. The room was neither provided with one hour fire rated construction, including a 3/4 hour rated self-closing door, nor was it sprinklered. In addition, the door opens to the corridor and was not positive latching.
4. On 8/18/10 at 11:15AM, one door of the pair of doors to the OR clean equipment storage room was tied open. The other door in the pair lacked a self closer and was provided with a concealed thumb latch which when in the open position prevent positive latching.
5. On 8/18/10 and again on 8/20/10, the door to the autopsy room, where the flammable liquid xylene is used, was noted held open and the door lacked a door closer. In addition, there was a sign on the open door stating " DANGER Potential Cancer Hazard." The practice of allowing the door to the room to be held open not only negates the protection of this hazardous area, but it also compromises the negative air pressure relationship to the corridor required in laboratories by NFPA 45 6-3.3.
6. On 8/19 at 3:25PM, it was noted that the hospital's soiled holding room, located on the ground floor of Wallace, was not protected as required. The walls of the room did not extend to the deck. In addition, the sprinklers in the room would not be fully effective because ductwork coming over the wall and into this room would partially block sprinkler head spray pattern.
7. On 8/19/10 at 3:30PM, medical records stored on the ground floor of Wallace, although sprinklered, were not protected with smoke partitions. A large quantity of paint and other supplies in the adjacent area.
8. On 8/19/10 at 3:40PM, the 1 & ? hr door in the 2 hr wall separating the general maintenance shop on the ground floor, where large quantities of paint and supplies are stored, was held open with door stops. In addition, the door was not positive latching.
9. A gap greater than 1/8 th inch in the storage room holding the hospital's clean linen was observed.
10.a On the afternoon of 8/20/2010, it was observed that on the ground floor Cancer Center, there were three doors within the 1 hr. fire barrier which were not appropriately labeled. Therefore, the facility could not ensure that these doors were rated for 45 minutes.
Specifically, this was found for the door to the Janitor's Closet (Room 039), the Backdoor to Reception Area, and the door to File Room (Corridor 007).

b. On 8/17/2010 at 11:25AM, it was observed that the Janitor's Closet door (Room 477) had louvers on it. Closer examination revealed that this door was not rated for 45 minutes as required for a door that is part of a 1 hr fire barrier.

c. On 8/18/2010 at 2:15PM, it was observed that the Gift Shop storage room door was not rated for 45 minutes as required for a door that is part of a 1 hr fire barrier.

d. All findings were verified by Staff #2 at the time of the observations, except for the findings on 8/20/2010 which were verified by Staff #1.

Based on observation and floor plan review, the hospital did not ensure that exit components provide a continuously protected path to a public way.
Findings include:
During a tour of first floor of the hospital on 8/23/10 at 11:00AM, it was noted that discharge from internal stairwells 4,6 & 8 did not offer the same 2 hour level of protection as the stairwell to a public way. In addition, the exit doors at ground level from Stair 6 did not open in the direction of egress. The doors opened in rather than out.

Based on record review, the hospital did not ensure that staff are familiar with all procedures and that all staff members participate.

Findings include:

1. During review of OR fire drill records, it was noted that an OR fire in-service was conducted on 1/28/10. According to the sign in sheet, OR nurses participated in this training; however, there was no documentation available to show that anesthesiologists or surgeons participated in that training or in any other OR fire safety training.

2. OR fire drills were not conducted periodically. Although requested, there was no documentation of any site specific OR fire drill conducted prior to 1/28/10.

3. Although electro surgical units (ESUs) and lasers are listed as an ignition source in the facility's OR fire plan, there was no documentation of the training of surgeons in the use of these devices. Documentation of this training was requested but not provided.

NFPA 99 1999 12-4.1.2.10

Based on document review and interview, fan shutdown was not tested as required.

Findings include:
During review of fire alarm system records on 8/19/10 at 10:40AM, it was noted that there was no documentation to show that the automatic HVAC fan shutdown devices were tested in the last 12 months. This was confirmed in interview with Staff #3.

Based on record review and interview, the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25.

Findings include:

1. Review of the vendor's sprinkler inspection report dated 3/10/10 indicates that internal inspections for obstructions were not conducted on the sprinkler piping, the alarm valves and associated trim, and check valves.

2. The main drain test was performed with the fire pump running which adds supply water while the system is draining and does not provide an accurate reading of the system's residual pressure.

3. The sprinkler system riser lacks an hydraulic name plate.

Based on documentation review, it was determined that the facility failed to ensure that all fire dampers were functional and in good repair in accordance with NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating systems.

Findings include:

During review of the fire/smoke damper report from the hospital's vendor on 08/19/10 at 1:45PM, it was noted that 12 dampers failed the testing protocol and 12 dampers were not tested, due to unavailably for testing. No follow up report or work order was provided to verify that the defective fire dampers were replaced/repaired. Finding was verified with Staff # 2.

Based on observation, interview, and record review, the hospital did not ensure that all means of egress are maintained free of all impediments to full instant use.
Findings include:
1 a. On 8/17/10 at 3:15PM, staff members on the hospitals's psychiatric unit were asked to open a fire exit door. Four (4) out of seven (7) staff members when asked to open the locked stairwell door were unable to do so because the key that they were carrying did not work in the door. These staff members included Staff #2, #5, #6 and #7. These staff members would not be able to open the door to the fire exit door on the psychiatric unit in the event of emergency.
By 5:15PM of the same day, new keys were cut and distributed to staff members. All staff members were then able to open the exit doors.
b. Review of the hospital's fire safety plan revealed that there was no system in place to ensure that all staff members have the correct key to fire exit doors at all times.
2. On 8/18/10 at 11:15AM, the two exit corridors from the the OR, corridors 2C16 and 2C12, were noted filled with storage shelves containing supplies and equipment which would impede egress in the event of an emergency.
3. On 818/10 at 11:25AM, a very heavy combustible load was noted in the sterile core of the OR suite impeding access to exit corridor 2C12. In the area adjacent to the staff lounge, the pathway was narrowed down to approximately 20". In the area adjacent to OR #6, the path to the exit door was narrowed to approximately 30". In addition, the exit light above the door leading to corridor 2C12 was not illuminated.
4. On 8/17/2010 at 12:30PM, it was observed that there was no Exit sign, for exiting purposes, out of the nursery (Room 307).

5. On 8/23/2010 at 12:00PM, it was observed that the Emergency Fire-hose was blocked by an IV Pole, a Fluid Warmer, and a Mayo Stand. A sign which stated "DO NOT BLOCK" was displayed in a easy to read location.

(Note: To ensure quick access this equipment must kept in an easy-to-access, labeled location.)

6. On the morning of 8/23/2010, it was observed that the exit discharge lighting outside of the Telecom Egress Exit Door, and also outside Stairwell Exit 5, only had one source of light. Illumination of the means of egress must be arranged so that, in the event of a single lighting fixture failure, the area will not left in darkness.

7. On the morning of 8/23/2010, it was observed that in the path of egress for Stairwell #3, an exterior grate was broken, the exterior stair nosings needed to be tightened or replaced, and the light fixture in the stairwell was burned out.

8. On the morning of 8/23/2010, it was observed that the path of egress from Stairwell #5, the ground was not level and was partially blocked by 2 cones.

9. Findings #4-8 were verified by Staff #2 at the time of the observations.

Based on observation, medical gas storage areas are not protected in accordance with NFPA 99.

Finding includes:

On 8/18/10 at 12:10PM seventeen (17) E size medical gas cylinders were noted inappropriately stored in a tightly closed space, i.e., a closet in the anesthesia workroom / storage room. Two of the cylinders were not secured and were lying on their side. Combustible material was also stored in this closet and the closet lacked ventilation.

NFPA 99 1999 4-3.1.1.2 (5) / 4-3.1.1.2(9)

Based on record review and interview, the hospital provided life support equipment but lacks a Type 1 Essential Electrical System.

Findings include:

Review of the facility's emergency generator records on 8/16/10 at 11:45AM indicated that the hospital's generator is not divided into separate life safety, critical, and equipment branches. This was confirmed in interview with Staff # 1 and Staff # 2.

Cross refer K 145.

Based on plan review and staff interview, the hospital did not ensure that suites of sleeping rooms and suites of non-sleeping rooms do not exceed square foot requirements.
Findings:
1. During review of the facility's floor plans and walk through on 8/20/10 at approximately 3:20PM, it was noted that the hospital's ICU, a sleeping suite, was greater than 5000 square feet and was not separated. Doors to the ICU were not positive latching.
2. During review of the facility's floor plans and walk through on 8/18/10 at 11:30AM it was noted the hospital's OR suite, a non-sleeping suite, exceeded 10,000 square feet and was not separated.

Based on observation and interview the hospital did not ensure that flammable liquids are stored in approved storage cabinets or safety cans or safety rooms.
Findings include:
1.a On 8/20/10 at 2:30PM, a 55 gallon drum containing formalin was noted stored on the floor of the autopsy room. The cap to drum had been taken off and a funnel inserted in the opening. This practice could allow formaldehyde gas vapors to escape from the drum. Gas vapors when mixed with air are flammable.
b. On 8/20/10 at 2:30PM, four 1 gallon plastic containers filled with xylene were noted being stored on top of an empty 55 gallon drum used for the collection of formalin. No more than 1 gallon of a flammable liquid is allowed outside a safety cabinet and no more than 2 gallons inside an approved storage cabinet. Based on interview, the practice is to pour the used xylene into a 55 gallon drum stored in the room. When full, there would be 55 gallons of a flammable liquid inappropriately stored in the autopsy room.
2. The hospital lacks an approved flammable or combustible liquid storage room. Confirmed in interview with Staff #1.
NFPA 99 1999 10-7.2.2
3. On 8/20/10, it was noted that the door to the autopsy room lacked signage indicating the fire hazards of materials used in the lab or to warn emergency response personnel.
NFPA 99 1999 10-8.2.1
4. Three 55 gallon drums were available to be filled with formalin and one 55 gallon drum was available for the storage of xylene in the lab before pick up by an outside vendor. The EPA allows only one 55 gallon drum at point of generation in a "satellite area".
40 C.F.R. ? 262. 34(c)(1)

Based on generator testing records the generator did not always pick up the load of the emergency system within 10 seconds after loss of power.

Finding incudes:

Review of generator records on 8/19 at 10:30AM revealed that the generator did not always transfer over within 10 seconds or less as required. Bimonthly records show that 7 generator tests between May 5, 2010 through August 18, 2010 had transfer times between 10.30 seconds to 14 seconds.
NFPA 99 1999 3-4.1.1.8

Based on observations and record review, the facility provides general anesthesia, has NFPA 99 - 1999 defined "Critical Care Areas" (i.e., Operating Rooms where NFPA 99 defined "invasive procedures" are performed and patients are connected to line operated patient care-related electrical appliances.) and the Essential Electrical System (EES) is not a Type 1 EES in full compliance with NFPA 99 and NFPA 70.

Finding includes:

The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System and the wiring for items required to be served by the Emergency System-Critical Branch was not separate from the wiring for items required to be served by the Emergency System - Life Safety Branch. The generator was provided with a single transfer switch. Verified in interview with Staff #1 and #2.

NFPA 99 - 1999: Ch 3, NFPA 70: Article 517, Article 700

Based on observation, interview and record review, the facility failed to ensure that corridors are seperated from use areas with walls appropriately fire rated.

Findings include:

1. Between 8/16/2010 and 8/23/2010 it was observed that the rated firestopping material that was sprayed onto the steel beams connected to floor/ceiling assembly to maintain the building's 332 rating was not present. Therefore, this invalidates the building's 332 rating, and makes the building non-compliant.

2.a. On 8/16/2010 at 11:30AM, it was observed that there was a gap above the smoke barrier door between the two I-Beams and the above floor deck located in the vicinity of rooms 722 and 725.

b. On 8/16/2010 at 12:00PM, it was observed that above the smoke barrier door in the vicinity of rooms 783 and 784, there was a 6" gap in which fiberglass material was inserted/stuffed up to the floor deck above.

c. On the afternoon of 8/16/2010, it was observed that above the smoke barrier door between rooms 683 and 641, a 12" x 6" piece of sheetrock had been cut out of barrier to accommodate piping.

d. On 8/16/2010 at 11:15AM, it was observed that two small circular holes were cut out of the smoke barrier in Room 482 to accommodate 110 V electrical wires.

3.a On the afternoon of 8/20/2010, it was observed that in the file room's 1 hour fire-rated wall there was a gap from the edge of the sheetrock to the steel beam of the floor above. This gap ran the whole length of the wall.

b. On 8/18/2010 at 3:30PM, it was observed that the penetrations around a 3 " tube and bunched voltage cables were not sealed in Room 145 (Soiled Holding Room) of the Cancer Center.

c. On 8/16/2010 at 3:00PM, it was observed that there was a duct that was not properly sealed in Room 583 (Soiled Utility Room) of the 5th Floor Wallace building. The rated firestopping material that was sprayed onto the steel beam was not present in some places and was in the process of falling off in other areas.

3.d. On 8/19/2010 at 11:00AM, it was observed that the HVAC tubing, which passes through both Room 038 (Soiled Utility Room) and Room 039 (Janitor's Closet), was not sealed properly.

4. On the morning of 8/18/2010, it was observed that the 2 hour fire barrier door entering G46 (Nutritional Care Services/Kitchen) had multiple cut-outs (for multiple pipes) which were not sealed. A concurrent observation of the other 2 hour fire barrier door entering the Kitchen revealed that the top of the barrier from the edge of the sheetrock to the steel beam was not sealed, with multiple small penetrations present.

5. All findings above were verified by Staff #2 at the time of the observations, except for the findings on 8/20/2010 which were verified by Staff #1.

6. On 8/19/10 at 3:55PM, three 2" conduits were noted penetrating the 2 hour separation between the general maintenance shop and construction on other side of the separation. The conduits lacked firestop material, thus compromising the integrity of the 2 hour separation.

Based on observations corridor doors were not constructed to resist the passage of smoke.
Findings include:
1. On 8/16/10 and 8/17/10, it was noted that janitor closet doors 466,566,666 & 766 located in the corridor and storing combustible supplies were provided with a louver for ventilation. Louvers are not permitted on corridor doors as they allow the passage of smoke.
2. On 8/17/10 at 11:25 AM, corridor doors 443 and 445 on the 4th floor medical surgical unit were not positive latching, as they were provided with a roller latch.

Based on observation and interview, the hospital's dumbwaiters were not enclosed with a fire resistance rating of at least 2 hours required for vertical shafts in a building greater than four stories in height.

Findings include:

1. Based on interview with Staff #2 on 8/20/10 at 10:30AM, the dumbwaiter is not used above the 3rd floor of the building. The dumbwaiter shaft openings on floors 4, 5, 6 & 7 were not sealed with the 2 hour resistive protection required when no longer in use.

2. On 8/23/10 at 10:30AM, it was noted that the dumbwaiter shaft doors used on the ground floor through the 3rd floor were not labeled to show that the required 11/2 hour fire resistance rating was provided.

Based on observation, record review, and interview the facility failed to ensure that doors were not held open by door stoppers.

Findings include:

1. On 8/18/2010 at 2:15PM, it was observed that the Gift Shop storage room door was held open by a door stopper.

2. On 8/23/2010 at 12:00PM, it was observed that both the Ambulatory Pantry and the Ambulatory Staff Lounge 1 ? hour rated doors were held open with door stoppers.

(Note: To ensure that the fire barrier maintains its rating these doors can only be held open by a Life Safety Code approved device. A fire-rated door which is held open improperly will not close automatically in case of an emergency. This can lead to the spread of smoke and fire.)

3. On 8/17/2010 at 11:30AM, it was observed that the 2 hr. fire barrier doors of Rooms 443 (Family Pantry) and 445 (Storage) did not positively latch. Later that afternoon it was also observed that the Mail Room fire barrier doors did not positively latch.

4. On the morning of 8/23/2010, it was observed that the Kitchen doors were kept open to a dirty hallway. There was a small readable sign on the door to keep it closed.

5. On 8/17/2010 at 12:30PM, it was observed that there was no Exit sign, for exiting purposes, out of the nursery (Room 307).

6. On the afternoon of 8/20/2010, it was observed that the Health Information Management/Billing Room door was fire rated at 45 minutes. For 2 hr fire barriers the doors are required to be rated for 1 ? hours.

7. All findings were verified by Staff #2 at the time of the observations, except for the findings on 8/20/2010 which were verified by Staff #1.

Based on observations, the hospital did not ensure that hazardous areas are protected as required.
Findings include:
1. On 8/17/2010 at 11:20AM, it was observed that patient rooms 711, 731, and 751 were converted into storage rooms. During a concurrent interview, Staff #2 stated that one patient room from each of the three compartments on the floor had been changed into a storage room to keep the corridors clear. He also stated that the smoke barriers on floors 4 through 7 were identical, and that 3 of the patient rooms on the 6th Floor and 4th Floor had been changed in a similar manner with one room per pod (corridor) being changed into a storage room. These rooms were neither provided with one hour fire rated construction, including a 3/4 hour rated self-closing door, nor were they sprinklered.

2. During tours of the 4th, 6th and 7th floor medical surgical units on 8/16 and 8/17/2010, it was noted that the sterile supply storage rooms adjacent to the staff lounge were not fully separated. An open doorway was noted between the two areas. This is also an infection control issue as cross contamination of clean supplies can occur.
3. On 8/17/10 at 11:05AM, the tub room (rm 440) was noted converted to a storage room. The room was neither provided with one hour fire rated construction, including a 3/4 hour rated self-closing door, nor was it sprinklered. In addition, the door opens to the corridor and was not positive latching.
4. On 8/18/10 at 11:15AM, one door of the pair of doors to the OR clean equipment storage room was tied open. The other door in the pair lacked a self closer and was provided with a concealed thumb latch which when in the open position prevent positive latching.
5. On 8/18/10 and again on 8/20/10, the door to the autopsy room, where the flammable liquid xylene is used, was noted held open and the door lacked a door closer. In addition, there was a sign on the open door stating " DANGER Potential Cancer Hazard." The practice of allowing the door to the room to be held open not only negates the protection of this hazardous area, but it also compromises the negative air pressure relationship to the corridor required in laboratories by NFPA 45 6-3.3.
6. On 8/19 at 3:25PM, it was noted that the hospital's soiled holding room, located on the ground floor of Wallace, was not protected as required. The walls of the room did not extend to the deck. In addition, the sprinklers in the room would not be fully effective because ductwork coming over the wall and into this room would partially block sprinkler head spray pattern.
7. On 8/19/10 at 3:30PM, medical records stored on the ground floor of Wallace, although sprinklered, were not protected with smoke partitions. A large quantity of paint and other supplies in the adjacent area.
8. On 8/19/10 at 3:40PM, the 1 & ? hr door in the 2 hr wall separating the general maintenance shop on the ground floor, where large quantities of paint and supplies are stored, was held open with door stops. In addition, the door was not positive latching.
9. A gap greater than 1/8 th inch in the storage room holding the hospital's clean linen was observed.
10.a On the afternoon of 8/20/2010, it was observed that on the ground floor Cancer Center, there were three doors within the 1 hr. fire barrier which were not appropriately labeled. Therefore, the facility could not ensure that these doors were rated for 45 minutes.
Specifically, this was found for the door to the Janitor's Closet (Room 039), the Backdoor to Reception Area, and the door to File Room (Corridor 007).

b. On 8/17/2010 at 11:25AM, it was observed that the Janitor's Closet door (Room 477) had louvers on it. Closer examination revealed that this door was not rated for 45 minutes as required for a door that is part of a 1 hr fire barrier.

c. On 8/18/2010 at 2:15PM, it was observed that the Gift Shop storage room door was not rated for 45 minutes as required for a door that is part of a 1 hr fire barrier.

d. All findings were verified by Staff #2 at the time of the observations, except for the findings on 8/20/2010 which were verified by Staff #1.

Based on observation and floor plan review, the hospital did not ensure that exit components provide a continuously protected path to a public way.
Findings include:
During a tour of first floor of the hospital on 8/23/10 at 11:00AM, it was noted that discharge from internal stairwells 4,6 & 8 did not offer the same 2 hour level of protection as the stairwell to a public way. In addition, the exit doors at ground level from Stair 6 did not open in the direction of egress. The doors opened in rather than out.

Based on record review, the hospital did not ensure that staff are familiar with all procedures and that all staff members participate.

Findings include:

1. During review of OR fire drill records, it was noted that an OR fire in-service was conducted on 1/28/10. According to the sign in sheet, OR nurses participated in this training; however, there was no documentation available to show that anesthesiologists or surgeons participated in that training or in any other OR fire safety training.

2. OR fire drills were not conducted periodically. Although requested, there was no documentation of any site specific OR fire drill conducted prior to 1/28/10.

3. Although electro surgical units (ESUs) and lasers are listed as an ignition source in the facility's OR fire plan, there was no documentation of the training of surgeons in the use of these devices. Documentation of this training was requested but not provided.

NFPA 99 1999 12-4.1.2.10

Based on document review and interview, fan shutdown was not tested as required.

Findings include:
During review of fire alarm system records on 8/19/10 at 10:40AM, it was noted that there was no documentation to show that the automatic HVAC fan shutdown devices were tested in the last 12 months. This was confirmed in interview with Staff #3.

Based on record review and interview, the hospital did not ensure that the sprinkler system is maintained in accordance with NFPA 25.

Findings include:

1. Review of the vendor's sprinkler inspection report dated 3/10/10 indicates that internal inspections for obstructions were not conducted on the sprinkler piping, the alarm valves and associated trim, and check valves.

2. The main drain test was performed with the fire pump running which adds supply water while the system is draining and does not provide an accurate reading of the system's residual pressure.

3. The sprinkler system riser lacks an hydraulic name plate.

Based on documentation review, it was determined that the facility failed to ensure that all fire dampers were functional and in good repair in accordance with NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating systems.

Findings include:

During review of the fire/smoke damper report from the hospital's vendor on 08/19/10 at 1:45PM, it was noted that 12 dampers failed the testing protocol and 12 dampers were not tested, due to unavailably for testing. No follow up report or work order was provided to verify that the defective fire dampers were replaced/repaired. Finding was verified with Staff # 2.

Based on observation, interview, and record review, the hospital did not ensure that all means of egress are maintained free of all impediments to full instant use.
Findings include:
1 a. On 8/17/10 at 3:15PM, staff members on the hospitals's psychiatric unit were asked to open a fire exit door. Four (4) out of seven (7) staff members when asked to open the locked stairwell door were unable to do so because the key that they were carrying did not work in the door. These staff members included Staff #2, #5, #6 and #7. These staff members would not be able to open the door to the fire exit door on the psychiatric unit in the event of emergency.
By 5:15PM of the same day, new keys were cut and distributed to staff members. All staff members were then able to open the exit doors.
b. Review of the hospital's fire safety plan revealed that there was no system in place to ensure that all staff members have the correct key to fire exit doors at all times.
2. On 8/18/10 at 11:15AM, the two exit corridors from the the OR, corridors 2C16 and 2C12, were noted filled with storage shelves containing supplies and equipment which would impede egress in the event of an emergency.
3. On 818/10 at 11:25AM, a very heavy combustible load was noted in the sterile core of the OR suite impeding access to exit corridor 2C12. In the area adjacent to the staff lounge, the pathway was narrowed down to approximately 20". In the area adjacent to OR #6, the path to the exit door was narrowed to approximately 30". In addition, the exit light above the door leading to corridor 2C12 was not illuminated.
4. On 8/17/2010 at 12:30PM, it was observed that there was no Exit sign, for exiting purposes, out of the nursery (Room 307).

5. On 8/23/2010 at 12:00PM, it was observed that the Emergency Fire-hose was blocked by an IV Pole, a Fluid Warmer, and a Mayo Stand. A sign which stated "DO NOT BLOCK" was displayed in a easy to read location.

(Note: To ensure quick access this equipment must kept in an easy-to-access, labeled location.)

6. On the morning of 8/23/2010, it was observed that the exit discharge lighting outside of the Telecom Egress Exit Door, and also outside Stairwell Exit 5, only had one source of light. Illumination of the means of egress must be arranged so that, in the event of a single lighting fixture failure, the area will not left in darkness.

7. On the morning of 8/23/2010, it was observed that in the path of egress for Stairwell #3, an exterior grate was broken, the exterior stair nosings needed to be tightened or replaced, and the light fixture in the stairwell was burned out.

8. On the morning of 8/23/2010, it was observed that the path of egress from Stairwell #5, the ground was not level and was partially blocked by 2 cones.

9. Findings #4-8 were verified by Staff #2 at the time of the observations.

Based on observation, medical gas storage areas are not protected in accordance with NFPA 99.

Finding includes:

On 8/18/10 at 12:10PM seventeen (17) E size medical gas cylinders were noted inappropriately stored in a tightly closed space, i.e., a closet in the anesthesia workroom / storage room. Two of the cylinders were not secured and were lying on their side. Combustible material was also stored in this closet and the closet lacked ventilation.

NFPA 99 1999 4-3.1.1.2 (5) / 4-3.1.1.2(9)

Based on record review and interview, the hospital provided life support equipment but lacks a Type 1 Essential Electrical System.

Findings include:

Review of the facility's emergency generator records on 8/16/10 at 11:45AM indicated that the hospital's generator is not divided into separate life safety, critical, and equipment branches. This was confirmed in interview with Staff # 1 and Staff # 2.

Cross refer K 145.

Based on plan review and staff interview, the hospital did not ensure that suites of sleeping rooms and suites of non-sleeping rooms do not exceed square foot requirements.
Findings:
1. During review of the facility's floor plans and walk through on 8/20/10 at approximately 3:20PM, it was noted that the hospital's ICU, a sleeping suite, was greater than 5000 square feet and was not separated. Doors to the ICU were not positive latching.
2. During review of the facility's floor plans and walk through on 8/18/10 at 11:30AM it was noted the hospital's OR suite, a non-sleeping suite, exceeded 10,000 square feet and was not separated.

Based on observation and interview the hospital did not ensure that flammable liquids are stored in approved storage cabinets or safety cans or safety rooms.
Findings include:
1.a On 8/20/10 at 2:30PM, a 55 gallon drum containing formalin was noted stored on the floor of the autopsy room. The cap to drum had been taken off and a funnel inserted in the opening. This practice could allow formaldehyde gas vapors to escape from the drum. Gas vapors when mixed with air are flammable.
b. On 8/20/10 at 2:30PM, four 1 gallon plastic containers filled with xylene were noted being stored on top of an empty 55 gallon drum used for the collection of formalin. No more than 1 gallon of a flammable liquid is allowed outside a safety cabinet and no more than 2 gallons inside an approved storage cabinet. Based on interview, the practice is to pour the used xylene into a 55 gallon drum stored in the room. When full, there would be 55 gallons of a flammable liquid inappropriately stored in the autopsy room.
2. The hospital lacks an approved flammable or combustible liquid storage room. Confirmed in interview with Staff #1.
NFPA 99 1999 10-7.2.2
3. On 8/20/10, it was noted that the door to the autopsy room lacked signage indicating the fire hazards of materials used in the lab or to warn emergency response personnel.
NFPA 99 1999 10-8.2.1
4. Three 55 gallon drums were available to be filled with formalin and one 55 gallon drum was available for the storage of xylene in the lab before pick up by an outside vendor. The EPA allows only one 55 gallon drum at point of generation in a "satellite area".
40 C.F.R. ? 262. 34(c)(1)

Based on generator testing records the generator did not always pick up the load of the emergency system within 10 seconds after loss of power.

Finding incudes:

Review of generator records on 8/19 at 10:30AM revealed that the generator did not always transfer over within 10 seconds or less as required. Bimonthly records show that 7 generator tests between May 5, 2010 through August 18, 2010 had transfer times between 10.30 seconds to 14 seconds.
NFPA 99 1999 3-4.1.1.8

Based on observations and record review, the facility provides general anesthesia, has NFPA 99 - 1999 defined "Critical Care Areas" (i.e., Operating Rooms where NFPA 99 defined "invasive procedures" are performed and patients are connected to line operated patient care-related electrical appliances.) and the Essential Electrical System (EES) is not a Type 1 EES in full compliance with NFPA 99 and NFPA 70.

Finding includes:

The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System and the wiring for items required to be served by the Emergency System-Critical Branch was not separate from the wiring for items required to be served by the Emergency System - Life Safety Branch. The generator was provided with a single transfer switch. Verified in interview with Staff #1 and #2.

NFPA 99 - 1999: Ch 3, NFPA 70: Article 517, Article 700