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It was determined by observation and staff interview during the course of the survey, December 13-16, 2011, that the doors leading into the Gift Shop did not conform to requirements in Section 19.3.6.3.4 of the 2000 edition of the Life Safety Code.

The doors separating the Gift Shop from the corridor, are manually-operated, sliding glass doors. Since these doors must be closed manually, they do not automatically close with activation of the fire alarm system. This requires deliberate human intervention during a fire emergency.

The Gift Shop, which has an area greater than 500 square feet, is considered a hazardous area under Section 19.3.2.5. Life Safety Code Section 19.3.6.3.4 requires hazardous areas open to the corridor to have door-closing devices.

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.

It was determined by observation and staff interview during the course of the survey, December 13 -16, 2011, that the Electrical Closet located in the "Credit Union" corridor did not conform to requirements of Section 5-13.11 of the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems at the following location.

The doors separating this electrical closet from the corridor are rated for only 60 minutes. Although the frame in which these doors are mounted is substantial, this electrical closet does not have a complete 2-hour fire-rated separation from the corridor, and this electrical closet, a hazardous area, contains three sets of three-phase, 15kV-Class, medium-voltage cables supplying 13,200 volts to an adjacent unit substation.

According to Section 5-13.11 of the 1999 edition of NFPA 13:
Sprinkler protection shall be required in electrical equipment rooms...
Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

This non-conformance can be corrected by adding sprinklers to the electrical closet, or by replacing the existing 60-minute doors with 90-minute doors, thereby, establishing a 2-hour separation from the corridor.

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.

It was determined by record review and staff interview during the course of the survey on December 13-16, 2011, that the facility failed to perform and document the exercising of all fire and or smoke dampers to verify they fully close, and latch if provided, with moving parts lubricated and fusible links replaced, as necessary, at least every six years, in accordance with Centers for Medicaid and Medicare Services (CMS) and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. This was evidenced by the following:

A review of the facility's Fire/Smoke Damper Inspection Inventory and maintenance records, provided by an independent fire alarm system contractor and dated 11/30/2009, indicated the results for approximately 930 dampers within the facility. The testing records identified fire and electric smoke dampers that were not exercised during the 11/30/2009 maintenance program. Comments were provided in the record that identified specific dampers and provided comment information that included descriptors such as "No access door," "Above hard lid," "No access," "No air," "No air open," "Limited access" and "Access Blocked."

Maintenance staff stated that some of the identified dampers have been accessed and exercised, however, it was stated that documentation was not maintained and was not available to identify any dampers that have been corrected.

This fire/smoke damper deficiency item was discussed with the Director of Plant Operations during a review of the facility's required documentation.

It was determined by observation during the survey on December 13-16, 2011, that the facility failed to provide exit corridor(s) that were maintained clear and unobstructed in accordance with (2000) LSC section 19.2.1 and referenced 7.1.10. This was evidenced by the following:

Customary access is provided to physical therapy patients on the ground floor level of the facility.

It was observed that three vending machines were provided as furnishings within a portion of the egress corridor located between the cafeteria and elevator #WP-13. The furnished items extended into the eight (8) foot wide corridor beyond the recessed column area, thereby, reducing the width of the exit corridor to between five and six feet.

This corridor obstruction deficiency item was discussed with the Director of Plant Operations during a tour of the facility.

Item A:
It was determined by record review/observation and/or staff interview during the survey on December 13-16, 2011, that the Main Hospital facility failed to provide a piped-in medical gas system meeting the requirements of NFPA 99, Health Care Facilities. This was evidenced by the following:

1.) The facility's cryogenic oxygen supply is located outside of the building served.

The required brass or bronze "pressure relief valve" could not be located at or near the "Emergency Oxygen Supply Connection" panel that is located on the exterior of the facility for use in connecting a temporary auxiliary source of supply for emergency or maintenance situations. This pressure relief valve is to be of adequate size to protect the downstream piping system and related equipment from exposure to pressures in excess of 50 percent higher than normal pipeline pressure as required by NFPA 99 section 4-3.1.1.8.(h).

2.) A review of the facility's Piped Medical Gas System Evaluation, provided to the facility by an independent medical gas system contractor and dated September 26, 2011, documented deficiency items that had not yet been corrected at the time of this survey, to include:

a) "The medical air dew point and CO are not currently being monitored locally or at the master alarm panels" as required in accordance with (1999) NFPA 99 section 4-3.1.1.9.(i)2.
b) "The nitrous oxide zone valves located outside OR10 and the and the oxygen zone valves outside Endo Admitting 3, outside ER 5, outside ER1, 2, outside ER 3, 4 and Respiratory Therapy leak when cycled. Although these valves do not leak while in the open position, they may not control the flow if they need to be shut off" in accordance with (1999) NFPA 99 section 4-3.1.2.3(d) for Gas Shutoff Valves.
c) "The "Lag Compressor in use," "Dew Point High," and "Vacuum Lag Pump In Use" alarm signals do not activate at either master alarm panel" as required in accordance with (1999) NFPA 99 sections 4-3.1.1.9 (d)1; 4-3.1.1.9(i)3 and 4-3.2.1.2.
d) "The zone alarm panels located in the Emergency Department do not monitor all rooms" as required in accordance with (1999) NFPA 99 sections 4-3.1.2.2(a)3 and 4-3.1.2.2(c)1.
e) "The oxygen zone alarm panel outside the Cardiac Catheterization Lab is not functioning properly" as required in accordance with (1999) NFPA 99 section 4-3.1.2.2(c)1.
f) "There are oxygen outlets throughout the facility that leak," i.e. Ortho Rooms #250 and #253. These outlets are not functioning in accordance with (1999) NFPA 99 section 4-3.1.2.4 Station Outlets.
g) "There are vacuum and WAGD hose drops located in the Operating Rooms that do not have sufficient flow," i.e. OR 2, OR 5 (2x), OR 10 and OR 12 (2x) as required in accordance with (1999) NFPA 99 section 4-3.4.2.1(c).

Maintenance staff stated that the above items have not been corrected.

The medical gas system deficiency items were discussed with the Director of Plant Operations during a tour of the facility.

Item B:
It was determined by observation during the survey on December 13-16, 2011, that the facility failed to provide a piped-in medical gas system meeting the requirements of NFPA 99, Health Care Facilities. This was evidenced by the following:

The required supply system "check valves" were not provided or could not be located upstream at each of three cylinder valves and at the cryogenic liquid storage unit for the Level 2 system in accordance with (1999) NFPA 99 section 4-3.1.1.8(f) General Requirements.

The medical gas system deficiency items were discussed with the Director of Plant Operations during a tour of the facility.

Item A:
It was determined by record review and staff interview during the course of the survey December 13-16, 2011, that the facility did not maintain the environment in the maternity Operating Rooms (ORs) of the Main Hospital as prescribed in the 1999 edition of NFPA 99, Health Care Facilities.

Records indicate that the humidity in ORs numbered 1 through 6, as well as OR number 10 was maintained between 19 and 23%. Staff interview further validated these data by stating that this was typical for all ORs. NFPA 99 requires the humidity be maintained at not less than 35%.

Section 5-4.1.1 of NFPA 99 states: "The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater."

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.

Item B:
It was determined by observation and staff interview during the course of the survey, December 16, 2011, that the smoke evacuation system in the Ambulatory Surgical Suites (ASC surgical suites), located in the Physicians' Office Building III, the Wolf Building (POB 3), did not conform to the requirements of Section 5-4.1.3 of the 1999 edition of NFPA 99, Health Care Facilities.

The environmental air supply system for the ASC surgical suites, attained a static condition when the smoke detectors within the surgical suites were activated.

According to the 1999 edition of NFPA 99, Section 5-4.1.3, "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.

Item C:
It was determined by record review and staff interview during the course of the survey, December 13-16, 2011, that the facility did not restrict the use of the Cherry Creek Eye Surgery Center to conformance with requirements of an Ambulatory Surgical Center or a Business Occupancy as outlined in the 2000 edition of NFPA 101, the Life Safety Code.

Staff interview and a review of the Records indicate that a general anesthetic had been administered to at least one patient since the Cherry Creek Eye Surgery Center was last surveyed to Life Safety Code requirements by the State of Colorado at the behest of the Center for Medicaid and Medicare Services (CMS) in 2010.

As long as the Cherry Creek Eye Surgery Center utilizes sedation practices that render patients incapable of self-preservation, life safety systems must be put in-place that mitigate the potential danger to patients who are unable to self-preserve. Among the potential life safety systems that this continued practice would require include, but may not necessarily be limited to:

1) A smoke evacuation system for the Operating Suites that conforms to the 1999 edition of NFPA 99, Health Care Facilities.
2) A Type I Emergency Power System that conforms to the 1999 edition of NFPA 99, Health Care Facilities, and the 1999 edition of NFPA 110, the Standard for Emergency and Standby Power Systems.

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.

It was determined by observation and staff interview during the course of the survey, December 13 - 16, 2011, that the emergency lighting did not meet the requirements contained in the 1999 edition of the NFPA 110, the Standard for Emergency and Standby Power Systems for the following areas:

1] The emergency light in the generator room did not illuminate with the test button depressed.

2] A walk-through of the South Wing Electrical Room (East Wing on the facility map) failed to find an emergency light installed for the transfer switches.

Section 5-3.1 of NFPA 110 states: "The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch."

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.

It was determined by observation and staff interview during the course of the survey, December 13-16, 2011, that the doors leading into the Gift Shop did not conform to requirements in Section 19.3.6.3.4 of the 2000 edition of the Life Safety Code.

The doors separating the Gift Shop from the corridor, are manually-operated, sliding glass doors. Since these doors must be closed manually, they do not automatically close with activation of the fire alarm system. This requires deliberate human intervention during a fire emergency.

The Gift Shop, which has an area greater than 500 square feet, is considered a hazardous area under Section 19.3.2.5. Life Safety Code Section 19.3.6.3.4 requires hazardous areas open to the corridor to have door-closing devices.

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.

It was determined by observation and staff interview during the course of the survey, December 13 -16, 2011, that the Electrical Closet located in the "Credit Union" corridor did not conform to requirements of Section 5-13.11 of the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems at the following location.

The doors separating this electrical closet from the corridor are rated for only 60 minutes. Although the frame in which these doors are mounted is substantial, this electrical closet does not have a complete 2-hour fire-rated separation from the corridor, and this electrical closet, a hazardous area, contains three sets of three-phase, 15kV-Class, medium-voltage cables supplying 13,200 volts to an adjacent unit substation.

According to Section 5-13.11 of the 1999 edition of NFPA 13:
Sprinkler protection shall be required in electrical equipment rooms...
Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

This non-conformance can be corrected by adding sprinklers to the electrical closet, or by replacing the existing 60-minute doors with 90-minute doors, thereby, establishing a 2-hour separation from the corridor.

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.

It was determined by record review and staff interview during the course of the survey on December 13-16, 2011, that the facility failed to perform and document the exercising of all fire and or smoke dampers to verify they fully close, and latch if provided, with moving parts lubricated and fusible links replaced, as necessary, at least every six years, in accordance with Centers for Medicaid and Medicare Services (CMS) and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. This was evidenced by the following:

A review of the facility's Fire/Smoke Damper Inspection Inventory and maintenance records, provided by an independent fire alarm system contractor and dated 11/30/2009, indicated the results for approximately 930 dampers within the facility. The testing records identified fire and electric smoke dampers that were not exercised during the 11/30/2009 maintenance program. Comments were provided in the record that identified specific dampers and provided comment information that included descriptors such as "No access door," "Above hard lid," "No access," "No air," "No air open," "Limited access" and "Access Blocked."

Maintenance staff stated that some of the identified dampers have been accessed and exercised, however, it was stated that documentation was not maintained and was not available to identify any dampers that have been corrected.

This fire/smoke damper deficiency item was discussed with the Director of Plant Operations during a review of the facility's required documentation.

It was determined by observation during the survey on December 13-16, 2011, that the facility failed to provide exit corridor(s) that were maintained clear and unobstructed in accordance with (2000) LSC section 19.2.1 and referenced 7.1.10. This was evidenced by the following:

Customary access is provided to physical therapy patients on the ground floor level of the facility.

It was observed that three vending machines were provided as furnishings within a portion of the egress corridor located between the cafeteria and elevator #WP-13. The furnished items extended into the eight (8) foot wide corridor beyond the recessed column area, thereby, reducing the width of the exit corridor to between five and six feet.

This corridor obstruction deficiency item was discussed with the Director of Plant Operations during a tour of the facility.

Item A:
It was determined by record review/observation and/or staff interview during the survey on December 13-16, 2011, that the Main Hospital facility failed to provide a piped-in medical gas system meeting the requirements of NFPA 99, Health Care Facilities. This was evidenced by the following:

1.) The facility's cryogenic oxygen supply is located outside of the building served.

The required brass or bronze "pressure relief valve" could not be located at or near the "Emergency Oxygen Supply Connection" panel that is located on the exterior of the facility for use in connecting a temporary auxiliary source of supply for emergency or maintenance situations. This pressure relief valve is to be of adequate size to protect the downstream piping system and related equipment from exposure to pressures in excess of 50 percent higher than normal pipeline pressure as required by NFPA 99 section 4-3.1.1.8.(h).

2.) A review of the facility's Piped Medical Gas System Evaluation, provided to the facility by an independent medical gas system contractor and dated September 26, 2011, documented deficiency items that had not yet been corrected at the time of this survey, to include:

a) "The medical air dew point and CO are not currently being monitored locally or at the master alarm panels" as required in accordance with (1999) NFPA 99 section 4-3.1.1.9.(i)2.
b) "The nitrous oxide zone valves located outside OR10 and the and the oxygen zone valves outside Endo Admitting 3, outside ER 5, outside ER1, 2, outside ER 3, 4 and Respiratory Therapy leak when cycled. Although these valves do not leak while in the open position, they may not control the flow if they need to be shut off" in accordance with (1999) NFPA 99 section 4-3.1.2.3(d) for Gas Shutoff Valves.
c) "The "Lag Compressor in use," "Dew Point High," and "Vacuum Lag Pump In Use" alarm signals do not activate at either master alarm panel" as required in accordance with (1999) NFPA 99 sections 4-3.1.1.9 (d)1; 4-3.1.1.9(i)3 and 4-3.2.1.2.
d) "The zone alarm panels located in the Emergency Department do not monitor all rooms" as required in accordance with (1999) NFPA 99 sections 4-3.1.2.2(a)3 and 4-3.1.2.2(c)1.
e) "The oxygen zone alarm panel outside the Cardiac Catheterization Lab is not functioning properly" as required in accordance with (1999) NFPA 99 section 4-3.1.2.2(c)1.
f) "There are oxygen outlets throughout the facility that leak," i.e. Ortho Rooms #250 and #253. These outlets are not functioning in accordance with (1999) NFPA 99 section 4-3.1.2.4 Station Outlets.
g) "There are vacuum and WAGD hose drops located in the Operating Rooms that do not have sufficient flow," i.e. OR 2, OR 5 (2x), OR 10 and OR 12 (2x) as required in accordance with (1999) NFPA 99 section 4-3.4.2.1(c).

Maintenance staff stated that the above items have not been corrected.

The medical gas system deficiency items were discussed with the Director of Plant Operations during a tour of the facility.

Item B:
It was determined by observation during the survey on December 13-16, 2011, that the facility failed to provide a piped-in medical gas system meeting the requirements of NFPA 99, Health Care Facilities. This was evidenced by the following:

The required supply system "check valves" were not provided or could not be located upstream at each of three cylinder valves and at the cryogenic liquid storage unit for the Level 2 system in accordance with (1999) NFPA 99 section 4-3.1.1.8(f) General Requirements.

The medical gas system deficiency items were discussed with the Director of Plant Operations during a tour of the facility.

Item A:
It was determined by record review and staff interview during the course of the survey December 13-16, 2011, that the facility did not maintain the environment in the maternity Operating Rooms (ORs) of the Main Hospital as prescribed in the 1999 edition of NFPA 99, Health Care Facilities.

Records indicate that the humidity in ORs numbered 1 through 6, as well as OR number 10 was maintained between 19 and 23%. Staff interview further validated these data by stating that this was typical for all ORs. NFPA 99 requires the humidity be maintained at not less than 35%.

Section 5-4.1.1 of NFPA 99 states: "The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater."

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.

Item B:
It was determined by observation and staff interview during the course of the survey, December 16, 2011, that the smoke evacuation system in the Ambulatory Surgical Suites (ASC surgical suites), located in the Physicians' Office Building III, the Wolf Building (POB 3), did not conform to the requirements of Section 5-4.1.3 of the 1999 edition of NFPA 99, Health Care Facilities.

The environmental air supply system for the ASC surgical suites, attained a static condition when the smoke detectors within the surgical suites were activated.

According to the 1999 edition of NFPA 99, Section 5-4.1.3, "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.

Item C:
It was determined by record review and staff interview during the course of the survey, December 13-16, 2011, that the facility did not restrict the use of the Cherry Creek Eye Surgery Center to conformance with requirements of an Ambulatory Surgical Center or a Business Occupancy as outlined in the 2000 edition of NFPA 101, the Life Safety Code.

Staff interview and a review of the Records indicate that a general anesthetic had been administered to at least one patient since the Cherry Creek Eye Surgery Center was last surveyed to Life Safety Code requirements by the State of Colorado at the behest of the Center for Medicaid and Medicare Services (CMS) in 2010.

As long as the Cherry Creek Eye Surgery Center utilizes sedation practices that render patients incapable of self-preservation, life safety systems must be put in-place that mitigate the potential danger to patients who are unable to self-preserve. Among the potential life safety systems that this continued practice would require include, but may not necessarily be limited to:

1) A smoke evacuation system for the Operating Suites that conforms to the 1999 edition of NFPA 99, Health Care Facilities.
2) A Type I Emergency Power System that conforms to the 1999 edition of NFPA 99, Health Care Facilities, and the 1999 edition of NFPA 110, the Standard for Emergency and Standby Power Systems.

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.

It was determined by observation and staff interview during the course of the survey, December 13 - 16, 2011, that the emergency lighting did not meet the requirements contained in the 1999 edition of the NFPA 110, the Standard for Emergency and Standby Power Systems for the following areas:

1] The emergency light in the generator room did not illuminate with the test button depressed.

2] A walk-through of the South Wing Electrical Room (East Wing on the facility map) failed to find an emergency light installed for the transfer switches.

Section 5-3.1 of NFPA 110 states: "The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch."

This non-conformance was discussed with the Director of Plant Operations, and others, during the course of the survey.