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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering, observed the following corridor doors were not smoke resistant or had door impediments mounted on some of the doors. In addition, a few of the operating room corridor doors the corridor wall above the doors had a hole which went through the entire wall of approximately two inches in length and 1/2 inch in width.

1. SPD in the basement
2. Outpatient Surgery double doors, 1st floor
3. Clean linen room double doors, basement.
4. Main Cafeteria double doors the smoke seals were torn/frayed

4. Operating rooms one through eleven smoke seals were either torn or missing on the double corridor doors and the corridor doors had door impediments in the doors to prop them open.

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the the facility failed to maintain self closing doors in smoke barriers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance clearance necessary for proper operation and shall be without undercuts, louvers, or grilles. The clearance for proper operation of smoke doors is defined as 1/8 inch.

Findings include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering, observed the following smoke barrier doors were not smoke resistant. The doors had more than an 1/8 inch gap between the double doors when closed due to some of the doors had torn, ripped or missing astragal's.

1. First floor by Stat Lab
2. Old Outpatient Surgery across room room six and Special procedures
3. Second floor outside of Pre-op, by PCCU
3. PACU/Endoscopy in the CDU
4. Four floor Four E. South
5. Fifth floor Five E. South

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire,
which could cause harm to the patients.

Based on observations the facility did not maintain the integrity, smoke resistance, of walls, doors or ceilings in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke.

Findings include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering, observed the following locations had either conduit penetrations, holes in walls or ceilings or the doors were not smoke resistant.

1. Mechanical room in the basement conduit penetrations
2. Second floor Electrical room by the Cath Lab conduit penetrations in three walls of the room, sheetrock was missing on the back rated two hour wall and the corridor double doors to the electrical room were not smoke resistant, no smoke seals or astragal's were on the doors. The entire electrical room was not smoke resistant the room was open to the exit corridor above the double corridor doors.
3. Communications/ED by room 254 conduit penetrations
4. Pre-OP Table room /Storage room the double doors were not self closing the room was over 50 square feet and had a gap in between the double doors when closed they were not smoke resistant.

5. Mechanical room sixth floor conduit penetrations
6. Mechanical room fifth floor conduit penetrations
7. Mechanical room fourth floor conduit penetrations
8. Second floor Mechanical room adjacent to PCCU conduit penetrations
9. Basement Emergency Department air handling room conduit penetrations
10. The kitchen dry food storage room was missing the entire door to the room. The room was measured to be 156 square feet

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering.

The pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which could cause harm to the patients.

Based on Observations the facility failed to document Monthly testing of the battery back up emergency lighting units.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On May 27, through the 31, 2011 the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering, observed the documentation for the batter backup emergency lighting units for the Operating rooms and generators. The documentation shown to the surveyor and per the facility engineering staff the battery backup lights were being done on a semi-annual basis. The only records shown to the surveyor were dated November 2010 and February 2011. In addition two lighting units in operating rooms nine and eleven did not function during a test of the lights.

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

Failing to test and maintain emergency lighting units could cause harm to the patients.

Based on observations the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

Findings Include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering, asked to see the written emergency policy manual at the nurse's stations throughout the hospital. The written fire and emergency policy manual was not found at the nursing stations. The staff at the nurses stations throughout the hospital when asked "where is the fire procedure manual, answered the fire procedures were on the computers."

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

In time of a fire, or emergency, an emergency policy manual must be readily available for the staff. Patients could be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Based on Observations the facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.1.5, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings Include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering,
observed Escutcheon plate missing from the sprinkler assembly in the following locations:

1. Room 288, 441, Quiet treatment room, Room 2 Trash chute room, DI Imaging Control Center, MRI storage room.

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on observation the facility failed to mount electrical light switches or a plug mode strip five feet above the floor in the oxygen storage rooms.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering observed wall mounted electric light switches or a plug mode strip in the oxygen storage rooms were measured to be approximately fifty four inches above the floor, when measured with a measuring tape.

1. CVICU on the second floor
2. Storage room ICU
3. Main Diagnostic Imaging room


During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

Failing to mount a light switches or plug mode strips five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.

Based on Observations the facility failed to provide medical gas cylinder storage room free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings include:

On May 27, through 31, 2011 the surveyor, accompanied by the Manager Facilities Engineering and Mechanical Engineering, observed the Respiratory Therapy/ Pump room adjacent to the sign shop had storage of plastics and cardboard boxes. next to six oxygen bottles.

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering, observed the following corridor doors were not smoke resistant or had door impediments mounted on some of the doors. In addition, a few of the operating room corridor doors the corridor wall above the doors had a hole which went through the entire wall of approximately two inches in length and 1/2 inch in width.

1. SPD in the basement
2. Outpatient Surgery double doors, 1st floor
3. Clean linen room double doors, basement.
4. Main Cafeteria double doors the smoke seals were torn/frayed

4. Operating rooms one through eleven smoke seals were either torn or missing on the double corridor doors and the corridor doors had door impediments in the doors to prop them open.

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the the facility failed to maintain self closing doors in smoke barriers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance clearance necessary for proper operation and shall be without undercuts, louvers, or grilles. The clearance for proper operation of smoke doors is defined as 1/8 inch.

Findings include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering, observed the following smoke barrier doors were not smoke resistant. The doors had more than an 1/8 inch gap between the double doors when closed due to some of the doors had torn, ripped or missing astragal's.

1. First floor by Stat Lab
2. Old Outpatient Surgery across room room six and Special procedures
3. Second floor outside of Pre-op, by PCCU
3. PACU/Endoscopy in the CDU
4. Four floor Four E. South
5. Fifth floor Five E. South

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire,
which could cause harm to the patients.

Based on observations the facility did not maintain the integrity, smoke resistance, of walls, doors or ceilings in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke.

Findings include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering, observed the following locations had either conduit penetrations, holes in walls or ceilings or the doors were not smoke resistant.

1. Mechanical room in the basement conduit penetrations
2. Second floor Electrical room by the Cath Lab conduit penetrations in three walls of the room, sheetrock was missing on the back rated two hour wall and the corridor double doors to the electrical room were not smoke resistant, no smoke seals or astragal's were on the doors. The entire electrical room was not smoke resistant the room was open to the exit corridor above the double corridor doors.
3. Communications/ED by room 254 conduit penetrations
4. Pre-OP Table room /Storage room the double doors were not self closing the room was over 50 square feet and had a gap in between the double doors when closed they were not smoke resistant.

5. Mechanical room sixth floor conduit penetrations
6. Mechanical room fifth floor conduit penetrations
7. Mechanical room fourth floor conduit penetrations
8. Second floor Mechanical room adjacent to PCCU conduit penetrations
9. Basement Emergency Department air handling room conduit penetrations
10. The kitchen dry food storage room was missing the entire door to the room. The room was measured to be 156 square feet

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering.

The pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which could cause harm to the patients.

Based on Observations the facility failed to document Monthly testing of the battery back up emergency lighting units.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On May 27, through the 31, 2011 the surveyor, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering, observed the documentation for the batter backup emergency lighting units for the Operating rooms and generators. The documentation shown to the surveyor and per the facility engineering staff the battery backup lights were being done on a semi-annual basis. The only records shown to the surveyor were dated November 2010 and February 2011. In addition two lighting units in operating rooms nine and eleven did not function during a test of the lights.

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

Failing to test and maintain emergency lighting units could cause harm to the patients.

Based on observations the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

Findings Include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering, asked to see the written emergency policy manual at the nurse's stations throughout the hospital. The written fire and emergency policy manual was not found at the nursing stations. The staff at the nurses stations throughout the hospital when asked "where is the fire procedure manual, answered the fire procedures were on the computers."

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

In time of a fire, or emergency, an emergency policy manual must be readily available for the staff. Patients could be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Based on Observations the facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.1.5, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings Include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering and the Manager Facilities Engineering and Mechanical Engineering,
observed Escutcheon plate missing from the sprinkler assembly in the following locations:

1. Room 288, 441, Quiet treatment room, Room 2 Trash chute room, DI Imaging Control Center, MRI storage room.

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on observation the facility failed to mount electrical light switches or a plug mode strip five feet above the floor in the oxygen storage rooms.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On May 27, through 31, 2011 the surveyors, accompanied by the Director Network Facilities Engineering observed wall mounted electric light switches or a plug mode strip in the oxygen storage rooms were measured to be approximately fifty four inches above the floor, when measured with a measuring tape.

1. CVICU on the second floor
2. Storage room ICU
3. Main Diagnostic Imaging room


During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

Failing to mount a light switches or plug mode strips five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.

Based on Observations the facility failed to provide medical gas cylinder storage room free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings include:

On May 27, through 31, 2011 the surveyor, accompanied by the Manager Facilities Engineering and Mechanical Engineering, observed the Respiratory Therapy/ Pump room adjacent to the sign shop had storage of plastics and cardboard boxes. next to six oxygen bottles.

During the exit conference on May 31, 2011 the above findings were again acknowledged by the Director Network of Facilities Engineering and the Facilities Engineering and Mechanical Engineering. .

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.