HospitalInspections.org

Based on observation, the facility failed to provide an astragal on a 1.5 hour rated fire door which separates a nonconforming building from a health care facility, failed to fill penetrations in wall between nonconforming buildings, failed to complete walls where nonconforming buildings attach to a health care facility, and failed to properly label all fire doors between health care facilities and nonconforming buildings.

Findings include:

1. The set of fire doors which separate the Womens Health Center in the hospital building from the Broadway Building were reviewed at 9:35 a.m. on March 1, 2010. The 1.5 hour rated fire doors did not have an astragal affixed to either door. There was a space between the doors of approximately one quarter inch when the doors were in the closed position. Fire doors can not have a space greater than one eighth inch when in the closed position.

2. The two hour barrier wall on second floor of the hospital was observed at 2:45 p.m. on March 2, 2010. The wall above the set of double doors at the two hour wall had one inch penetration of the wallboard which was not sealed.



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3. The set of corridor doors adjacent to the Student study room (across the hall from the Laboratory) on the first floor was shown as being part of a two-hour fire barrier on the floor plans of the building. One of the two doors did not have a label attesting to it being at least a one and one-half hour rated door for use in openings in fire barriers as observed at 2:31 p.m. on March 1, 2010. Note: The other door did have a one and one-half hour label on it.



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4. The second floor two hour barrier between the hospital and the Broadway building was reviewed on March 3, 2010 between 8:02 a.m. and 8:11 a.m. The following deficiencies were found:

a) a disconnected, open ended electrical conduit was found that penetrated the barrier,

b) the right hand side of the wall was incomplete from the wall to the ceiling pan above door 0169 from the Broadway building going into the hospital, and

c) the right hand side of the wall was incomplete from the wall to the ceiling pan above door 0169 from the Hospital into the Broadway building.

Based on observations made on March 1-2, 2010, the facility failed to maintain the fire and smoke resistance rating of ceiling and wall assemblies.

The findings include:

1. The ceiling tile in Day Surgery on the second floor of the hospital was observed at 11:30 a.m. on March 1, 2010. There were approximately eight penetrations in the ceiling tile where the old telemetry system had been removed, these were approximately 3/4 inch in diameter each.

2. The utility room in the Emergency Room was observed at 1:05 p.m. on March 1, 2010. There were approximately fifteen 1/2 inch penetrations in the back wall where some shelving had been removed.

3. The janitors closet at Day Surgery was observed at 3:10 p.m. on March 2, 2010. The ceiling tile was missing in this room, exposing an unprotected area to the ceiling cap above.



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4. The housekeeping department storage room located at the southeast corner of the first floor of the building was examined at 1:50 p.m. on March 1, 2010. Removal of one or more panels in a lay-in ceiling have the potential to hinder the ability of the sprinkler installed in that type of ceiling assembly to activate by allowing heat and smoke to enter into interstitial spaces and collect there, delaying the activation of the sprinkler to control the fire and the fire alarm system to activate. One large ceiling tile being two feet by four feet and two other smaller size tiles were observed to be out of place in the ceiling assembly of this room.

5. The enclosure housing the sterilizer units on the first floor of the building was examined at 2:21 p.m. on March 1, 2010. Removal of any section of a monolithic ceiling has the potential to hinder the ability of the sprinkler installed in that type of ceiling assembly to activate by allowing heat and smoke to enter into interstitial spaces and collect there, delaying the activation of the sprinkler to control the fire and the fire alarm system to activate. A section of the monolithic ceiling assembly measuring approximately 20 inches by 20 inches had been removed and was open to the interstitial space above.

6. An elevator mechanical room was accessed from the Central Processing suite on the first floor of the building and examined at 3:12 p.m. on March 1, 2010. The elevator mechanical room was located on a level lower than that of the Central Processing suite and accessed by means of stairs. An open penetration in the wall of this room for the hydraulic piping serving the elevator was observed and needs to be sealed with fire rated material.

7. The telephone service room on the first floor of the building located between the two banks of elevators was examined at 3:55 p.m. on March 1, 2010. Two ceiling tiles were observed to be out of place in the ceiling assembly.

Based on observation, the facility failed to provide documentation that all interior wall finishes comply with Section 10.2.3 of NFPA 101 Chapter 39 Existing Business Occupancies in all exit ways and corridors.

NFPA 101 39.3.3.1 Interior finish shall be in accordance with Section 10.2.

NFPA 101
10.2.3.2* Products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale.

Findings include:

There is a large amount of wood (cedar) used on the wall finishes in the exit ways of the building. Maintenance staff were not certain that the walls had been sprayed with a material to meet Class A or Class B finish requirements.

Based on observations and interviews with nursing and maintenance staff made on March 1-3, 2010, the facility failed to assure that there were no impediments to closing and latching corridor doors.

In accordance with section 19.6.6.3.3 of NFPA 101, 2000 edition; doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close.

The findings include:

1. A bladder scanner was observed to be blocking the door from closing the corridor door to Medical Intensive Care Unit (MICU) on the third floor of the hospital as observed at 2:20 p.m. on March 1, 2010.



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2. There are two doors opening onto the west exit corridor from the Pharmacy on the first floor of the building. One of the two corridor doors was no longer in use as observed at 2:38 p.m. on March 1, 2010. A shelf with supplies had been placed against this opening into the corridor system.

3. A cart storage room located off of what was described as the "dirty side" of central processing had a door opening onto the west exit corridor. Wheeled red carts were placed against this opening into the corridor system.

Based on observation, the facility failed to protect all vertical openings between floors as required by Sections 39.3.1.1, and 39.3.1.2 of NFPA 101 Chapter 39 Existing Business Occupancies.

NFPA 101 Section 39.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

NFPA 101 Section 8.2.5.4 The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four stories or more in new construction - 2-hour fire barriers
(2) Other enclosures in new construction - 1-hour fire barriers
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers

NFPA 101 Section 39.3.1.2 Floors below the street floor used for storage or other than business occupancy shall have no unprotected openings to business occupancy floors.


Findings include:

1. The north east mechanical penthouse was observed at 1:30 p.m. on March 3, 2010.

a) There were three openings in the north wall to the level below around electrical wiring.

b) There were five openings in the west wall of the mechanical room into the stairway for electrical wiring and open conduits.

c) There were three holes in the wall where the Fire Alarm Control Panel (FACP) was located, these were open to the level below.

d) There were two holes in the adjoining wall for the atrium around pipes/conduits.

e) There were seven openings in the wall between the stairway and the north east penthouse for communication wire.

2. The north west mechanical penthouse was observed at 1:40 p.m. on March 3, 2010.

a) There is a hole in the adjoining wall to the medical center which was open.

3. The southwest mechanical penthouse was observed at 1:50 p.m. on March 3, 2010.

a) There were five conduit openings in the floor of the penthouse which were open to the level below.

b) There were three vertical openings for communication wiring which were open to the level below.

c) There were three open penetrations in the north wall of the penthouse which were open to the atrium of the medical center.

4. The partial basement of the medical center was observed for vertical opening at 2:00 p.m. on March 3, 2010. There is a penetration around a vent in the stairway leading to the basement.

Based on observations which were made during a tour of the building on March 1-3, 2010, it was determined that the facility did not ensure that all doors requiring self closing hardware were closed or could close to positive latching.

Findings include:

1. The fire door (labeled 0510) on fifth north of the hospital did not latch when exercised at 7:50 a.m. on March 2, 2010.

2. The fire door to the dumb waiter access on sixth floor of the hospital did not latch as the spring had been removed and it would not self-close as required at 8:50 a.m. on March 2, 2010.



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3. A supply/storage room within the first floor maintenance suite was shown as being enclosed by one-hour construction on the floor plans of the building. The fire rated door into this supply/storage room had a chock holding it open as observed at 10:10 a.m. on March 1, 2010. There was no one occupying or using the supply/storage room at the time of the observation and the chock inhibited the self-closure mechanism on the fire door from closing and latching the door.

4. The maintenance suite area on the first floor was separated from an exit stairway to the second floor by a set of fire doors in the immediate area of the power lift assembly. A movable/wheeled bed was placed in the doorway of these fire doors as observed at 10:24 a.m. on March 1, 2010. The placement of the bed would inhibit the doors from closing and latching upon their release from the magnetic hold devices in case of an emergency. Note: The bed was removed from the doorway after the observation was made and confirmed by the surveyor while on-site.

5. The northeast exit stairway accessed from the second floor of the boiler room suite was examined at 1:10 p.m. on March 2.2010. The one and one-half hour rated door was being held open by a chock which inhibited the door from self-closing and latching.

Based on observations, the facility failed to maintain the fire and smoke resistive rating of smoke/fire barriers.

Findings include:

1. The electrical room in the Emergency Room (ER) was observed at 12:55 a.m. on March 1, 2010. There were three penetrations along an I beam along the corridor wall which were not sealed.

2. The two hour wall between the ambulance garage and the paramedics charting room was observed at 11:45 a.m. on March 2, 2010. Two unsealed sleeve penetrations were found through the south wall for communication wiring.

3. The soiled utility room in the E.R. was observed at 11:50 a.m. on March 2, 2010. Two penetrations were found in the east wall, one in the south wall, and one in the west wall. All penetrations were for communication wiring.

4. The locker room in the E.R. was observed at 1:00 p.m. on March 2, 2010. Two penetrations were found in the north wall, one was an open three inch sprinkler pipe, and the other was a three quarter inch conduit that was open.

5. The E.R. exit foyer was observed at 1:10 p.m. on March 2, 2010. Seven penetrations were found in the east wall above the exit door at the two hour wall.

6. The east corridor wall outside of E.R. was examined at 1:12 p.m. on March 2, 2010. One three inch sprinkler pipe had not been sealed above the fire extinguisher cabinet.

7. The north wall at the double doors into Radiology was examined at 1:30 p.m. on March 2, 2010. One penetration was found in the wall above the double doors.

8. The wall was examined above the double doors into X-Ray at 1:32 p.m. on March 2, 2010. Two sleeves extending through the wall were not sealed at the end of the sleeves.

9. The east wall, near X-Ray, across from smoke detector LO3D42, was examined at 1:35 p.m. on March 2, 2010. There was a one and one half inch hole in the wallboard which was not sealed.

10. The smoke barrier wall at the X-Ray reading room was examined at 1:40 p.m. on March 2, 2010. A three inch conduit leading to a cable tray was not sealed at the smoke barrier wall.

11. The smoke barrier wall separating X-Ray from the corridor was examined at 1:50 p.m. on March 2, 2010. A sprinkler collar penetrated the wallboard on the east wall to X-Ray, exposing a hole in the wallboard around the collar.

12. The two hour wall at the second set of service elevators was examined at 2:00 p.m. on March 2, 2010. There were five penetrations of the fire wall above the set of fire rated doors.

13. The east wall of Post-Operations was examined at 2:05 p.m. on March 2, 2010. One two inch conduit was not sealed at this location along with a phone box cover missing which had branch lines extending through the same wall.

14. The smoke barrier wall at the entrance to Surgery was examined at 2:10 p.m. on March 2, 2010. A communications cable tray was not sealed at the smoke barrier wall above the doors to Surgery.

15. The smoke barrier wall at Surgery was examined at 2:15 p.m. on March 2, 2010. A three inch sewer pipe was not sealed as it passed through the north wall at Surgery.

16. The east corridor wall just south of the double doors to Surgery was observed at 2:20 p.m. on March 2, 2010.

a) There are approximately ten penetrations at the top of the smoke barrier wall where the wallboard meets the ceiling support beam.

b) A two foot by three foot piece of wallboard panel was not screwed to the smoke barrier wall and fire taped.

17. The smoke barrier wall in the mens dressing room of the Operating Room (OR) was observed at 2:30 p.m. on March 2, 2010. One penetration for communication wiring conduit was not sealed.

18. The smoke barrier wall in the women's dressing room of the O.R. was observed at 2:35 p.m. on March 2, 2010. The east wall was incomplete to the ceiling cap and there was one penetration of a communication wire through the same wall which was not sealed.

19. The east corridor wall across from Day Surgery was observed at 2:40 p.m. on March 2, 2010. There was one penetration of a three quarter inch conduit which was not sealed above the Day Surgery double doors.

20. The store room behind the Chapel was observed at 3:30 p.m. on March 2, 2010. There were six penetrations of the north wall (all conduits) which were not sealed. The wall where it intersected the ceiling cap was incomplete as the wallboard did not close off the deck flutes.

21. Second floor of the hospital, in the mens dressing room, at the west end of the smoke barrier wall between Surgery and Radiology, was observed at 8:00 a.m. on March 3, 2010. There were two penetrations of the smoke barrier wall where chilled water return and supply pipes were not sealed.

22. The smoke barrier wall between Surgery and Radiology was observed at 8:10 a.m. on March 3, 2010. There were three penetrations of the smoke barrier wall above the ceiling tile. Two of the penetrations were for conduits not sealed and the remaining was for a communication wire not sealed where it went through the wall.

23. The smoke barrier wall which separates Radiology from Surgery was observed at 8:12 a.m. om March 3, 2010.

a) There was one penetration in cubicle #5 where wallboard did not butt up to one another exposing a two inch by six inch hole in the smoke barrier wall.

b) There was one penetration at the lower right hand corner of a large two foot by two foot duct not sealed at cubicle #4 in Radiology.

c) There was one penetration of the smoke barrier wall where a one half inch conduit was not sealed in cubicle #4.

d) There was a pneumatic fire damper hose through the smoke barrier wall above the sitting area in Radiology which was not sealed.

e) There were two penetrations of the smoke barrier wall in Radiology at cubicle #2, both penetrations were for sleeves extending through the wall which were not sealed.

f) In cubicle #1, there was one junction box without a cover which had conduit extending through the smoke barrier wall.

24. The smoke barrier wall between Surgery and Nuclear Medicine was reviewed at 8:35 a.m. on March 3, 2010. There were penetrations of the smoke barrier wall where a return air trunk line extends through the wall of Nuclear Medicine by damper #480.

25. The Specials Computer Room at Radiology was reviewed at 9:30 a.m. on March 3, 2010. There were two penetrations above the ceiling tile near smoke alarm # LO2D86, one was a support wire and the other was a pneumatic tube through the smoke barrier wall which were not sealed.

26. Fire Dampers were observed at 10:20 a.m. on March 3, 2010 on fifth floor north and again on third floor north. The following is a listing of penetrations of the smoke barrier wall which were found on third north:

a) The north wall at the door to the core had a two inch penetration where communication wiring extends through the wall.

b) The east wall at the same location had two penetrations which were not sealed. One was a sleeve which was not sealed and the remaining was a air supply duct which was not sealed at the lower left hand corner.




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27. The smoke barrier above the corridor door that leads to the Credit Union office from the corridor by the first floor conference rooms was examined at 10:32 a.m. on March 2, 2010. There was an open unsealed space around a conduit that penetrates this portion of the smoke barrier.

28. The smoke barrier above the corridor door into the Central Processing suite from the corridor by the first floor elevator lobby was examined at 10:38 a.m. on March 2, 2010. There was an open unsealed space around a 12 inch white pipe and around a drain pipe that penetrate this portion of the smoke barrier. Furthermore, a thermofiber/wool type material had been used a sealant around other penetrations. The Centers for Medicare & Medicaid Services (CMS) does not accept thermofiber/wool material as a sealant in walls that require a fire resistance rating.

29. The smoke barrier above the set of corridor doors into the area that was previously the Bio-med suite on the first floor of the building was examined at 11:00 a.m. on March 2, 2010. There was an open faced conduit being used as a pass through for a white wire that was unsealed. Furthermore, a thermofiber/wool type material had been used a sealant at the meeting edge of the smoke barrier wall and the fluted deck.

30. The smoke barrier above the set of corridor doors into the IT suite from the corridor by the kitchen area on the first floor of the building was examined at 11:08 a.m. on March 2, 2010. There was an open unsealed space around a conduit that penetrates this portion of the smoke barrier. Furthermore, the meeting edges of sheetrock used in the smoke barrier wall were not fire taped/sealed completely.

31. The smoke barrier being the south wall of the IT office suite on the first floor of the building was examined at 11:17 a.m. on March 2, 2010. There was an open faced conduit with open unsealed space around it that penetrates this portion of the smoke barrier. Furthermore, there were two other conduit with open unsealed spaces around them that penetrate this smoke barrier.

32. The smoke barrier above the entry door into the Credit Union office on the first floor of the building was examined at 11:27 a.m. on March 2, 2010. There was a small round open unsealed hole in the smoke barrier.

33. The smoke barrier above the "T" intersection of the corridors by the Credit Union office and the north conference room on the first floor of the building was examined at 11:45 a.m. on March 2, 2010. A thermofiber/wool type material had been used a sealant at the meeting edge of the smoke barrier wall and the fluted deck. Furthermore, the same thermofiber/wool material had been used as a sealant around two white pipes that penetrate this smoke barrier.

34. The smoke barrier above the biohazard waste storage room on the first floor of the building was examined at 11:48 a.m. on March 2, 2010. There was no sealant at the meeting edge of the smoke barrier wall and the fluted deck.

35. The smoke barrier being the west wall of the Central Supply room on the first floor of the building was examined at 11:58 a.m. on March 2, 2010. There were two conduit with open unsealed spaces around them that penetrate this smoke barrier.

36. The smoke barrier above the north office space in what was previously the Bio-med suite on the first floor of the building was examined at 1:33 p.m. on March 2, 2010. There was an open unsealed space around a sprinkler pipe that penetrates this smoke barrier.

37. The smoke barriers above what was once the engineering secretary's office space in the area that was previously the Bio-med suite on the first floor of the building was examined at 1:40 p.m. on March 2, 2010. Both the west and south walls of this space constitute a smoke barrier. The west smoke barrier had no sealant at the meeting edges of the wall with the fluted deck. The south smoke barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.




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38. The fifth floor fire doors were reviewed on March 3, 2010 at 11:17 a.m. On the north side above these doors, a telemetry sleeve was found that had not been sealed on the end.

39. The fourth floor waiting room was reviewed on March 3, 2010 at 11:22 a.m. The smoke barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

40. The fourth floor fire doors were reviewed at 11:24 a.m. on March 3, 2010. On the south side above these doors. A steel pipe passing through the barrier was not sealed around where it entered the barrier.

41. The fourth floor fire doors was reviewed on March 3, 2010 at 11:22 a.m. The fire barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

42. The fourth floor smoke barrier was reviewed on March 3, 2010 at 11:31 a.m. at Jani's Office. The barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

43. The fourth floor barrier wall was reviewed on March 3, 2010 at 11:33 a.m. above the 4 north doors. There were two deficiencies noted:

a) the wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck, and

b) a open ended telemetry sleeve was found that passes through the barrier.

44. The third floor main pipe/utility chase barrier was reviewed on March 2, 2010 at 1:04 p.m. The wall of the chase was incomplete to the fluted deck above.

45. The second floor vertical shafts were reviewed on March 3, 2010 between 8:15 and 8:35 a.m. The following deficiencies were noted:

a) the dumb waiter vertical shaft wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck, and

b) the post operation surgery area and the vertical pipe chase that passes through the area had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

Based on observation, the facility failed to install fire doors on all hazardous areas (including boiler rooms and storage rooms).

NFPA 101 Section 39.3.2.1 Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.


NFPA 101 Section 8.4.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

NFPA 101 Section 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Findings include:

The main floor telecommunications room was observed at 2:05 p.m. on March 3, 2010. There was no self-closing device on the door to this hazardous room.

Based on observations on March 1 - 3, 2010; the exit enclosures for two stairways were not properly rated.

Findings include:

1. The first floor stairway enclosure at the southeast stairway near the housekeeping department serves as the ground level means of egress for five stories. The door protecting this stairway shall be at least a one and one-half hour rated door. There was no label on the door protecting this stairway to attest to its fire rating as observed at 2:08 p.m. on March 1, 2010.

2. The north stairway that serves as an exit from the seventh floor Life Flight office area was being used for storage purposes as observed at 9:52 a.m. on March 2, 2010. A red tarp was found to be draped over the handrail system of the stairway at this level.

Based on observations made in the facility on March 3, 2010; the facility stored materials in stair landings which are part of the egress.

In accordance with 7.1.3.2.3 and 7.2.2.5.3 of NFPA 101, an exit enclosure, including an exit stairway, shall not have any open space within the enclosure used for any purpose (storage) that has the potential to interfere with egress.

Findings include:
The second story landing near the loading dock was observed at 11:55 a.m. on March 3, 2010. The landing area contained carts used for holding meal containers used for transporting meals to other areas much like "Meals on Wheels". Storage of items in a stair enclosure is not allowed under Section

Based on observation, the facility failed to maintain exits free of all obstructions.

NFPA 101 Chapter 39 Existing Business Occupancies 39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

NFPA 101 Chapter 7 Means of Egress, Section 7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

NFPA 101 Chapter 7 Means of Egress, Section 7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.


Findings include:

1. The south exit from Physical Therapy (PT) was observed at 11:00 a.m. on March 1, 2010. The exit was blocked by beverage canisters and a clear path was not being maintained as required.

2. The south exit from PT to the public way was observed at 11:05 a.m. on March 1, 2010. The sidewalk was not finished to the public way as it ended approximately three feet outside the building. There was approximately thirty five feet of grass to another sidewalk out near the street.

Based on observation, the facility failed to ensure that all exit discharges were provided with illumination.


According to Section 7.9.2.1 of NFPA 101, emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

Findings include:

The south exit discharge from the second floor was reviewed on March 2, 2010 at approximately 10:00 a.m. There was no external lighting at the exit.

Based on observations made on March 1, 2010 the facility failed to maintain an exit sign to assure that when fully illuminated the letters could be plainly read.

The findings include:

An exit sign located on the south wall of the southeast portion of the Laboratory suite on the first floor showed signs of heat having affected the transparency of the material used for the letters as observed at 12:50 p.m. on March 1, 2010. The heat had darkened the material to the point where the lights behind the letters were no longer capable of illuminating them for visual purposes. Note: The placard material used for the letters on the sign was replaced after the observation was made and confirmed by the surveyor on-site.

Based on observations made on March 1, 2010, the facility failed to assure that a manual pull station for the fire alarm system was accessible.

The findings include:

Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible per 2-8.2.1 of NFPA 72, 1999 edition. The manual pull station located along the east wall of the kitchen area on the first floor was obstructed by the placement of carts in front of it as observed at 3:35 p.m. on March 1, 2010.

Based on interview, the facility failed to test all smoke/heat detectors in accordance with NFPA 72.

Findings include:

1. A partial fire alarm system was in the Garden City Medical Arts Building as observed at 1:30 p.m. on March 3, 2010. When asked if the fire alarm system had received inspections, testing and maintenance since occupying the building, the maintenance staff replied that no testing of the alarm system had occurred since it was occupied.

2. The main fire alarm control panel was installed in the north east penthouse. Heat and duct detectors were installed in the building as part of the fire alarm system. Smoke and heat detectors installed as part of a fire alarm system, whether required or not, shall be maintained and tested in accordance with NFPA 72. There was no record indicating that the fire alarm system had received inspection, testing or maintenance since the building was occupied. There was no record of sensitivity testing on any heat and duct detectors since the building was occupied.

Based on observations and interview with maintenance staff on March 1-3, 2010, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system.

The findings include:

In accordance with section 5-13.8.1 of NFPA 13, 1999 edition; sprinklers shall be installed under exterior roofs or combustible canopies exceeding 4 feet in width. The building is of Type I (332) construction which requires that it be protected throughout by an approved automatic sprinkler system.

1. The access space to the top of the dumb waiter shaft was observed at 8:50 a.m. on March 2, 2010. The access space measured approximately twelve feet by twenty feet and was not protected by the facility sprinkler system.



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2. The area previously used for the Bio-med department on the first floor of the building was in the process of being remodeled at the time of the survey. Two existing closets on the west side of this area did not have sprinkler protection within their confined spaces as observed at 10:52 a.m. on March 1, 2010.

3. A mechanical room was accessed through the locker room for the Laboratory personnel on the first floor of the building. The mechanical room had ductwork that exceeded four feet in width and in accordance with 5-5.5.3.1 of NFPA 13, 1999 edition sprinklers shall be installed under fixed obstructions over four feet wide such as ducts, decks, open grate flooring cutting tables, and overhead doors. Under one of the ducts that exceeds four feet in width was stored cardboard boxes, filters and foam mattresses. There was no sprinkler located under this ductwork to provide coverage for these stored items or the general area as observed at 1:10 p.m. on March 1, 2010.

4. An elevator mechanical room was accessed from the Central Processing suite on the first floor of the building. The elevator mechanical room was located on a level lower than that of the Central Processing suite and accessed by means of stairs. There was no sprinkler protection provided in the lower level area of the elevator mechanical room as observed at 3:12 p.m. on March 1, 2010.

5. The room housing the transfer switches for the emergency generators was located in a two-hour fire rated enclosure/room located off of the chiller room on the first floor of the building. The room was not protected by the sprinkler system as observed at 1:00 p.m. on March 2, 2010.

Based on observations made on March 2, 2010, the facility failed to provide for electronic supervision of sprinkler control valves.

The findings include:

The water pipe for supplying water to the fire pump and riser system originating from the fire pump was examined at 1:15 p.m. on March 2, 2010. The water supply pipe located on the first floor of the chiller room had two control valves, one on each side of the backflow device. These two control valves were provided with chains and locks as a means of securing them in the open position. There were no tamper switches attached to these two control valves to provide for electronic supervision and alarm notification of the valves when closed.

Based on review of the fire sprinkler service and testing reports on March 1-3, 2010, the facility failed to assure that the sprinkler system is maintained in accordance with the standards of NFPA 13 and NFPA 25. The facility also failed to keep the sprinkler pattern coverage free and unobstructed

The findings include:

1. The fire sprinkler service and testing reports were reviewed between 4:30 and 5:30 p.m. at the facility on March 1, 2010. There was no information in the reports which listed the static pressure or the residual pressure for the installed sprinkler system. There was evidence that all necessary monthly and quarterly reports had been done on a timely basis, but not all the required information was in the reports.



04703

2. The locker room for the Laboratory personnel on the first floor of the building was examined at 1:10 p.m. on March 1, 2010. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane below the sprinkler deflector or the top of storage shall be maintained with a minimum of 18 inches clearance per 5-5.5.3 and 5-5.6 of NFPA 13, 1999 edition. The majority of lockers in this room had a slanted top to prevent the storage of items on top of the lockers. The lockers which protrude from the wall into the center of the room had flat tops and personal items were stored on top of the lockers. The items were within 18 inches of the sprinkler head in this location and obstructed the coverage pattern of that sprinkler.

3. The sprinkler service and inspection reports for the building were reviewed between 4:30 and 5:30 p.m. on March 1, 2010. An anti-freeze loop was installed and the valve and testing piping for that system was located in a room adjacent to the power lift assembly in the first floor maintenance area suite. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary per 2-3.4 of NFPA 25, 1998 edition. The antifreeze solution shall be prepared with a freezing point below the expected minimum temperature for the locality per 4-5.2.3 of NFPA 13, 1999 edition. There was no documentation found that noted the gravity (rating) of the anti-freeze in that loop to assure that it was of sufficient strength to prevent freezing.

4. The penthouse housing the elevator mechanical room accessed from a stairway by the seventh floor Life Flight helicopter offices was examined at 9:50 a.m. on March 2, 2010. Sprinkler piping or hangers shall not be used to support nonsystem components per 6-1.1.5 of NFPA 13. 1999 edition. Grounding wires were found to be attached to the sprinkler piping in this room.

Based on observation, the facility failed to maintain all portable fire extinguishers in accordance with NFPA 10.

NFPA 101 Section 39.3.5 Extinguishment Requirements. Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 39.4.)

NFPA 101 Section 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Findings include:

A portable fire extinguisher located in the northeast penthouse was observed for proper maintenance at 1:45 p.m. on March 3, 2010. The fire extinguisher had been placed in service in 1995 and carried a identification of GCMP#1. The next hydo test was in 2008, thirteen years after being placed in service. There was no tag identifying that the extinguisher had received a six year maintenance test, in 2001 or the twelve year hydro test required in 2007.

Based on observations made on March 1 - 3, 2010; the facility failed to maintain adequate means of egress. The means of egress from the storage area in the basement area was reduced in size by storage of kitchen related items.

According to Section 7.1.10.1 of NFPA 101; means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings include:

1. The first floor, north kitchen storage area was reviewed at 11:41 a.m. on March 1, 2010. Two deficiencies were noted:

a) Several kitchen related items; food warmers, metal racks, plastic garbage bins, etc., were stored in the exit reducing width of egress.

b) The gate on the west side of the elevator door in the storage room was locked with a keyed lock.

2. During the fourth floor fire drill on March 3, 2010 at approximately 11:00 a.m., a handwashing stand was noted as being in the corridor as the fire drill occurred. This item will have to be located in an area where it will not reduce the width of the corridor or hung on the wall.

3. On the third floor on March 3, 2010 at approximately 11:30 a.m., a fire drill was performed. Four chairs were noted to be in the corridor and were used for new patients as they are admitted as indicated by staff. These chairs need to moved out of the egress corridor to a location that does not reduce the width of the corridor.

Based on observations made on March 2, 2010; the facility failed to provide documentation or proof that draperies, cubicle curtains, etc. were fire retardant as required.

According to Section 10.3.1 of NFPA 101; where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Findings include:

1. The fourth floor "gym" was reviewed on March 2, 2010 at 9:10 a.m. Two curtains used to separate space were found to not be labeled to indicate they meet NFPA 701 as being flame resistant. When asked, the maintenance staff could not provide documentation that these curtains meet NFPA 701.

2. The second floor counselors file room 2 was observed on March 2, 2010. There were no tags indicating the flame resistance of two curtains hung in the room. When asked the maintenance staff could not provide documentation that they meet NFPA 701.

3. The second floor mission leadership office was reviewed. There were no tags indicating the flame resistance of curtains hung in the room. When asked the maintenance staff could not provide documentation that they meet NFPA 701.

4. The second floor ambulatory surgical suite was reviewed on March 2, 2010 at 11:03 a.m. Two curtains were found in the suite that were not tagged indicating their flame resistance. When asked the maintenance staff could not provide documentation that they meet NFPA 701.

Based on observations made on March 1, 2010, the facility failed to maintain the medical gas or compressed gas systems and cylinder storage areas in conformance with the standards of NFPA 99, 1999 edition.

The findings include:

1. The medical gas manifold and storage room was located off of the loading dock on the south end of the first floor of the building. Freestanding or unsecured cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99. An "E" size cylinder of oxygen was observed to be unsecured and lying on the floor surface of this room at 2:10 p.m. on March 1, 2010.

2. The medical gas manifold and storage room was located off of the loading dock on the south end of the first floor of the building. In any storage location housing nonflammable gases the electric wall fixtures, switches, and receptacles in that enclosure shall be installed in fixed locations not less than 5 feet above the floor as a precaution against their physical damage per 4-3.1.1.2(a)4 of NFPA 99. The light switch in this room was measured and found to be four feet from the floor surface as observed at 2:10 p.m. on March 1, 2010.

3. A hazardous materials room containing other pressurized gases was adjacent to the medical gas manifold and storage room located off of the loading dock on the south end of the first floor of the building. This room was separated by one-hour construction from other portions of the building. Storage of flammable and nonflammable gases in cylinders shall comply with 4-3.1.1.1 and 10-10.2.1 of NFPA 99. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. A free-standing cylinder of Ethanol (flammable gas) and a free-standing cylinder of Carbon Dioxide (nonflammable gas) were observed at 2:15 p.m. on March 1, 2010 in this room.

Based on observations made on March 3, 2010, the facility failed to assure that a cylinder of oxygen was properly secured from falling over or being knocked down. In addition, three R-22 refrigerant tanks were stored in a mechancial room.

Freestanding cylinders of nonflammable gases such as oxygen, shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down (Section 8-
3.1.11.2(h) and 4-3.5.2.1(b) of NFPA 99, 1999 edition).

The findings include:

1. An "E" size cylinder of oxygen was found to be freestanding at the bottom of the stairway which leads to a roof top store room as observed at 1:00 p.m. on March 3, 2010.

2. Three R-22 refrigerant cylinders were located in the northwest mechanical penthouse as observed at 1:45 p.m. on March 3, 2010. R-22 refrigerant gas is combustible by nature and should not be stored in the penthouse space.

Based on observation, the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70.

Extension cords, including power strips or multiple adaptors, used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction. One means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 edition and 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99, 1999 edition. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle and not connected in series or "daisy chained".

NFPA 70, Article 110-26 states that ufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

NFPA 70, Article 384-13 requires that all panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. NFPA 70, Article 110-22. Identification of Disconnecting Means states that each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

Findings include:

1. An orange extension cord was found in use in the northeast penthouse as observed at 1:20 p.m. on March 3, 2010.

2. There were two multi-plug adaptors found in use in the northeast penthouse as observed at 1:21 p.m. on March 3, 2010.

3. There were two surge protected cords found in series (plugged one into the other) in the northeast penthouse.

3. A brown extension cord was in use for a ceiling light in the northwest penthouse as observed at 1:45 p.m. on March 3, 2010.

4. Two extension cords were found in use along the east wall of the telecommunications room as observed at 1:50 p.m. on March 3, 2010.

5. Stored items were located in front of the electrical panels of the telecommunications room as observed at 1:51 p.m. on March 3, 2010.

6. Stored items were located in front of the main electrical panel in the basement as observed at 2:00 p.m. on March 3, 2010.

Based on review of the fire plan on March 3, 2010; the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with Section 9.7.6.1 of NFPA 101; where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire plan was provided to the survey team and was reviewed at 7:30 a.m. on March 3, 2010. The fire watch policy addressed the procedures to be followed whenever the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period. However, the fire watch policy did not specifically include notification of the State Agency at 406-444-4170 whenever the sprinkler system was out of service for longer than 4 hours in 24 hour period

Based on review of the fire plan on March 3, 2010; the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with Section 9.6.1.8 of NFPA 101; where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire plan was provided to the survey team at 7:30 a.m. on March 3, 2010. The fire plan did have a fire watch policy that addressed the procedures to be followed whenever the fire alarm system was out of service. The policy did not specifically include notification of the State Agency at 406-444-4170 whenever the fire alarm system was out of service for more than 4 hours in a 24 hour period.

Based on observations made on March 1, 2010, the facility failed to assure that Alcohol Based Hand Rub (ABHR) dispensers were not installed over an ignition source.

The findings include:

An ABHR dispenser was installed directly above two light switches adjacent to the south corridor door from the "dirty side" room of the first floor Central Processing suite as observed at 2:50 p.m. on March 1, 2010.