HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide a building construction type with a floor to floor rating that complies with Table 19.1.6.2, Construction Type Limitations. Findings:

St. Anthony - 7, 8, 9, 10, and 11 th Floors:
1) Unsealed floor penetrations for pipes to the convectors in patient rooms are open open to the floor below.
2) Floor penetrations for bath tub plumbing block-outs are open to the floor below.
3) Plumbing pipe penetrations were not sealed throughout the building from the seventh floor and above.
4) Pipes sealed with foam shall have the foam removed and replaced with material capable of maintaining the fire resistance of the floor to floor fire barrier.
5) Between the 11 th and 12 th Floors, the floor access panel to the 12 th floor penthouse does not have a 2-hour fire rating.
6) Room 2022 & 2024 structural steel beam has missing fire proofing on the bottom of the beam.

Bone and Joint:
1) Unsealed floor penetrations were found, including above the Waiting Room on the Second Floor, adjacent to the south smoke compartment wall (smoke barrier), and in the Data Closet Room 2219D.
2) Plumbing pipe penetrations were not sealed through-out the building.

Saints South:
1) Unsealed floor penetrations for pipes to the convectors in patient rooms are open open to the floor below.
2) Plumbing pipe penetrations were found not sealed throughout the building.

Based on observation and interview with staff, in areas not protected by a sprinkler system, the facility failed to provide corridors that are separated from use areas by walls constructed with at least 1/2 hour fire resistance rating per 19.3.6.2.1. Findings:

St. Anthony:
1) Egress corridors in the portions of the hospital not protected by a sprinkler system have voids and unsealed penetrations in the egress corridor walls and are therefore not 1/2 hour fire resistance rated.
2) 3 rd and 4 th Floors have areas not protected by a sprinkler system that are not separated from sprinklered areas by walls constructed with at least a 2-hour fire resistance rating.

Based on observation and interview with staff, the facility failed to provide Smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

All Locations:
1) Unsealed and unrated voids and penetrations were found in most of the smoke barriers through-out; including, around wiring, conduit, ductwork, piping, and structural members passing through the smoke barriers. Typical examples include:

St. Anthony:
1) Ground Level: There is an unrated window and the smoke compartment wall was not intact between Smoke Compartment Zone G.2 and the Egress Corridor.
2) Second Floor: There are unsealed penetrations around pipes thru the wall at Smoke Compartment Zone 2.3.
3) Third Floor: There are unsealed penetrations in the combination fire and smoke wall that terminates at Joe Hodge's office (across from Lab), this smoke barrier does not extend to an outside wall.
4) Fifth Floor: There are unsealed penetrations in the smoke barrier at Smoke Compartment Zone 5.4 and the un-identified smoke compartment to the west.

Bone and Joint:
1) Second Floor: Unrated penetrations and an open gap at the top of the wall above Door SD 2218.

St. Anthony South:
1) First Floor: Between Smoke Compartments 1.6 and 1.7, the wall was not intact in the smoke compartment wall.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 18.3.2.1/19.3.2.1. Findings:

Saint Anthony
1) On the 3rd & 4th Floor ICU Units, the soiled work rooms were in excess of 100 SF, the facility failed to protect these rooms with 1-hour fire rated walls and 3/4 our doors, the doors had glass panels.
2) On the 4th Floor, the vacant Surgery Rooms are in excess of 100 SF and they are used to store equipment and combustibles, the facility failed to protect these rooms with 1-hour fire rated construction with 3/4 hour fire rated doors that are self-closing.
3) On the 4th Floor, the vacant OB Delivery Rooms are hazardous area in excess of 100 SF, they are used to store excessive amounts combustibles, the facility failed to protect these rooms with 1-hour fire rated construction with 3/4 hour fire rated doors that are self-closing.
4) Store Room Door 5M526 was blocked open by a chair. Automatic door closer cannot function with furniture blocking the door.

Based on observation and interview with staff, the gift shop is used for display of combustibles in quantities considered hazardous, the facility failed to protect the gift shop as a hazardous area protected with walls of 1-hour fire resistance rating. 19.3.2.5 Findings:

St. Anthony:
1) The Gift Shop is considered a hazardous area and requires a 1-hour separation, there are two air transfer openings (without dampers) into the plenum return of the corridor above the ceiling.

Based on observation and interview with staff, the facility failed to provide stairways enclosed with construction having a fire resistance rating of at least one hour. 8.2.5.2, 19.3.1.1 Findings,

Bone and Joint:
1) The stairwell enclosure in the Executive Administration Corridor at Door 1276 (near Waiting) is not intact above the ceiling on the north and east sides of the stairwell.

Saints South:
1) The stairwell enclosure located near Medical Records is not intact above the ceiling on the north side of the stairwell.

Based on observation and interview with staff, the facility failed to provide exit passageways that have not less than the same fire resistance rating as required for the stair enclosures. 7.2.6, 19.2.2.7 Findings:

Saints South:
1) The stairwell located near Medical Records and the stairwell located across from the large Clean Linen Room both discharge into exit passageways that leads to the exterior. Both of these exit passageways have unsealed voids and penetrations in the walls and do not provide the same fire resistance rating as required of the stair enclosure.

Based on observation and interview with staff, the facility failed to provide exits that are readily accessible at all times in accordance with Section 7.1. Findings:

Saints South:
1) The exit passageway leading from the stairwell located near the large Clean Linen Room to the exterior of the building fails to provide an exit accessible at all times. A metal gate was found in the path to the public way and provided a potential impediment to egress. The means of egress leading to a public way must be illuminated (refer to Section 7.8.1.2). No illumination was provided in this means of egress.

Saints South (Myro Center)
1) Exit at Door FD118 must extend to a public way. 7.7 Discharge from exits.

Based on observation and interview with staff, the facility failed to provide suites of sleeping rooms of not more than 5,000 square feet. 19.2.5.2, 19.2.5.6 Findings,

St. Anthony:
The 3rd Floor and 4th Floor ICU are sleeping room suites (more than 24 hour stay), the suite of rooms (cubicles) are more than 5,000 square feet. 19.2.5.6

Based upon observation and interview with staff, the facility failed to provide exit and directional signs displayed in accordance with section 7.10 for all required locations. 19.2.10.1 Findings:

Bone & Joint
1) First Floor, Executive Corridor, need exit sign above double egress doors outside of Room 1276.
2) Near Room 1226, need exit sign.

St. Anthony South - Myro Center
1) Existing exit sign at Door 140, exit sign is pointing in the wrong direction.

Based on observation and interview with staff, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 and NFPA 72. Findings:

St Anthony:
1) The facility failed to provide re-acceptance testing after repairs are made, Work orders were reviewed, repairs were made, however re-acceptance testing by the Fire Detection Company was not performed in accordance with NFPA 72 chapter 7 -1.6.2.1.

2) Annual Testing by the fire alarm company failed to identify smoke detector that were located within 3 feet of a supply diffuser. This condition was found through out the facility.

3) Directory of points for equipment connected to the Fire Alarm System was not complete. The directory failed to depict Control Zones that actuate multiple numbers of devices (example: control zones that control combination fire and smoke doors (powered assist doors that are required to drop out of power), combination fire and smoke dampers (how many), smoke evacuation systems, atriums motor controls, magnetic door locks, etc.)

3) The smoke detectors located at the east entrance to the south tunnel were not within minimum 5 feet from door and were not on both sides of the door.

4) Smoke detector monitoring the 3rd floor cross walk are not within minimum 5 feet from door on both sides and are required to disable powered assist doors upon activation of alarm.

5) There is no smoke detector in the 8 East Waiting Room, which is open to the corridor.

Saints South (Myro Center):
1) RM111A has a smoke detector within 3 feet of a supply grille.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system in all areas that is installed in accordance with NFPA 13. Findings:

St. Anthony:
1) The facility is not fully sprinkled, areas not sprinkled include:
Ground Floor - 8,785 sq
First Floor Kitchen - 12,386 sq
Second Floor Cafeteria Office - 12,314 sq
Penthouse Central Tower - 3,226 sq
2) At the west entrance, the two spaces on either side of the revolving door were not sprinkled.
3) Space in the corner of the water feature at 2nd Floor west Lobby is not sprinkled.
4) The walk-in Incubators located in the Micro- Biology Department were not sprinkled.
5) In the Gift Shop, items were stored on shelves less than 18" from the ceiling.
6) Room 2034, missing escutcheon on sprinkler head.
7) Room 10603 has electrical conduit touching sprinkler pipe, typical for other locations, including wiring draped over the sprinkler pipe.

Saints South (Myro Center)
1) Fire Pump Room is not sprinkled

Based on observation and interview with staff, the facility failed to provide HVAC complying with 19.5.2.2 and 9.2. Findings:

St. Anthony:
1) 2nd Floor, Salon (Door 2105): There is no exhaust in the Salon to eliminate odors from the room and adjacent corridor.
2) 11th Floor, Room 11714: Exhaust is not operationing in the toilet room.

Based on observation and interview with staff, the facility failed to continuously maintained corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency. 7.1.10 Findings:

St. Anthony:
1) The Cath Lab Egress Corridor on the 4th Floor was obstructed with equipment, supplies, equipment racks, and stretchers. This condition was also found in other areas.
2) The vacant OB Suite Egress Corridor on the 4th Floor was obstructed by furniture and stored material.
3) Egress path was not provided and maintained through the construction area adjacent to the 4th Floor Cath Lab.

Bone and Joint:
1) Basement Level: The large Storage Room adjacent to the large Mechanical Room has items blocking egress from the Mechanical Room, and has items blocking egress to the exterior exit stairwell on the north side of the building. This exterior stairwell provides the required second exit from both the Storage Room and the Mechanical Room.

Based on observation and interview with staff, the facility failed to provide medical gas storage protected in accordance with NFPA 99, 4-3.1.1.2. Findings:

Bone and Joint:
1) Basement: The Med Gas Cylinder Storage Room (adjacent to Pharmacy) has an open gap at the intersection of the gypsum board and the floor deck above, un-taped gypsum board joints, unrated duct penetrations through walls, unrated penetrations, and the room does not have an exhaust system. Rooms with over 3000 cu ft of gas storage requires a 1-hour rated enclosure and mechanical ventilation. The light switch is located less than 60" above the floor.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99, 4-3.1.2.3. Findings:

St. Anthony:
1) Ground Floor: Three (3) medical gas outlets are located in GR 21, which is open to the corridor where the zone valve serving these outlets is located.

An intervening wall between the zone valve and the outlets served must be provided, and must include a door where an opening in the wall exists. There is an existing opening approximately five feet wide on the southwest side of GR 21. NFPA 99, 4-3.1.2.3 (d) Zone Valves, requires "station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet."

Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99. Findings:

St. Anthony
1) The Interventional Radiology Department, Cardiac Cath Lab and the MRI are periodically used as Anesthetizing Locations. These rooms were not provided with humidification equipment or have a automatic smoke evacuation equipment.
2) The governing body failed to identify Anesthetizing Locations in accordance with NFPA 99 1999 edition, Chapter 12-2.7
3) The Operating Room Fire Loss Prevention Orientation and Training program failed to include contract Physicians and Surgeons in the General Safety and Fire Drills periodically conducted.
3) The effectiveness of the Emergency Procedures Training Program in the Anesthetizing Locations failed to provide staff with knowledge of all equipment in the Operating Room Suite. A staff member in the operating room suite was asked, but could not explain what the Line Isolation Monitor was or its function. 12-4.1.2.10
4) The staff in the Interventional Radiology Suite failed to identify the location of the Oxygen Shut Off Valves. 12-4.1.2.10
5) The Endoscopic Suite has anesthesia carts with Nitrous Oxide. The Director of Nursing stated that the Endoscopy Suite was no longer an anesthetizing location. This locations does not meet standards as an anesthetizing location.
6) The MRI Suite Humidifier was turned off, humidifying equipment for anesthetizing locations shall be kept in operable condition and be continuously operating during procedures. 5-6.1.1
7) Emergency Power in the MRI Suite was not fed from the Critical Care Branch. 5-4.1.4.

St Anthony Power Plant
Based on observation and interview with staff, the facility failed to provide separation of the Essential Emergency Electrical System powered by a generator from other functions by construction capable of a fire resiance rating of 2-hours in accordance with NFPA 99, 3-4.1.1.6. Findings,

1) The emergency generator in the boiler room was not separated from the remainder of the room by a two-hour fire barrier.

Saint Anthony South:
1 ) Based on observation and interview with staff, the facility constructed renovations that
failed to maintain egress in not less than two directions. 4-6.7, 18.2.5.10 Findings:

On the 3rd floor, East End of the South Wing, the facility added a meeting room, this renovation created a dead end corridor greater than 30 feet.

2) Based on observation and interview with staff, the facility failed to provide training on proper procedures and to provide the required equipment to establish continuity of essential systems in the event of a disaster. NFPA 99, 1999 edition, Chapter 11, Health Care Emergency Preparedness, 11-5.3.2 Findings:

The facility failed to locate portable propane tanks required for operating the boiler pilot light for the diesel fired boilers in the event of the loss of natural gas . The facility failed to demonstrate training for the staff on these emergency procedures.

Saint Anthony,
Based on observation and interview with staff, the facility failed to provide the Micro-Biology Suite with negative pressure. NFPA 99, 5-4.2.1 Findings,

1) The facility failed to balanced the room exhaust system in conjunction with the fume hood for the Micro-Biology Suite to be negative relative to the hospital's adjacent spaces.

Based on observation and interview with staff, the facility failed to provide documentation of performance ground testing in patient care areas in accordance with NFPA 70, NFPA 99 3-3.3. Findings:

All Facilities
1) The new receptacles installed in patient rooms for the epic computer equipment did not have documentation of Impedance Ground Testing..
2) There is no documentation of Impedance Ground Testing in remodeled patient care areas, other than the Line Isolation Monitors in the Operating Rooms Suite.

St. Anthony:
1) 2nd Floor, Salon (door 2105): need GFI outlet near sink. Multi-plug receptacle is not permitted.
2) 2nd Floor, open junction box above ceiling near Door FD2045.
3) 2nd Floor, Room 2034, open junction box.
4) Open junction boxes in Rooms; 10608, 10701, 9505, 6177, 4077, 4090.

Bone & Joint:
1) 2nd Floor, Executive Administration, near South Mechanical Chase/Shaft has open junction box.
2) 2nd Floor, Main Corridor has open junction boxes near double filter grille and in front of Nurse's Station.
3) 2nd Floor, above Door SD2218 by the Data Closet has junction box.
4) Basement Mechanical Corridor has open Junction Box (FA).

Based on observation and interview with staff, the facility failed to provide a building construction type with a floor to floor rating that complies with Table 19.1.6.2, Construction Type Limitations. Findings:

St. Anthony - 7, 8, 9, 10, and 11 th Floors:
1) Unsealed floor penetrations for pipes to the convectors in patient rooms are open open to the floor below.
2) Floor penetrations for bath tub plumbing block-outs are open to the floor below.
3) Plumbing pipe penetrations were not sealed throughout the building from the seventh floor and above.
4) Pipes sealed with foam shall have the foam removed and replaced with material capable of maintaining the fire resistance of the floor to floor fire barrier.
5) Between the 11 th and 12 th Floors, the floor access panel to the 12 th floor penthouse does not have a 2-hour fire rating.
6) Room 2022 & 2024 structural steel beam has missing fire proofing on the bottom of the beam.

Bone and Joint:
1) Unsealed floor penetrations were found, including above the Waiting Room on the Second Floor, adjacent to the south smoke compartment wall (smoke barrier), and in the Data Closet Room 2219D.
2) Plumbing pipe penetrations were not sealed through-out the building.

Saints South:
1) Unsealed floor penetrations for pipes to the convectors in patient rooms are open open to the floor below.
2) Plumbing pipe penetrations were found not sealed throughout the building.

Based on observation and interview with staff, in areas not protected by a sprinkler system, the facility failed to provide corridors that are separated from use areas by walls constructed with at least 1/2 hour fire resistance rating per 19.3.6.2.1. Findings:

St. Anthony:
1) Egress corridors in the portions of the hospital not protected by a sprinkler system have voids and unsealed penetrations in the egress corridor walls and are therefore not 1/2 hour fire resistance rated.
2) 3 rd and 4 th Floors have areas not protected by a sprinkler system that are not separated from sprinklered areas by walls constructed with at least a 2-hour fire resistance rating.

Based on observation and interview with staff, the facility failed to provide Smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

All Locations:
1) Unsealed and unrated voids and penetrations were found in most of the smoke barriers through-out; including, around wiring, conduit, ductwork, piping, and structural members passing through the smoke barriers. Typical examples include:

St. Anthony:
1) Ground Level: There is an unrated window and the smoke compartment wall was not intact between Smoke Compartment Zone G.2 and the Egress Corridor.
2) Second Floor: There are unsealed penetrations around pipes thru the wall at Smoke Compartment Zone 2.3.
3) Third Floor: There are unsealed penetrations in the combination fire and smoke wall that terminates at Joe Hodge's office (across from Lab), this smoke barrier does not extend to an outside wall.
4) Fifth Floor: There are unsealed penetrations in the smoke barrier at Smoke Compartment Zone 5.4 and the un-identified smoke compartment to the west.

Bone and Joint:
1) Second Floor: Unrated penetrations and an open gap at the top of the wall above Door SD 2218.

St. Anthony South:
1) First Floor: Between Smoke Compartments 1.6 and 1.7, the wall was not intact in the smoke compartment wall.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 18.3.2.1/19.3.2.1. Findings:

Saint Anthony
1) On the 3rd & 4th Floor ICU Units, the soiled work rooms were in excess of 100 SF, the facility failed to protect these rooms with 1-hour fire rated walls and 3/4 our doors, the doors had glass panels.
2) On the 4th Floor, the vacant Surgery Rooms are in excess of 100 SF and they are used to store equipment and combustibles, the facility failed to protect these rooms with 1-hour fire rated construction with 3/4 hour fire rated doors that are self-closing.
3) On the 4th Floor, the vacant OB Delivery Rooms are hazardous area in excess of 100 SF, they are used to store excessive amounts combustibles, the facility failed to protect these rooms with 1-hour fire rated construction with 3/4 hour fire rated doors that are self-closing.
4) Store Room Door 5M526 was blocked open by a chair. Automatic door closer cannot function with furniture blocking the door.

Based on observation and interview with staff, the gift shop is used for display of combustibles in quantities considered hazardous, the facility failed to protect the gift shop as a hazardous area protected with walls of 1-hour fire resistance rating. 19.3.2.5 Findings:

St. Anthony:
1) The Gift Shop is considered a hazardous area and requires a 1-hour separation, there are two air transfer openings (without dampers) into the plenum return of the corridor above the ceiling.

Based on observation and interview with staff, the facility failed to provide stairways enclosed with construction having a fire resistance rating of at least one hour. 8.2.5.2, 19.3.1.1 Findings,

Bone and Joint:
1) The stairwell enclosure in the Executive Administration Corridor at Door 1276 (near Waiting) is not intact above the ceiling on the north and east sides of the stairwell.

Saints South:
1) The stairwell enclosure located near Medical Records is not intact above the ceiling on the north side of the stairwell.

Based on observation and interview with staff, the facility failed to provide exit passageways that have not less than the same fire resistance rating as required for the stair enclosures. 7.2.6, 19.2.2.7 Findings:

Saints South:
1) The stairwell located near Medical Records and the stairwell located across from the large Clean Linen Room both discharge into exit passageways that leads to the exterior. Both of these exit passageways have unsealed voids and penetrations in the walls and do not provide the same fire resistance rating as required of the stair enclosure.

Based on observation and interview with staff, the facility failed to provide exits that are readily accessible at all times in accordance with Section 7.1. Findings:

Saints South:
1) The exit passageway leading from the stairwell located near the large Clean Linen Room to the exterior of the building fails to provide an exit accessible at all times. A metal gate was found in the path to the public way and provided a potential impediment to egress. The means of egress leading to a public way must be illuminated (refer to Section 7.8.1.2). No illumination was provided in this means of egress.

Saints South (Myro Center)
1) Exit at Door FD118 must extend to a public way. 7.7 Discharge from exits.

Based on observation and interview with staff, the facility failed to provide suites of sleeping rooms of not more than 5,000 square feet. 19.2.5.2, 19.2.5.6 Findings,

St. Anthony:
The 3rd Floor and 4th Floor ICU are sleeping room suites (more than 24 hour stay), the suite of rooms (cubicles) are more than 5,000 square feet. 19.2.5.6

Based upon observation and interview with staff, the facility failed to provide exit and directional signs displayed in accordance with section 7.10 for all required locations. 19.2.10.1 Findings:

Bone & Joint
1) First Floor, Executive Corridor, need exit sign above double egress doors outside of Room 1276.
2) Near Room 1226, need exit sign.

St. Anthony South - Myro Center
1) Existing exit sign at Door 140, exit sign is pointing in the wrong direction.

Based on observation and interview with staff, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 and NFPA 72. Findings:

St Anthony:
1) The facility failed to provide re-acceptance testing after repairs are made, Work orders were reviewed, repairs were made, however re-acceptance testing by the Fire Detection Company was not performed in accordance with NFPA 72 chapter 7 -1.6.2.1.

2) Annual Testing by the fire alarm company failed to identify smoke detector that were located within 3 feet of a supply diffuser. This condition was found through out the facility.

3) Directory of points for equipment connected to the Fire Alarm System was not complete. The directory failed to depict Control Zones that actuate multiple numbers of devices (example: control zones that control combination fire and smoke doors (powered assist doors that are required to drop out of power), combination fire and smoke dampers (how many), smoke evacuation systems, atriums motor controls, magnetic door locks, etc.)

3) The smoke detectors located at the east entrance to the south tunnel were not within minimum 5 feet from door and were not on both sides of the door.

4) Smoke detector monitoring the 3rd floor cross walk are not within minimum 5 feet from door on both sides and are required to disable powered assist doors upon activation of alarm.

5) There is no smoke detector in the 8 East Waiting Room, which is open to the corridor.

Saints South (Myro Center):
1) RM111A has a smoke detector within 3 feet of a supply grille.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system in all areas that is installed in accordance with NFPA 13. Findings:

St. Anthony:
1) The facility is not fully sprinkled, areas not sprinkled include:
Ground Floor - 8,785 sq
First Floor Kitchen - 12,386 sq
Second Floor Cafeteria Office - 12,314 sq
Penthouse Central Tower - 3,226 sq
2) At the west entrance, the two spaces on either side of the revolving door were not sprinkled.
3) Space in the corner of the water feature at 2nd Floor west Lobby is not sprinkled.
4) The walk-in Incubators located in the Micro- Biology Department were not sprinkled.
5) In the Gift Shop, items were stored on shelves less than 18" from the ceiling.
6) Room 2034, missing escutcheon on sprinkler head.
7) Room 10603 has electrical conduit touching sprinkler pipe, typical for other locations, including wiring draped over the sprinkler pipe.

Saints South (Myro Center)
1) Fire Pump Room is not sprinkled

Based on observation and interview with staff, the facility failed to provide HVAC complying with 19.5.2.2 and 9.2. Findings:

St. Anthony:
1) 2nd Floor, Salon (Door 2105): There is no exhaust in the Salon to eliminate odors from the room and adjacent corridor.
2) 11th Floor, Room 11714: Exhaust is not operationing in the toilet room.

Based on observation and interview with staff, the facility failed to continuously maintained corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency. 7.1.10 Findings:

St. Anthony:
1) The Cath Lab Egress Corridor on the 4th Floor was obstructed with equipment, supplies, equipment racks, and stretchers. This condition was also found in other areas.
2) The vacant OB Suite Egress Corridor on the 4th Floor was obstructed by furniture and stored material.
3) Egress path was not provided and maintained through the construction area adjacent to the 4th Floor Cath Lab.

Bone and Joint:
1) Basement Level: The large Storage Room adjacent to the large Mechanical Room has items blocking egress from the Mechanical Room, and has items blocking egress to the exterior exit stairwell on the north side of the building. This exterior stairwell provides the required second exit from both the Storage Room and the Mechanical Room.

Based on observation and interview with staff, the facility failed to provide medical gas storage protected in accordance with NFPA 99, 4-3.1.1.2. Findings:

Bone and Joint:
1) Basement: The Med Gas Cylinder Storage Room (adjacent to Pharmacy) has an open gap at the intersection of the gypsum board and the floor deck above, un-taped gypsum board joints, unrated duct penetrations through walls, unrated penetrations, and the room does not have an exhaust system. Rooms with over 3000 cu ft of gas storage requires a 1-hour rated enclosure and mechanical ventilation. The light switch is located less than 60" above the floor.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99, 4-3.1.2.3. Findings:

St. Anthony:
1) Ground Floor: Three (3) medical gas outlets are located in GR 21, which is open to the corridor where the zone valve serving these outlets is located.

An intervening wall between the zone valve and the outlets served must be provided, and must include a door where an opening in the wall exists. There is an existing opening approximately five feet wide on the southwest side of GR 21. NFPA 99, 4-3.1.2.3 (d) Zone Valves, requires "station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet."

Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99. Findings:

St. Anthony
1) The Interventional Radiology Department, Cardiac Cath Lab and the MRI are periodically used as Anesthetizing Locations. These rooms were not provided with humidification equipment or have a automatic smoke evacuation equipment.
2) The governing body failed to identify Anesthetizing Locations in accordance with NFPA 99 1999 edition, Chapter 12-2.7
3) The Operating Room Fire Loss Prevention Orientation and Training program failed to include contract Physicians and Surgeons in the General Safety and Fire Drills periodically conducted.
3) The effectiveness of the Emergency Procedures Training Program in the Anesthetizing Locations failed to provide staff with knowledge of all equipment in the Operating Room Suite. A staff member in the operating room suite was asked, but could not explain what the Line Isolation Monitor was or its function. 12-4.1.2.10
4) The staff in the Interventional Radiology Suite failed to identify the location of the Oxygen Shut Off Valves. 12-4.1.2.10
5) The Endoscopic Suite has anesthesia carts with Nitrous Oxide. The Director of Nursing stated that the Endoscopy Suite was no longer an anesthetizing location. This locations does not meet standards as an anesthetizing location.
6) The MRI Suite Humidifier was turned off, humidifying equipment for anesthetizing locations shall be kept in operable condition and be continuously operating during procedures. 5-6.1.1
7) Emergency Power in the MRI Suite was not fed from the Critical Care Branch. 5-4.1.4.

St Anthony Power Plant
Based on observation and interview with staff, the facility failed to provide separation of the Essential Emergency Electrical System powered by a generator from other functions by construction capable of a fire resiance rating of 2-hours in accordance with NFPA 99, 3-4.1.1.6. Findings,

1) The emergency generator in the boiler room was not separated from the remainder of the room by a two-hour fire barrier.

Saint Anthony South:
1 ) Based on observation and interview with staff, the facility constructed renovations that
failed to maintain egress in not less than two directions. 4-6.7, 18.2.5.10 Findings:

On the 3rd floor, East End of the South Wing, the facility added a meeting room, this renovation created a dead end corridor greater than 30 feet.

2) Based on observation and interview with staff, the facility failed to provide training on proper procedures and to provide the required equipment to establish continuity of essential systems in the event of a disaster. NFPA 99, 1999 edition, Chapter 11, Health Care Emergency Preparedness, 11-5.3.2 Findings:

The facility failed to locate portable propane tanks required for operating the boiler pilot light for the diesel fired boilers in the event of the loss of natural gas . The facility failed to demonstrate training for the staff on these emergency procedures.

Based on observation and interview with staff, the facility failed to provide documentation of performance ground testing in patient care areas in accordance with NFPA 70, NFPA 99 3-3.3. Findings:

All Facilities
1) The new receptacles installed in patient rooms for the epic computer equipment did not have documentation of Impedance Ground Testing..
2) There is no documentation of Impedance Ground Testing in remodeled patient care areas, other than the Line Isolation Monitors in the Operating Rooms Suite.

St. Anthony:
1) 2nd Floor, Salon (door 2105): need GFI outlet near sink. Multi-plug receptacle is not permitted.
2) 2nd Floor, open junction box above ceiling near Door FD2045.
3) 2nd Floor, Room 2034, open junction box.
4) Open junction boxes in Rooms; 10608, 10701, 9505, 6177, 4077, 4090.

Bone & Joint:
1) 2nd Floor, Executive Administration, near South Mechanical Chase/Shaft has open junction box.
2) 2nd Floor, Main Corridor has open junction boxes near double filter grille and in front of Nurse's Station.
3) 2nd Floor, above Door SD2218 by the Data Closet has junction box.
4) Basement Mechanical Corridor has open Junction Box (FA).