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Based on observation and staff interviews, the facility failed to provide a two-hour rating required to separate two buildings of different types of construction class in accordance to Section 19.1.6.1 and Table 19.1.6.2 in NFPA 101-Life Safety Code as evidenced by the following item(s). This deficiency could affect all of the patients, staff and and undetermined number of visitors within two of the Thirteen (13) smoke compartments on this floor of the hospital.

Findings include:
1.[POC due date- 2/9/15] On October 27th at 2:38 PM it was observed that the West wall of Corridor #701A and Walk-in Cooler #719 (Ground floor) were not shown as two-hour fire barriers on the Life Safety plan to maintain the class of construction separation between an addition with a different class of construction than the hospital.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff NN (VP Hospital Operations).

Based on observation and staff interviews, the facility failed to provide corridor doors that "...shall be constructed to resist the passage of smoke..." and "be equipped with an astragal,..." in accordance to NFPA 101-Life Safety Code Section 19.3.6.3 Corridor Doors, subsection 19.3.6.3.1 and 19.3.6.3.6, as evidenced by the following item(s). This deficiency could affect all of the patients, staff and and undetermined number of visitors within one of the three (3) smoke compartments on this floor of the hospital.

Findings Include:
1. [Recite] On January 12, 2015 at 11:48 AM, during the walk-through of the Third floor of the West Building; it was observed that the paired doors into PICU-Suite 3W-1 from the Corridor were provided with brush gaskets. A brush gasket was installed on each leaf of the doors in the opening; the brush gasket does not meet the UL testing for an astragal. This does not comply with Section 19.3.6.3.1 and 19.3.6.3.6 which states; "...and shall resist the passage of smoke." and "be equipped with an astragal...". This condition was found at both sets of paired doors into this suite.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff NN (VP Hospital Operations).

Based on observation and staff interviews, the facility failed to provide corridor doors that "...shall be constructed to resist the passage of smoke...", "be equipped with an astragal,..."and "device...capable of keeping the door fully closed...Roller latches are prohibited..." in accordance to NFPA 101-Life Safety Code Section 19.3.6.3 Corridor Doors, subsection 19.3.6.3.1, 19.3.6.3.2 and 19.3.6.3.6, as evidenced by the following item(s). This deficiency could affect all of the patients, staff and and undetermined number of visitors within one of the twelve (12) smoke compartments on this floor of the hospital.

Findings Include:
1.[Recite-POC due date 1/12/15] On January 12, 2015 at 12:06 PM [on the third floor], it was observed that the paired doors from Respiratory Care #3A29 into the corridor were not equipped with an astragal. A brush gasket was installed on each leaf of the paired door in the opening; the brush gasket does not meet the UL testing for an astragal. This does not comply with Section 19.3.6.3.1 and 19.3.6.3.6 which states; "...and shall resist the passage of smoke." and "be equipped with an astragal..."

2.[Recite-POC due date 1/12/15] On January 12, 2015 at 12:09 PM [on the second floor], it was observed that the paired doors from the ED department into the Corridor #2A101 (near Room #10) were not equipped with an astragal. A brush gasket was installed on each leaf of the paired door in the opening; the brush gasket does not meet the UL testing for an astragal. This does not comply with Section 19.3.6.3.1 and 19.3.6.3.6 which states; "...and shall resist the passage of smoke." and "be equipped with an astragal..."

3.[Recite-POC due date 1/12/15] On January 12, 2015 at 12:10 PM [on the second floor], it was observed that the paired doors at the south end of Corridor #2B27 were not equipped with an astragal. A brush gasket was installed on each leaf of the paired door in the opening; the brush gasket does not meet the UL testing for an astragal. This does not comply with Section 19.3.6.3.1 and 19.3.6.3.6 which states; "...and shall resist the passage of smoke." and "be equipped with an astragal..."

4.[POC due date 2/23/15] On October 29th at 10:01 AM [on the second floor], it was observed that the following doors into Corridor #2B73 were not equipped with positive latching. Or provided with a suitable means to keep the door closed if 5 lb/ft of force is applied at the strike side to comply with Section 19.3.6.3.2 which states; ""...had sufficient means to keep the door closed when 5 lb/ft is applied to the latch side..." The doors are from CR Equip #2B74, X-ray #1(2B79, X-ray #2(2B75), X-ray #3(2B68), X-ray #4(2B66) and the southeast door from X-ray #4 into Corridor #2B63.

5.[POC due date 6/15/15] On October 29th at 11:30 AM [on the second floor], it was observed that the following doors within the Surgery Department did not have positive latching. Or provided with a suitable means to keep the door closed if 5 lb/ft of force is applied at the strike side to comply with Section 19.3.6.3.2 which states; ""...had sufficient means to keep the door closed when 5 lb/ft is applied to the latch side..." The main door into OR #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 and OR/Interop MRI.

6.[POC due date 6/15/15] On October 29th at 11:40 AM [on the second floor], it was observed that the following doors within the Surgery Department did not have positive latching [or a suitable means to keep the door closed] and were not smoke-tight to comply with Section 19.3.6.3.1 and 19.3.6.3.6. The doors are located in Scrub #2C91, #2C96, #2C102, #2C108, #2C114, #2C121, #2C126.

7.[Recite: POC due date 1/12/15] On January 12, 2015 at 12:13 PM [on the second floor], it was observed that the two sets of paired doors from Corridor #2304 and Corridor #2352 into Suites #2-F2, #2-F4 were not equipped with an astragal. A brush gasket was installed on each leaf of the paired door in the opening; the brush gasket does not meet the UL testing for an astragal. This does not comply with Section 19.3.6.3.1 and 19.3.6.3.6 which states; "...and shall resist the passage of smoke." and "be equipped with an astragal..."

8.[Recite: POC due date 1/12/15] On January 12, 2015 12:17 PM [on the first floor], it was observed that the paired doors from Procedure #1C84 into the Corridor were not equipped with an astragal. A brush gasket was installed on each leaf of the paired door in the opening; the brush gasket does not meet the UL testing for an astragal. This does not comply with Section 19.3.6.3.1 and 19.3.6.3.6 which states; "...and shall resist the passage of smoke." and "be equipped with an astragal..."

9. [POC due date 2/23/15] On October 29th at 1:43 PM [on the first floor], it was observed that the door into Office #1I56 could not keep the door closed if 5 lb/ft of force was applied at the strike side to comply with Section 19.3.6.3.2 which states; ""...had sufficient means to keep the door closed when 5 lb/ft is applied to the latch side..."

10.[POC due date 2/23/15] On October 29th at 1:50 PM [on the first floor], it was observed that the southwest door from the Gym #1I65 could not keep the door closed if 5 lb/ft of force was applied at the strike side to comply with Section 19.3.6.3.2 which states; ""...had sufficient means to keep the door closed when 5 lb/ft is applied to the latch side..." The door was also equipped with a manual deadbolt.

11.[Recite: POC due date 1/12/15] On January 12, 2015 12:18 PM [on the first floor], it was observed that the two sets of paired doors from Waiting #114 into the Corridor were not equipped with an astragal. A brush gasket was installed on each leaf of the paired door in the openings; the brush gasket does not meet the UL testing for an astragal. This does not comply with Section 19.3.6.3.1 and 19.3.6.3.6 which states; "...and shall resist the passage of smoke." and "be equipped with an astragal..."

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff NN (VP Hospital Operations).

Based on observation and staff interviews, it was observed that the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors per NFPA 101 [2000 Ed] Section 19.3.2.1 Hazardous areas, as evidenced by the following item(s). This deficient practice could affect all of the patients in the smoke compartment where these rooms were located, as well as an undetermined number of staff and visitors.

Findings include:
1.[POC due date-1/2/15-Corrected]

2.[POC due date- 3/30/15] On October 28th at 10:45 AM [on the seventh floor] it was observed the south door (45-minute rated) into Clean Utility #7051 had been field modified. Field modifications negate the rating established by the door manufacturer.

3.[POC due date- 3/30/15] On October 28th at 11:09 AM [on the sixth floor] it was observed the south door (45-minute rated) into Soiled Utility #6053 had been field modified. Field modifications negate the rating established by the door manufacturer.

4.[POC due date- 3/30/15] On October 28th at 12:29 PM [on the fifth floor] it was observed the door (45-minute rated) into Soiled Utility #5B109 had been field modified. Field modifications negate the rating established by the door manufacturer.

5.[POC due date- 3/30/15] On October 28th at 3:48 PM [on the third floor] it was observed the paired doors (45-minute rated) into Workroom Storage #3A33 were not marked with 45-minute tags.

6.[POC due date- 3/9/15] On October 28th at 3:59 PM [on the third floor] it was observed the south wall of Workroom Storage #3A33 was not taped and mudded or fire caulked to a one-hour fire barrier standard.

7.[POC due date- 3/9/15] On October 29th at 7:56 AM [on the third floor] it was observed that five holes were found in the wall of EKG/EEG.

8.[POC due date- 3/9/15] On October 29th at 8:37 AM [on the second floor] it was observed in Soiled Utility #2A147 that the penetrations into the walls of this room were not fire-caulked to a one-hour standard.

9.[POC due date- 3/9/15] On October 29th at 9:21 AM [on the second floor] it was observed that the east wall of Clean Utility #2B19 was not drywalled to the deck above. A complete one-hour enclosure for a hazardous area is missing.

10.[POC due date- 3/9/15] On October 29th at 9:23 AM [on the second floor] it was observed in Soiled Utility #2B21 was not drywalled to the deck above at the north and east walls. A complete one-hour enclosure for a hazardous area is missing.

11.[POC due date- 3/9/15] On October 29th at 9:25 AM [on the second floor] it was observed on the east wall of Storage #2B18 the screwheads were not mudded to a one-hour standard. Two electrical conduit into the south wall were not fire-caulked to a one-hour.

12.[POC due date- 3/9/15] On October 29th at 9:25 AM [on the second floor] it was observed that the south wall of Storage #2B143 was not taped and mudded to a one-hour standard. An hvac duct penetrating the east and south walls was not provided with a metal angle at the wall face and fire caulked. Two electrical conduits into the west wall were not fire caulked.

13.[POC due date- 3/9/15] On October 29th at 10:18 AM [on the second floor] it was observed within Biomed Workroom #2B61 that holes in the east and north wall holes were not covered with gypsum wallboard and taped and mudded to a one-hour. The west wall had no gypsum wallboard installed along its' face. No penetrations were fire caulked. A complete one-hour enclosure for a hazardous area is missing.

14.[POC due date- 3/30/15] On October 29th at 2:25 PM [on the first floor] it was observed in Soiled Utility #1415 that the concrete block surrounding this room did not have any penetrations fire-caulked to a one-hour standard. The two doors into this room were not fire-rated to a 45-minute rating.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff NN (VP Hospital Operations).

Based on observation and staff interviews, the facility failed to provide exit access doors in accordance to NFPA 101-Life Safety Code [2000 Ed], Section 19.2.5.1 which states, "Every habitable room shall have an exit access door leading directly to a corridor", as evidenced by the following item(s). This deficiency could affect all of the patients, staff and and undetermined number of visitors within one of the fourteen (14) smoke compartments on this floor of the hospital.

Findings include:
1.[POC due date- 5/15/15] On October 27th at 3:15 PM it was observed within the First Floor Life Safety plan that the following rooms did not have a door that opened directly to a corridor. The rooms are: Office #1C41, Staff #1C39, Office #1C37, #1C42 and Passage #1C43.

2.[POC due date- 5/15/15] On October 27th at 3:15 PM it was observed within the First Floor Life Safety plan that the following rooms did not have a door that opened directly to a corridor. The rooms are: Diagnostic #1C87, Control #1C86, Toilet #1C85, Passage #1C84, Proc. Inject #1C84c, Proc. Inject #1C84b, Proc. Inject #1C84c and Workroom #1C83.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff NN (VP Hospital Operations).

Based on observation and staff interviews, it was observed that the facility in accordance to NFPA 101-Life Safety Code [2000 Ed] Section 9.2.1, NFPA 90A [1999 Ed] Section 6-1.2.1 ASHRAE Handbook [1996] , as evidenced by the following item. This deficiency could affect all of the patients, staff and and undetermined number of visitors within this hospital.

Findings Include:
1.[POC due date- 2/15/15] On October 28th, 2014 at 3:22 PM it was observed in the Med ICU suites that the patient rooms were equipped with a toilet in the same space as the patient bed. Air exchanges shall meet more restrictive requirements for a toilet room in accordance to ASHRAE Standards.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff NN (VP Hospital Operations).

Based on observation and staff interviews, it was observed that the facility failed to provide the proper signage per NFPA 101-Life Safety Code- Sections 19.2.2.2.4-Exception No.2 and 7.2.1.6.1(d) as evidenced by the following item(s). This deficient practice could affect all of the patients within the three (3) smoke compartments of this floor, as well as an undetermined number of staff and visitors.

Findings include:
1. [Recite-POC completion date 12/12/14] On January 12, 2015 at 11:35 AM it was observed that all of the doors into the exit stairwells from the Fifth floor were equipped with delayed locks for the patients' safety (brain trauma unit). The POC from the facility stated; "DoF will ensure the door will be returned to passage function and no longer locked". A passage function was installed on the door. The facility installed a 'wonder-guard' system that is activated by bracelets worn by some patients. Proper signs were installed noting the delayed locking system; when the braceleted occupants are near the door. The facility changed their POC and did not contact CMMS and request an amended POC. The State agency was not involved in a plan review for this new system installed at these locations.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff NN (VP Hospital Operations).

Based on observation and staff interviews, the facility failed to provide components within the building that met NFPA 101-Life Safety Code as evidenced by the following item(s). This deficiency could affect all of the patients, staff and and undetermined number of visitors within one of the fourteen (14) smoke compartments on this floor of the hospital.

Findings include:
1. On October 27th at 2:55 PM it was observed within the First Floor Life Safety plan that Suite #1-E7 was 11,004 square feet in size. This does not meet Section 19.2.5.7 which states, "Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 square ft."

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff NN (VP Hospital Operations).