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Based on observation and interview, the facility did not provide compliant corridor separation doors. This deficiency occurred in 1 of the 42 smoke compartments, and had the potential to affect 20 of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

2. On 7-28-2015 at 9:25 am it was observed in the 1NW smoke compartment on the 1st floor in the #1075 corridor, that the door in the 1/2-hour rated separation wall could not be verified of having at least a 20 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.

3. On 7-28-2015 at 10:10 am it was observed in the 1NW smoke compartment on the 1st floor in the #1077 corridor, that the door in the 1/2-hour rated separation wall could not be verified of having at least a 20 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) EEEE (Fac Op Admin Asst), staff WWW (Dir of Quality), and XXXX (VP Operations).

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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with and self closing hardware. This deficiency occurred in 2 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 07/27/2015 at 8:20 am surveyor observed on the Basement floor in the LL-FD 010, that a pair of smoke barrier doors did not close automatically. The doors were installed with automatic closers and had an astragal, but the door coordinator installed to "coordinate" closure of the two doors does not work. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XXXX (Chief Clinical Services Officer), staff ZZZZ (SVP Social Responsibility, ADC), staff SSS (Hospital Property Management), staff VVV (Supervisor Facilities-ASLSS), staff AAAA (Facilities OP), and staff WWW (QM Data Support Specialist ASLSS).

2. On 07/27/2015 at 9:05 am surveyor observed on the First floor in the IF-FD 015, that a pair of smoke barrier doors did not close automatically. The doors were installed with automatic closers and had an astragal, but the door coordinator installed to "coordinate" closure of the two doors did not allow the doors to close. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XXXX (Chief Clinical Services Officer), staff ZZZZ (SVP Social Responsibility, ADC), staff SSS (Hospital Property Management), staff VVV (Supervisor Facilities-ASLSS), staff AAAA (Facilities OP), and staff WWW (QM Data Support Specialist ASLSS).

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors. This deficiency occurred in 1 of the 42 smoke compartments, and had the potential to affect 20 of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

16. On 7-28-2015 at 9:55 am it was observed in the BPOB smoke compartment on the Basement floor in the #C010 electrical vault, that the door in the 1-hour rated separation wall could not be verified of having at least a 45 minute rating. The walls were labeld as 1-hour fire rated. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) EEEE (Fac Op Admin Asst), staff WWW (Dir of Quality), and XXXX (VP Operations).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The federal Centers for Medicare Services and state agency Wisconsin Department of Health Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self-preservation and rely on a highly reliable sprinkler system to defend in place. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. This deficiency occurred in 20 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.

Findings include:

1. On 07/27/15 at 10:15 am, survey verified on the basement floor, that elevator machine room NB-65-F1 was not sprinkler protected to NFPA 13 - 1999 section 5-13.6. The machine room contained combustible hydraulic fluid and did not meet an exception for sprinkler protection.

2. On 07/27/15 at 10:20 am, survey verfied on the basement floor, that service elevators 17, 18, and 19 were not sprinkler protected to NFPA 13 - 1999 section 5-13.6. The elevator pits were directly observed to contain a hydraulic fluid delivery system and did not meet the sprinkler requirement of NFPA 13 section 5-13.6.1. Contracted elevator personnel from Schindler substantiated the top of the shafts were also not sprinkler protected and did not meet NFPA 13 section 5-13.6.3. This condition was applicable to additional existing elevators within the facility. The facility could not substantiate the car enclosure non-combustibility to American Society of Mechanical Engineering (ASME) - 17.1, nor that the hydraulic fluid was non-combustible.

3. On 07/27/15 at 10:25 am, survey verified on the basement floor, that service elevator P for Central Storage transport was not sprinkler protected to NFPA 13 - 1999 section 5-13.6. The elevator pit was directly observed to not be sprinkler protected. Contracted elevator personnel from Schindler substantiated the top of the shaft was also not sprinkler protected and did not meet NFPA 13 section 5-13.6.3. The facility could not substantiate the car enclosure non-combustibility to ASME - 17.1.

4. On 07/27/15 at 10:30 am, survey verified on the basement floor, that the loading dock, trash compactor, and cardboard recycling compactor space were not sprinkler protected. This space is enclosed on three sides, is approximately 50 ft. wide and 100 ft. in depth, and is located under a fully sprinkler protected receiving department located on the first level directly above this loading dock / compactor space. Combustibles present at the time of survey were 2 - 25 cubic yard trash compactors, 1 - 30 cubic yard cardboard compactor, and 1 pick-up truck. The two bay semi-trailer loading dock was not observed to have any vehicles at the time of the survey, yet is actively used for hospital purposes. Per NFPA 13 - 1999 section 5-13.8, sprinklers shall be installed under exterior roofs and canopies greater than 4 foot wide attached to sprinkler protected structures containing combustible storage.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), staff MMM (Manager, Facilities Operations), and staff QQQ (Coordinator, QI).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers at required exterior locations, sprinklers that were too far from the ceiling, and sprinklers free of obstructions near the ceiling. This deficiency occurred in 1 of the 42 smoke compartments, and had the potential to affect all of the 386 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 7-28-2015 at 10:30 am it was observed in the 1S smoke compartment on the 1st floor in the Loading Dock, that sprinkler protection was not provided at the loading dock roofed area. The roofed area is subject to protection based on NFPA 13-1999 s. 5-13.7 This observed situation was not compliant with NFPA 13 (1999 edition), 5-13.7.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff AAAA (Fac Op Mngr), staff BBBB (Fac Op Reg Dir), staff CCCC (Safety Coor), staff DDDD (Fac Op Planner) EEEE (Fac Op Admin Asst), staff WWW (Dir of Quality), and XXXX (VP Operations).

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Item 3 / Recite:
Based on observation and interview, the facility did not ensure that the means of egress was arranged that exits are readily accessible at all time as required by NFPA 101 sections 39.2.1.1 and 7.1. This deficiency had the potential to affect all outpatients, staff, and visitors within this facility.

FINDINGS INCLUDE:

On 07/27/15 at 3:30 pm, surveyor observed at the 1st floor entry vestibule, was a required exit that had a storefront bi-parting sliding door system with a latching device. The latching device releases the latch by having occupants move a lever handle into an upwards position. No other exit door releasing device in the facility releases a door latch with an upward movement with a lever handle. This conflict in use for building occupants poses as a means of confusion. Inconsistencies in exit door hardware is a hazard. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities) staff VVVV (Manager, Plant Operations), and QQQ (Coordinator, QI).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with non-compliance, working clearances at electrical panels, fixed wiring rather than extension cords, and closed electrical raceways. This deficiency occurred in 1 of the 34 smoke compartments and had the potential to affect all patients, staff, and visitors within this smoke compartment.

FINDINGS INCLUDE:
1. On 07/27/2015 at 10:30 am surveyor observed on the Fourth floor in the Intake Management #2, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a lamp and a large fan. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XXXX (Chief Clinical Services Officer), staff ZZZZ (SVP Social Responsibility, ADC), staff SSS (Hospital Property Management), staff VVV (Supervisor Facilities-ASLSS), staff AAAA (Facilities OP), and staff WWW (QM Data Support Specialist ASLSS).

Based on document review and interview, the facility did not provide and use a program to respond to outages of the automatic sprinkler system by having complete and reliable procedures for responding to outages. This deficiency occurred in 139 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 07/27/15 at 9:50 am, during a review of facility documents, the facility interim life safety Policy 216 was verified as pending corporate approval and therefore the facility lacked reliable actions to be taken if the automatic sprinkler system was out-of-service for more than 4 hours in a 24-hour period. Reliable fire watch procedures are required for NFPA 13 sprinkler protected structures or the facility is required to evacuate the affected area per NFPA 101 section 9.7.6.1. This situation was not compliant with NFPA 101 section 9.7.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), and staff MMM (Manager, Facilities Operations).

Based on document review and interview, the facility did not provide and use a program to respond to outages of the automatic fire alarm system by having complete and reliable procedures for responding to outages. This deficiency occurred in 139 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1. On 07/27/15 at 9:55 am, during a review of facility documents, the facility interim life safety Policy 216 was verified as pending corporate approval and therefore the facility lacked reliable actions to be taken if the automatic fire alarm system is out-of-service for more than 4 hours in a 24-hour period. Reliable fire watch procedures are required for NFPA 72 fire alarm protected structures or the facility is required to evacuate the affected area per NFPA 101 section 9.6.1.8. This situation was not compliant with NFPA 101 section 9.6.1.8 The condition was confirmed at the time of discovery by a concurrent observation and interview with staff LLL (Senior Director, Facilities), and staff MMM (Manager, Facilities Operations).