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Based on observation and interview with staff, the facility failed to provide corridors separated from treatment use areas by walls constructed to comply with 19.3.6.1. Findings,

The X-Ray Holding Room in Chapman Tower, First Floor is a treatment area and has Oxygen outlets, there is not a wall separating this area from the corridor.

Based on observation and interview with staff, the facility failed to provide smoke barriers that provide at least a one half hour fire resistance rating in existing areas (19.3.7.3) and at least a one hour fire resistance rating in new areas (18.3.7.3). Findings,

Smoke compartment walls (smoke barriers) do not meet the fire resistance rating requirements at various locations throughout the facility. Penetrations were found around piping, wiring, conduit and cable trays that were not sealed with materials capable of a fire resistance rating equal to the wall. Gaps were found at the juncture of the gypsum wall board and the deck above; other gaps and missing gypsum wall board were found in the wall itself, these gaps and open wall were not sealed with materials capable of a fire resistance rating equal to the wall.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 19.3.2.1. Areas renovated or constructed after 9/11/03 are subject to 18.3.2.1. Findings,

Chapman Tower, 7 th Floor - the locker room on the north corridor is being used as a storage room and is not protected with one hour fire rated construction as required per 18.3.2.1.

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

The 3rd Floor ICU (Chapman Tower) are sleeping rooms (more than 24 hour stay), the suite of rooms (cubicles) is more than 5,000 square feet. 19.2.5.6

Based upon observation, interview with staff and review of records, the facility failed to document that fire drills were conducted at unexpected times under varying conditions, at least quarterly on each shift and that personnel are drilled not less than once in each 3 month period. The facility failed to provide proper documentation of the fire drill in the outpatient radiology center. 19.7.1.2, A 19.7.1.2 Findings:

Drills were held for only 3 floors at a time (a floor and the floors above and below) for each quarter on each shift. Fire Drills should be scheduled on a random basis to ensure that personnel are drilled not less than once in each 3 month period. A 19.7.1.2

Fire Drill Reports for the outpatient Radiology Center were not completely filled out and signed.

Based on observation and interview with staff, the facility failed to provide automatic sprinkler systems maintained in reliable operating condition and inspected periodically. 19.7.7.6 Findings,

Sprinkler lines had low voltage wiring and bundled wiring draped over and around them in many locations throughout the facility. NFPA 25, Section 5.2.2.2 reads "sprinkler piping shall not be subject to external loads by materials either resting on the pipe or hung from the pipe".

Based on observation and interview with staff, the facility failed to provide HVAC complying with 18.5.2.1, 19.5.2.1, 9.2, and 90 A. Findings,

Exhaust fans in patient toilet rooms are not operational on the 11th Floor of Chapman Tower.

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

1) NFPA 99, Section 4-3.1.2.3(d) Zone Valves reads "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." Zone Valve 5-2 serving the oxygen outlets in the Gym area on the 5th floor of Mary Chapman Health Plaza is located within the served area, without intervening walls.

2) The location of the zone valve serving X-ray Holding in Chapman Tower, First Floor, was not found by the survey team nor staff.

Based on observation and interview with staff, the facility failed to ensure that adapted procedures for in-service training are being implemented and that staff are knowledgeable of equipment and fire safety procedures in the operating suite. NFPA 99, 12-4.1.2.10 Findings,

A staff member in the operating room used for treatment of kidney stones, in the presence of the Director of Bio Medical Equipment, Executive Director of Engineering, and a staff member of the Bio Medical Department failed to exhibit knowledge associated with The Fire Loss and Hazards Policies and Procedures adopted for the Operating Room Suite in accordance with NFPA 99, 1999 edition. The staff member could not explain what the Line Isolation Monitor was, or its function. The staff member was also asked where the Oxygen Shut Off Valve was located and could not identify the location for that operating room.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings,

1) Open junction boxes were found throughout the facility.
2 ) Low voltage wiring is laying on the ceiling grid in various areas and not bundled and supported from the structure above.



13580


Based on observation and interview with staff, the facility failed to follow required procedures to ensure that electrical equipment located in the operating room suite for treatment of kidney stones was inspected, tested and had identifying approval stickers in accordance with NFPA 99 1999 Edition Chapter 3. Findings,

1 ) The Lithotripsy Machine (temporary equipment), electrical safety sticker was out of date for inspection. Staff failed to recognize the piece of equipment was out of date and failed to remove it from service.

2 ) The documentation of electrical safety sticker for the C-Arm located in the Operating Room and used for treatment of kidney stones was not available and had not been tagged in accordance with Bio-Medical Policy and Procedures for Non Fixed Equipment.

Based on observation and interview with staff, the facility failed to provide corridors separated from treatment use areas by walls constructed to comply with 19.3.6.1. Findings,

The X-Ray Holding Room in Chapman Tower, First Floor is a treatment area and has Oxygen outlets, there is not a wall separating this area from the corridor.

Based on observation and interview with staff, the facility failed to provide smoke barriers that provide at least a one half hour fire resistance rating in existing areas (19.3.7.3) and at least a one hour fire resistance rating in new areas (18.3.7.3). Findings,

Smoke compartment walls (smoke barriers) do not meet the fire resistance rating requirements at various locations throughout the facility. Penetrations were found around piping, wiring, conduit and cable trays that were not sealed with materials capable of a fire resistance rating equal to the wall. Gaps were found at the juncture of the gypsum wall board and the deck above; other gaps and missing gypsum wall board were found in the wall itself, these gaps and open wall were not sealed with materials capable of a fire resistance rating equal to the wall.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 19.3.2.1. Areas renovated or constructed after 9/11/03 are subject to 18.3.2.1. Findings,

Chapman Tower, 7 th Floor - the locker room on the north corridor is being used as a storage room and is not protected with one hour fire rated construction as required per 18.3.2.1.

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

The 3rd Floor ICU (Chapman Tower) are sleeping rooms (more than 24 hour stay), the suite of rooms (cubicles) is more than 5,000 square feet. 19.2.5.6

Based upon observation, interview with staff and review of records, the facility failed to document that fire drills were conducted at unexpected times under varying conditions, at least quarterly on each shift and that personnel are drilled not less than once in each 3 month period. The facility failed to provide proper documentation of the fire drill in the outpatient radiology center. 19.7.1.2, A 19.7.1.2 Findings:

Drills were held for only 3 floors at a time (a floor and the floors above and below) for each quarter on each shift. Fire Drills should be scheduled on a random basis to ensure that personnel are drilled not less than once in each 3 month period. A 19.7.1.2

Fire Drill Reports for the outpatient Radiology Center were not completely filled out and signed.

Based on observation and interview with staff, the facility failed to provide automatic sprinkler systems maintained in reliable operating condition and inspected periodically. 19.7.7.6 Findings,

Sprinkler lines had low voltage wiring and bundled wiring draped over and around them in many locations throughout the facility. NFPA 25, Section 5.2.2.2 reads "sprinkler piping shall not be subject to external loads by materials either resting on the pipe or hung from the pipe".

Based on observation and interview with staff, the facility failed to provide HVAC complying with 18.5.2.1, 19.5.2.1, 9.2, and 90 A. Findings,

Exhaust fans in patient toilet rooms are not operational on the 11th Floor of Chapman Tower.

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

1) NFPA 99, Section 4-3.1.2.3(d) Zone Valves reads "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." Zone Valve 5-2 serving the oxygen outlets in the Gym area on the 5th floor of Mary Chapman Health Plaza is located within the served area, without intervening walls.

2) The location of the zone valve serving X-ray Holding in Chapman Tower, First Floor, was not found by the survey team nor staff.

Based on observation and interview with staff, the facility failed to ensure that adapted procedures for in-service training are being implemented and that staff are knowledgeable of equipment and fire safety procedures in the operating suite. NFPA 99, 12-4.1.2.10 Findings,

A staff member in the operating room used for treatment of kidney stones, in the presence of the Director of Bio Medical Equipment, Executive Director of Engineering, and a staff member of the Bio Medical Department failed to exhibit knowledge associated with The Fire Loss and Hazards Policies and Procedures adopted for the Operating Room Suite in accordance with NFPA 99, 1999 edition. The staff member could not explain what the Line Isolation Monitor was, or its function. The staff member was also asked where the Oxygen Shut Off Valve was located and could not identify the location for that operating room.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings,

1) Open junction boxes were found throughout the facility.
2 ) Low voltage wiring is laying on the ceiling grid in various areas and not bundled and supported from the structure above.



13580


Based on observation and interview with staff, the facility failed to follow required procedures to ensure that electrical equipment located in the operating room suite for treatment of kidney stones was inspected, tested and had identifying approval stickers in accordance with NFPA 99 1999 Edition Chapter 3. Findings,

1 ) The Lithotripsy Machine (temporary equipment), electrical safety sticker was out of date for inspection. Staff failed to recognize the piece of equipment was out of date and failed to remove it from service.

2 ) The documentation of electrical safety sticker for the C-Arm located in the Operating Room and used for treatment of kidney stones was not available and had not been tagged in accordance with Bio-Medical Policy and Procedures for Non Fixed Equipment.