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Based on observation and interview, the facility failed to ensure 1 of 4 basement smoke barrier walls above the smoke barrier doors was constructed to provide at least a one half hour fire resistance rating. This deficient practice affects any patients using the cafeteria located near the new addition.

Findings include:

Based on observation with the maintenance supervisor on 07/25/12 at 12:20 p.m., the basement corridor smoke barrier above the set of smoke barrier doors where the 1997 addition was constructed onto the 1949 original building did not have drywall along the entire length of the smoke barrier wall two feet above the smoke barrier doors to the concrete deck above. This was verified by the maintenance supervisor at the time of observation and confirmed at the exit conference on 07/25/12 at 2:50 p.m.

Based on observation and interview, the facility failed to ensure 1 of 16 sets of smoke barrier doors in the original building would restrict the movement of smoke for at least 20 minutes. LSC, Section 19.3.7.6 requires doors in smoke barriers shall comply with LSC, Section 8.3.4. LSC, Section 8.3.4.1 requires doors in smoke barriers to close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch to restrict the movement of smoke. This deficient practice could affect any patients who use the main dining room.

Findings include:

Based on observation on 07/25/12 at 1:50 p.m., the first floor Sleep Study Hall smoke barrier doors were closed on three separate attempts and left a four inch gap in the closed position. This was verified by the maintenance supervisor at the time of observation and confirmed at the exit conference on 07/25/12 at 2:50 p.m.

Based on observation and interview, the facility failed to ensure the corridor doors to 4 of 12 basement non sprinklered hazardous areas, such as combustible storage rooms over 50 square feet in size and laboratory rooms, were provided with doors with a fire resistance rating of 45 minutes or a self closing device. This deficient practice could affect any patient using the basement laboratory services area.

Findings include:

Based on observations on 07/23/12 during a tour of the facility from 10:00 a.m. to 3:30 p.m. and 07/25/12 during a tour of the facility from 10:30 a.m. to 3:00 p.m., the following non sprinklered hazardous area rooms were not provided with forty five minute fire rated doors; the center laboratory room and the basement west laboratory room leading to the basement Laboratory Hall each lacked a door with a fire resistance label, the basement storage room by the boiler room which measured ninety six square feet and stored combustible paper and cardboard boxes lacked a door with a fire resistance label, the basement housekeeping storage room which measured two hundred sixty square feet and stored sixteen wooden shelves of combustible paper, plastic and cardboard boxes was equipped with a ninety minute fire rated door and lacked a self closing device. The four basement doors lacking a fire resistance label and a self closing device were verified by the maintenance supervisor at the time of observation and confirmed at the exit conference on 07/25/12 at 2:50 p.m.

Based on observation and interview, the facility failed to ensure 4 of 16 stairway exits were provided with doors having a fire resistance rating of at least one hour to protect 9 of 9 patients. LSC 8.2.5.4 refers to 7.1.3.2.1 for enclosure of exits. LSC 7.1.3.2.1(a) says the separation shall have not less than a 1 hour fire resistance rating where the exit connects three stories or less. This deficient practice could affect all patients in the facility.

Findings include:

Based on observations on 07/23/12 during a tour of the facility from 10:00 a.m. to 3:45 p.m. and 07/25/12 during a tour of the facility from 10:25 a.m. to 3:00 p.m. with the maintenance supervisor, the following stairway exit doors lacked a fire resistance rating label; the basement stairway exit door in the Service Hall by the maintenance office, the basement stairway exit door by the kitchen back door, the second floor stairway exit door by the Outpatient Surgery Hall, and the third floor stairway exit door by the medical staff coordinator office. The four doors were observed by the maintenance supervisor at the time of observations along the sides and top of each door and each door lacked a fire resistance label, which was confirmed at the exit conference on 07/25/12 at 2:50 p.m.

Based on record review and interview, the facility failed to include the transmission of the alarm to the fire department and the use of the kitchen portable fire extinguisher in the written plan for the protection of 9 of 9 patients in the event of an emergency. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice affects all patients in the facility.

Findings include:

Based on a review of the facility's written fire disaster plan labeled Rush Hospital Fire or Threat of Fire Plan on 07/23/12 at 10:30 a.m. with the administrator, the Rush Hospital Fire or Threat of Fire Plan did not address the transmission of the alarm to the fire department, and the use of the K class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system. This was acknowledged by the maintenance supervisor on 07/25/12 at the 2:50 p.m. exit conference.

Based on observation and interview, the facility failed to ensure 2 of 74 smoke detector were not installed where air flow would adversely affect its operation. LSC 9.6.1.3 says the provisions of 9.6 cover the basic functions of a complete fire alarm system. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect any patient in the Sleep Study Hall, which is also located near the information technology suite of rooms.

Findings include:

Based on an observations with the maintenance supervisor on 07/25/12 during a tour of the first floor from 11:10 a.m. to 12:20 p.m., the Sleep Study Hall smoke detector near the smoke barrier set of doors was located six inches from a return air duct and the information technology computer room smoke detector was located two feet from a supply air duct.
This was verified by the maintenance supervisor at the time of observations and confirmed at the exit conference on 07/25/12 at 2:50 p.m.

Based on observation and interview, the facility failed to ensure 1 of 3 basement egress corridors was not being used as a portion of a return air system/plenum for heating, ventilating, or air conditioning (HVAC) ductwork serving adjoining areas. NFPA 90A, Standard for the Installation of Air Conditioning and Ventilation Systems at 2-3.11.1 requires egress corridors shall not be used as a portion of a supply return or exhaust air system serving adjoining areas. This deficient practice could affect any patient using the basement cafeteria, located in the corridor near the food storage room, the food supervisor room, the nutrition room, and the dietary office room.

Findings include:

Based on observations on 07/23/12 during a tour of the basement from 12:20 p.m. to 3:45 p.m. with the maintenance supervisor, the basement egress corridor by the south kitchen exit was being used as a return air system for the food storage room, the food supervisor room, the nutrition room and the dietary office. This was verified by the maintenance supervisor at the time of observations and acknowledged at the exit conference on 07/25/12 at 2:50 p.m.

Based on observation and interview, the facility failed to ensure 1 of 4 basement smoke barrier walls above the smoke barrier doors was constructed to provide at least a one half hour fire resistance rating. This deficient practice affects any patients using the cafeteria located near the new addition.

Findings include:

Based on observation with the maintenance supervisor on 07/25/12 at 12:20 p.m., the basement corridor smoke barrier above the set of smoke barrier doors where the 1997 addition was constructed onto the 1949 original building did not have drywall along the entire length of the smoke barrier wall two feet above the smoke barrier doors to the concrete deck above. This was verified by the maintenance supervisor at the time of observation and confirmed at the exit conference on 07/25/12 at 2:50 p.m.

Based on observation and interview, the facility failed to ensure 1 of 16 sets of smoke barrier doors in the original building would restrict the movement of smoke for at least 20 minutes. LSC, Section 19.3.7.6 requires doors in smoke barriers shall comply with LSC, Section 8.3.4. LSC, Section 8.3.4.1 requires doors in smoke barriers to close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch to restrict the movement of smoke. This deficient practice could affect any patients who use the main dining room.

Findings include:

Based on observation on 07/25/12 at 1:50 p.m., the first floor Sleep Study Hall smoke barrier doors were closed on three separate attempts and left a four inch gap in the closed position. This was verified by the maintenance supervisor at the time of observation and confirmed at the exit conference on 07/25/12 at 2:50 p.m.

Based on observation and interview, the facility failed to ensure the corridor doors to 4 of 12 basement non sprinklered hazardous areas, such as combustible storage rooms over 50 square feet in size and laboratory rooms, were provided with doors with a fire resistance rating of 45 minutes or a self closing device. This deficient practice could affect any patient using the basement laboratory services area.

Findings include:

Based on observations on 07/23/12 during a tour of the facility from 10:00 a.m. to 3:30 p.m. and 07/25/12 during a tour of the facility from 10:30 a.m. to 3:00 p.m., the following non sprinklered hazardous area rooms were not provided with forty five minute fire rated doors; the center laboratory room and the basement west laboratory room leading to the basement Laboratory Hall each lacked a door with a fire resistance label, the basement storage room by the boiler room which measured ninety six square feet and stored combustible paper and cardboard boxes lacked a door with a fire resistance label, the basement housekeeping storage room which measured two hundred sixty square feet and stored sixteen wooden shelves of combustible paper, plastic and cardboard boxes was equipped with a ninety minute fire rated door and lacked a self closing device. The four basement doors lacking a fire resistance label and a self closing device were verified by the maintenance supervisor at the time of observation and confirmed at the exit conference on 07/25/12 at 2:50 p.m.

Based on observation and interview, the facility failed to ensure 4 of 16 stairway exits were provided with doors having a fire resistance rating of at least one hour to protect 9 of 9 patients. LSC 8.2.5.4 refers to 7.1.3.2.1 for enclosure of exits. LSC 7.1.3.2.1(a) says the separation shall have not less than a 1 hour fire resistance rating where the exit connects three stories or less. This deficient practice could affect all patients in the facility.

Findings include:

Based on observations on 07/23/12 during a tour of the facility from 10:00 a.m. to 3:45 p.m. and 07/25/12 during a tour of the facility from 10:25 a.m. to 3:00 p.m. with the maintenance supervisor, the following stairway exit doors lacked a fire resistance rating label; the basement stairway exit door in the Service Hall by the maintenance office, the basement stairway exit door by the kitchen back door, the second floor stairway exit door by the Outpatient Surgery Hall, and the third floor stairway exit door by the medical staff coordinator office. The four doors were observed by the maintenance supervisor at the time of observations along the sides and top of each door and each door lacked a fire resistance label, which was confirmed at the exit conference on 07/25/12 at 2:50 p.m.

Based on record review and interview, the facility failed to include the transmission of the alarm to the fire department and the use of the kitchen portable fire extinguisher in the written plan for the protection of 9 of 9 patients in the event of an emergency. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice affects all patients in the facility.

Findings include:

Based on a review of the facility's written fire disaster plan labeled Rush Hospital Fire or Threat of Fire Plan on 07/23/12 at 10:30 a.m. with the administrator, the Rush Hospital Fire or Threat of Fire Plan did not address the transmission of the alarm to the fire department, and the use of the K class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system. This was acknowledged by the maintenance supervisor on 07/25/12 at the 2:50 p.m. exit conference.

Based on observation and interview, the facility failed to ensure 2 of 74 smoke detector were not installed where air flow would adversely affect its operation. LSC 9.6.1.3 says the provisions of 9.6 cover the basic functions of a complete fire alarm system. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect any patient in the Sleep Study Hall, which is also located near the information technology suite of rooms.

Findings include:

Based on an observations with the maintenance supervisor on 07/25/12 during a tour of the first floor from 11:10 a.m. to 12:20 p.m., the Sleep Study Hall smoke detector near the smoke barrier set of doors was located six inches from a return air duct and the information technology computer room smoke detector was located two feet from a supply air duct.
This was verified by the maintenance supervisor at the time of observations and confirmed at the exit conference on 07/25/12 at 2:50 p.m.

Based on observation and interview, the facility failed to ensure 1 of 3 basement egress corridors was not being used as a portion of a return air system/plenum for heating, ventilating, or air conditioning (HVAC) ductwork serving adjoining areas. NFPA 90A, Standard for the Installation of Air Conditioning and Ventilation Systems at 2-3.11.1 requires egress corridors shall not be used as a portion of a supply return or exhaust air system serving adjoining areas. This deficient practice could affect any patient using the basement cafeteria, located in the corridor near the food storage room, the food supervisor room, the nutrition room, and the dietary office room.

Findings include:

Based on observations on 07/23/12 during a tour of the basement from 12:20 p.m. to 3:45 p.m. with the maintenance supervisor, the basement egress corridor by the south kitchen exit was being used as a return air system for the food storage room, the food supervisor room, the nutrition room and the dietary office. This was verified by the maintenance supervisor at the time of observations and acknowledged at the exit conference on 07/25/12 at 2:50 p.m.