HospitalInspections.org

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the revisit, it was determined that the facility failed to construct new enclosures in accordance with the Life Safety Code Sections 19.7.5.5, 18.3.2.1, 4.67, and 8.4. This was evidenced by the following:

Newly constructed hazardous areas were not enclosed with one-hour rated construction and protected openings, as required. The following newly constructed hazardous areas were not one-hour fire rated enclosures and were not equipped with labeled fire door frames on the corridor door openings.

1. Second floor nursing storage room, approximately 14 ft. x 20 ft. Two of four enclosure walls were not one-hour fire rated and did not extend to the roof structure above. Two of 2 corridor doors were 90-minute fire rated, however, the doors were installed in non-labeled steel door frames.
2. Second floor soiled holding room, enclosure walls were not one-hour fire rated and did not extend to the roof structure above. The corridor door was 90-minute fire rated, however, the door was installed in a non-labeled steel door frame.
The Director of Building and Grounds acknowledged the enclosure and protection of the newly constructed hazardous areas during a tour of the facility.

The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 18.3.2.1 and Section 8.4. Section 8.4.1.3 requires that doors in fire rated barriers have a minimum ? hour fire resistance rating and that the doors be self-closing or automatic closing. Rated fire doors must be installed in fire-rated and labeled door frames in accordance with NFPA 80.
Life Safety Code Section 4.6.7 requires, in part, that altered, modernized or renovated portions of an existing building, system or individual component meet the applicable code requirements for new construction.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the revisit, it was determined that the facility failed to maintain the means of egress in accordance with Life Safety Code Section 19.2.1 and Chapter 7. This was evidenced by the following:

A) Openings in exit enclosures were not limited to those required for access to the enclosure from normally occupied spaces and corridors, as required. Stair #1 opened directly to the south air handling equipment room that is not considered a normally occupied space. Life Safety Code (2000) Section 7.1.3.2.1(d) requires that openings in exit enclosures be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

B) Exit enclosures were not maintained free of storage that had the potential to interfere with egress, as required. Stair #1 was being used for storage, as follows:
1. mechanical room landing: chair, garden hose, snow shovel and small drum with de-icer chemical.
2. helipad level landing: metal cart, 2 snow shovels and two foam pads.
The Director of Building and Grounds acknowledged the egress stair arrangement during a tour of the facility.

The Life Safety Code Section 7.1.3.2.3 requires that an exit enclosure not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. The Life Safety Code Annex (explanatory material) A.7.1.3.2.3 explains that this provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be "sterile" with respect to fire safety hazards.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview during the revisit, it was determined that the facility failed to install and maintain horizontal exits in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code Section 18.2.2.5 and 7.2.4. This was evidenced by the following:

A) Cross-corridor horizontal exit doors did not positively latch, as required. The non-latching 1? hour rated horizontal exit doors were located as follows:
1. Corridor on the second floor near the O/R suite, 1 of 2 door leafs.
2. Corridor on the second floor near the Imaging Department, 1 of 2 door leafs.
Life Safety Code Section 8.2.3 requires that fire doors be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

B) Cross-corridor horizontal exit doors were not equipped with vision panels, as required. The cross-corridor doors, near the Imaging Suite, were not equipped with vision panels.
Life Safety Code Section 18.2.2.5.6: An approved vision panel shall be required in each horizontal exit.
The Director of Building and Grounds acknowledged the above horizontal exit door arrangements during a tour of the facility.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the revisit, it was determined that the facility failed to install and maintain horizontal exits in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code Section 19.2.2.5 and 7.2.4. This was evidenced by the following:

Cross-corridor horizontal exit doors did not positively latch, as required. The non-latching 1? hour rated horizontal exit doors were located as follows:
1. Corridor on the second floor near the O/R suite, 1 of 2 door leafs.
2. Corridor on the second floor near the Imaging Department, 1 of 2 door leafs.
The Director of Building and Grounds acknowledged the above horizontal exit door arrangements during a tour of the facility.
Life Safety Code Section 8.2.3 requires that fire doors be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

2007 Building (Aspen ID: A-2)
Based on observation, record review and staff interview during the course of the revisit, it was determined that the facility failed to install and maintain anesthetizing location equipment in accordance with NFPA 99, Health Care Facilities. This was evidenced by the following:

A) The line isolation monitor systems, installed in Operating Rooms #1 and #2, were not tested every 6 months in accordance with NFPA 99 Section 3-3.3.4.2. Engineering Staff believed there was a 6 month testing program for the line isolation monitors, but documentation of the tests could not be located during the revisit.

B) Staff response to line-isolation system alarms and training frequency, was inadequate. The Director of Surgical Services reported that staff response to LIM alarms was reviewed at the staff meeting held on September 17, 2008. The meeting minutes documented that the staff response to a line-isolation alarm would be to unplug the equipment and call Engineering.

When testing of the systems in accordance with NFPA 99 Section 3-3.3.4.2 has been completed, all operating room staff shall be trained on the proper use of the equipment and appropriate response to an alarm condition. Records of all testing shall be maintained in accordance with Section 3-3.4.3. All line isolation alarms shall be of such volume that they can be easily heard by staff over normal ambient noise levels in the anesthetizing location.
NFPA 99 Section 3-3.3.4.2 Line Isolation Monitor Tests:
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

C) It could not be determined if mechanical ventilation systems in anesthetizing locations were installed in accordance with National Fire Protection Association Standard 99, Health Care Facilities, Section 5-4.1. Records were not available to document that anesthetizing locations (O/R's 1 & 2) were arranged to automatically vent smoke and products of combustion in accordance with NFPA 99 Section 5-4.1.2. Records on premises documented the installation of supply and return duct detectors on both AHU-1 and AHU-2 which serve O/R #1 and #2, respectively. Information was not available to document the programming of the duct detectors and the sequence of controls during an alarm from one of the duct detectors. The O/R's were not equipped with smoke detection at ceiling level. Other air-handling units installed were previously reported to shut down upon activation of the individual unit supply or return duct detector.
NFPA 99 Section 5-4.1.2: Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

D) Records were not available on premises to document testing of the grounding system in all patient care areas, as required. Records on premises documented testing of the line-isolation monitor system in both O/R #1 and #2 in April 2007. The test records for the O/R's did properly document the test method as being in accordance with NFPA 99 Section 3-3.3. There were no other records to document grounding system testing, in accordance with NFPA 99 Section 3-3.3, in all other patient care areas.
NFPA 99 Section 3-3.3.2.1 requires that the effectiveness of the grounding system be determined by voltage measurements and impedance measurements. In new construction, the effectiveness of the grounding system shall be evaluated before acceptance.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the course of the revisit, it was determined that the facility failed to install the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This was evidenced by the following:

A) The Life Safety Branch of the essential electrical system was supplying branch circuits that were not considered essential to life safety nor specifically allowed on the Life Safety Branch in accordance with Section 3-4.2.2.2 (b). The following circuit breakers, as identified on the panelboard index card, were not considered essential to life safety nor specifically allowed on the Life Safety Branch:
a) breaker #16 - receptacles for power strips with radio battery charges.
b) breaker #18 - receptacles for power strips with radio battery charges.

NFPA 99 Section 3-4.2.2.2 (b) Life Safety Branch: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code.
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems"
4. * Hospital communication systems, where used for issuing instruction during emergency conditions.
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location.
6. Elevator cab lighting, control, communication, and signal systems.
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

B) The Critical Branch and Equipment Branch of the essential electrical system were supplying branch circuits that should be supplied by the Life Safety Branch, as follows:
a) Panelboard CL2A breaker #18: Med Gas Alarm/Receptacles
b) Panelboard EML1 breaker #3: Elevator cab lights
The Director of Building and Grounds believed that the circuits had been upgraded for compliance with NFPA 99 Section 3-4.2.2.2 (b), but the index cards had not been properly revised.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the revisit, it was determined that the facility failed to construct new enclosures in accordance with the Life Safety Code Sections 19.7.5.5, 18.3.2.1, 4.67, and 8.4. This was evidenced by the following:

Newly constructed hazardous areas were not enclosed with one-hour rated construction and protected openings, as required. The following newly constructed hazardous areas were not one-hour fire rated enclosures and were not equipped with labeled fire door frames on the corridor door openings.

1. Second floor nursing storage room, approximately 14 ft. x 20 ft. Two of four enclosure walls were not one-hour fire rated and did not extend to the roof structure above. Two of 2 corridor doors were 90-minute fire rated, however, the doors were installed in non-labeled steel door frames.
2. Second floor soiled holding room, enclosure walls were not one-hour fire rated and did not extend to the roof structure above. The corridor door was 90-minute fire rated, however, the door was installed in a non-labeled steel door frame.
The Director of Building and Grounds acknowledged the enclosure and protection of the newly constructed hazardous areas during a tour of the facility.

The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 18.3.2.1 and Section 8.4. Section 8.4.1.3 requires that doors in fire rated barriers have a minimum ? hour fire resistance rating and that the doors be self-closing or automatic closing. Rated fire doors must be installed in fire-rated and labeled door frames in accordance with NFPA 80.
Life Safety Code Section 4.6.7 requires, in part, that altered, modernized or renovated portions of an existing building, system or individual component meet the applicable code requirements for new construction.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the revisit, it was determined that the facility failed to maintain the means of egress in accordance with Life Safety Code Section 19.2.1 and Chapter 7. This was evidenced by the following:

A) Openings in exit enclosures were not limited to those required for access to the enclosure from normally occupied spaces and corridors, as required. Stair #1 opened directly to the south air handling equipment room that is not considered a normally occupied space. Life Safety Code (2000) Section 7.1.3.2.1(d) requires that openings in exit enclosures be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

B) Exit enclosures were not maintained free of storage that had the potential to interfere with egress, as required. Stair #1 was being used for storage, as follows:
1. mechanical room landing: chair, garden hose, snow shovel and small drum with de-icer chemical.
2. helipad level landing: metal cart, 2 snow shovels and two foam pads.
The Director of Building and Grounds acknowledged the egress stair arrangement during a tour of the facility.

The Life Safety Code Section 7.1.3.2.3 requires that an exit enclosure not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. The Life Safety Code Annex (explanatory material) A.7.1.3.2.3 explains that this provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be "sterile" with respect to fire safety hazards.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview during the revisit, it was determined that the facility failed to install and maintain horizontal exits in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code Section 18.2.2.5 and 7.2.4. This was evidenced by the following:

A) Cross-corridor horizontal exit doors did not positively latch, as required. The non-latching 1? hour rated horizontal exit doors were located as follows:
1. Corridor on the second floor near the O/R suite, 1 of 2 door leafs.
2. Corridor on the second floor near the Imaging Department, 1 of 2 door leafs.
Life Safety Code Section 8.2.3 requires that fire doors be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

B) Cross-corridor horizontal exit doors were not equipped with vision panels, as required. The cross-corridor doors, near the Imaging Suite, were not equipped with vision panels.
Life Safety Code Section 18.2.2.5.6: An approved vision panel shall be required in each horizontal exit.
The Director of Building and Grounds acknowledged the above horizontal exit door arrangements during a tour of the facility.

2007 Building (Aspen ID: A-2)
Based on observation, record review and staff interview during the course of the revisit, it was determined that the facility failed to install and maintain anesthetizing location equipment in accordance with NFPA 99, Health Care Facilities. This was evidenced by the following:

A) The line isolation monitor systems, installed in Operating Rooms #1 and #2, were not tested every 6 months in accordance with NFPA 99 Section 3-3.3.4.2. Engineering Staff believed there was a 6 month testing program for the line isolation monitors, but documentation of the tests could not be located during the revisit.

B) Staff response to line-isolation system alarms and training frequency, was inadequate. The Director of Surgical Services reported that staff response to LIM alarms was reviewed at the staff meeting held on September 17, 2008. The meeting minutes documented that the staff response to a line-isolation alarm would be to unplug the equipment and call Engineering.

When testing of the systems in accordance with NFPA 99 Section 3-3.3.4.2 has been completed, all operating room staff shall be trained on the proper use of the equipment and appropriate response to an alarm condition. Records of all testing shall be maintained in accordance with Section 3-3.4.3. All line isolation alarms shall be of such volume that they can be easily heard by staff over normal ambient noise levels in the anesthetizing location.
NFPA 99 Section 3-3.3.4.2 Line Isolation Monitor Tests:
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

C) It could not be determined if mechanical ventilation systems in anesthetizing locations were installed in accordance with National Fire Protection Association Standard 99, Health Care Facilities, Section 5-4.1. Records were not available to document that anesthetizing locations (O/R's 1 & 2) were arranged to automatically vent smoke and products of combustion in accordance with NFPA 99 Section 5-4.1.2. Records on premises documented the installation of supply and return duct detectors on both AHU-1 and AHU-2 which serve O/R #1 and #2, respectively. Information was not available to document the programming of the duct detectors and the sequence of controls during an alarm from one of the duct detectors. The O/R's were not equipped with smoke detection at ceiling level. Other air-handling units installed were previously reported to shut down upon activation of the individual unit supply or return duct detector.
NFPA 99 Section 5-4.1.2: Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

D) Records were not available on premises to document testing of the grounding system in all patient care areas, as required. Records on premises documented testing of the line-isolation monitor system in both O/R #1 and #2 in April 2007. The test records for the O/R's did properly document the test method as being in accordance with NFPA 99 Section 3-3.3. There were no other records to document grounding system testing, in accordance with NFPA 99 Section 3-3.3, in all other patient care areas.
NFPA 99 Section 3-3.3.2.1 requires that the effectiveness of the grounding system be determined by voltage measurements and impedance measurements. In new construction, the effectiveness of the grounding system shall be evaluated before acceptance.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the course of the revisit, it was determined that the facility failed to install the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This was evidenced by the following:

A) The Life Safety Branch of the essential electrical system was supplying branch circuits that were not considered essential to life safety nor specifically allowed on the Life Safety Branch in accordance with Section 3-4.2.2.2 (b). The following circuit breakers, as identified on the panelboard index card, were not considered essential to life safety nor specifically allowed on the Life Safety Branch:
a) breaker #16 - receptacles for power strips with radio battery charges.
b) breaker #18 - receptacles for power strips with radio battery charges.

NFPA 99 Section 3-4.2.2.2 (b) Life Safety Branch: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code.
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems"
4. * Hospital communication systems, where used for issuing instruction during emergency conditions.
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location.
6. Elevator cab lighting, control, communication, and signal systems.
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

B) The Critical Branch and Equipment Branch of the essential electrical system were supplying branch circuits that should be supplied by the Life Safety Branch, as follows:
a) Panelboard CL2A breaker #18: Med Gas Alarm/Receptacles
b) Panelboard EML1 breaker #3: Elevator cab lights
The Director of Building and Grounds believed that the circuits had been upgraded for compliance with NFPA 99 Section 3-4.2.2.2 (b), but the index cards had not been properly revised.