HospitalInspections.org

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the re-visit (4WB424), 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, as required. The following hazardous areas, newly constructed at the time of the original survey on July 3, 2008, were not one-hour fire rated enclosures.
1. Second floor nursing storage room, approximately 14 ft. x 20 ft. was not fully enclosed with a fire barrier that had a 1-hour fire resistance rating in accordance with Section 8.2. The gypsum board wall sheathing, installed on the interior side of the room, was continuous to the roof deck. Corridor walls and walls in the adjacent rooms did not have gypsum board installed continuous to the roof deck. The gypsum board sheathing, installed on the corridor side of the enclosure walls (north and south corridors) was observed to end above the suspended ceiling. Approximately 18"-24" of unprotected wall stud was exposed above the corridor ceiling. The adjacent shower room, housekeeping room and clean utility room did not have gypsum board installed on the room side above the ceiling. The walls must be upgraded to meet an appropriate U.L. Listed assembly for a one-hour fire rated fire barrier.

2. The second floor soiled holding room enclosure walls were not one-hour fire rated, as required. The gypsum board wall sheathing, installed on the interior side of the room, was continuous to the roof deck. The corridor wall and walls in the adjacent rooms did not have gypsum board installed continuous to the roof deck. The gypsum board sheathing, installed on the corridor side of the enclosure wall (north corridor), was observed to end above the suspended ceiling. Approximately 18"-24" of unprotected wall stud was exposed above the corridor ceiling. The adjacent closet and clean utility room did not have gypsum board installed on the room side above the ceiling. The walls must be upgraded to meet an appropriate U.L. Listed assembly for a one-hour fire rated fire barrier.

The Director of Building and Grounds acknowledged the enclosure wall construction 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. 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. Section 8.2.3.1.1: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2.

2007 Building (Aspen ID: A-2)
Based on observation, record review and staff interview during the course of the revisit (4WB424), it was determined that the facility failed to arrange anesthetizing location environmental equipment, and test electrical equipment in accordance with NFPA 99, Health Care Facilities. This was evidenced by the following:

A) 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 and prevent the recirculation of smoke and products of combustion in accordance with NFPA 99 Section 5-4.1.3. 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 HVAC sequence of operation upon activation of any duct detector. The O/R's were not equipped with smoke detection at ceiling level. The Director of Building and Grounds reported that the facility HVAC contractor had been consulted since the January 14, 2010 re-visit regarding any common ducting arrangements between the two air handling units, but there had been no smoke detectors installed in the operating rooms and no testing or re-programming of the existing fire alarm system sequence of operation.

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.

B) 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.