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Based on observations, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.3.4(5).

Findings include:

1. During an observation on 6/28/22 at 8:53 a.m., the 3rd floor of the patient tower was inspected. There was a room chair placed in the hall, it was not bolted to the wall or the floor near room 302.

2. During an observation on 6/28/22 at 8:59 a.m., there were two chairs in the hallway of the third floor of the patient tower, they were not bolted to the wall or floor near the west stairwell.

Based on observations, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.3.4. This deficiency affects 1 of 4 smoke compartments on the first floor.

Findings include:

1. During an observation on 6/28/22 at 11:31 a.m., the OR south exit was inspected. It was found to be obstructed by equipment normally used in the OR being stored on both sides of the corridor. The corridor led to a marked egress, the egress width was less than 48" in some places.

2. During an observation on 6/28/22 at 1:09 p.m., there was a chair in the corridor of patient rooms near room 3214. It was not bolted to the wall or the floor.

Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3 and 7.2.1.6.2.

Findings include:

1. During an observation on 6/28/22 at 1:27 p.m., the 2nd floor center east exit stairwell out of the PT area was inspected. The door was a marked exit to the stairwell, it was found to be mag-locked and lacked the delayed egress programming the facility would need at that exit.

Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3 and 7.2.1.6.2.

Findings include:

1. During an observation on 6/27/22 at 3:34 p.m., the marked egress fastrack double doors to the ER were inspected. The right leaf was maglocked but was not opening upon an occupant approaching or with a delayed egress function.

2. During an observation on 6/27/22 at 8:34 a.m., the double doors between the patient tower to the surgical tower were inspected. When closed the mag locks were engaged without any delayed egress are access controlled egress motion detectors. The path was a marked exit egress pathway.

Based on observation, the facility failed to ensure exits were free and clear of obstruction to egress and signs or objects which may confuse exiting occupants, in accordance with NFPA 101, 2012 Edition, Section 7.1.10.1 and 7.1.10.2.1.

Findings include:

1. During an observation on 6/29/22 at 1:35 p.m., the northeast exit doors were a marked exit. The doors contained a paper sign stating "no exit." These types of confusing signs are not allowed on marked exit doors.

Based on observation, the facility failed to ensure smoke-proof rated stairway enclosures were continuously maintained per NFPA 101-2012, Section 7.2.3.3.1.

Findings include:

1. During an observation on 6/27/22 at 2:10 p.m., the cath lab basement west exit door to the stairwell was exercised. The door failed to close and latch under the power of the self-closer.

2. During an observation on 6/27/22 at 2:14 p.m., the door to the east stairwell by radioactive materials was exercised. The door failed to close and latch under the power of the self-closer.

3. During an observation on 6/27/22 at 3:49 p.m., the X-ray to central stairwell corridor door was exercised. The door failed to close and latch under the power of the self-closer.

Based on observation, the facility failed to prevent the use of an enclosed exit stairway for storage purposes per NFPA 101-2012, Sections 7.1.3.2.3 and 7.2.2.5.3;

Findings include:

1. During an observation on 6/28/2022 at 2:36 p.m., Montana Children's stairwell C was inspected. There were chairs being stored under the stairwell stairs. Stairwells cannot have any items stored or interrupting the egress path in the stairwell.

Based on observation, the facility failed to ensure a second exit sign was located to guide occupants to a second exit where egress was not obvious in accordance with NFPA 101, 2012 edition, section 7.10.1.9, and failed to maintain visibility of exit signs in accordance with NFPA 101-2012, Section 7.10.1.8.

Findings Include:

1. During an observation on 6/27/22 at 12:55 p.m., the Central Supply was inspected. The room was large and lacked a second exit sign to guide occupants to the second exit from the room, as the pathway was around a corner and would not be obvious during a time of heavy smoke or darkness.

2. During an observation on 6/27/22 at 3:45 p.m., the ER entrance near the Comm Center was inspected. The exit sign guiding occupants to the ER office area was obstructed from view down the hall by a large sign pointing to the ER.

Based on observation, the facility failed to maintain continuous illumination for all exit signs in accordance with NFPA 101, 2012 Edition, Section 7.10.5.1.

Findings include:

1. During an observation on 6/29/2022 at 10:09 a.m.., the exit signage in the main lobby was inspected. The sign over the exit door was found to have one of the two bulbs burned out.

Based on observation, the facility failed to maintain visibility of exit signs in accordance with NFPA 101-2012, Section 7.10.1.8.

Findings include:

1. During an observation on 6/29/22 at 1:02 p.m., an exit sign behind the check-out desks was blocked from view by hanging signage.

Based on observation, the facility failed to use directional exit signs in accordance with NFPA 101-2012, Section 7.10.

Findings include:

1. During an observation on 6/29/22 at 1:48 p.m., the exam hall was inspected. There were no visible exit signs in the corridor.

Based on observation, where the path of egress was not obvious, the facility failed to mark the path of egress by approved exit or directional exit signs in accordance with NFPA 101, 2012 Edition, Section 7.10.1.2.2, and 7.10.1.5.2.

Findings include:

1. During an observation on 6/28/22 at 2:44 p.m., the area between the NICU and Peds. corridor was inspected. The area needs an exit sign placed for the direction of emergency egress, as it is not obvious to the occupants.

Based on observation, where the path of egress was not obvious, the facility failed to mark the path of egress by approved exit or directional exit signs in accordance with NFPA 101, 2012 Edition, Section 7.10.1.2.2, and 7.10.1.5.2.

Findings include:

1. During an observation on 6/29/22 at 3:06 p.m., the egress of the 2nd floor of suite C was inspected. The area needs an exit sign placed for the direction of emergency egress, as it is not obvious to the occupants.

Based on observation, the facility failed to assure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 6/28/2022 at 7:52 a.m., the endoscopy soiled utility room was inspected. The corridor door was blocked open by a housekeeping cart and was unable to close and latch under the power of the self-closer.

2. During an observation 6/28/2022 at 9:21 a.m., the basement hallway was inspected. There were five large rolling bins of clean linen being left and stored in the hallway. The quantity of linen is deemed hazardous and should be stored in a room with a self-closing door.

Based on observation, the facility failed to assure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 6/28/22 at 11:10 a.m., the clean linen room was inspected. The room was observed being used as a storage area for other combustible items as well, and it is over 50 square feet. There was no self-closing device on the corridor door as required for storage rooms.

2. During an observation on 6/28/22 at 1:39 p.m., the paitent room next to DHI was found to be used as a storage room. The door has a self-closer but the room was over-full of equipment and the door was blocked from closing.

Based on observation, the facility failed to assure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 6/28/22 at 2:33 p.m., the Peds. equipment storage room 135 Q was inspected. The room is considered a hazardous room because it is over 50 square feet. The corridor door failed to latch under the power of the self-closer.

Based on observation and interview, the facility failed to sprinkle an outside overhang four feet or longer in depth in accordance with NFPA 13, 2010 Edition, Section 8.15.7.1.

Findings include:

1. During an observation on 6/29/22 at 2:04 p.m., the administration east exit was inspected. The overhang at this exit was constructed of wood product and exceeded 48 inches in depth from the building to the outer edge of the canopy. The area was not sprinkled.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings include:

1. During an observation on 6/27/22 at 1:31 p.m., the kitchen housekeeping closet was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

2. During an observation on 6/28/22 at 9:26 a.m., the patient tower visitor elevator machine room was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

Based on observation, the facility failed to fully sprinkle the building in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 39.1.1.4 and 4.5.7.

Findings include:

1. During an observation on 6/29/22 at 1:14 p.m., the nurse's stations were inspected. Two of the stations were found to be lacking sprinkler coverage where the rest of the building was fully sprinkled.

Based on observation, the facility failed to sprinkle a room in the OR area in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.5.3. The deficiency affects 1 of 3 smoke compartments.

Findings include:

1. During an observation on 6/28/22 at 11:23 a.m., room 173 A, EVS was inspected. The room was found to be lacking any sprinkler coverage.

Based on observation, the facility failed to:

a) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.

b) maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5.

c) continuously maintain automatic fire sprinklers in reliable operating condition including examination of the heads per NFPA 25-2011, Sections 5.2.1.1.2.

d) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3)

Findings include:

1. During an observation on 6/27/2022 at 1:02 p.m., a mechanical room was inspected. There was a medical air sensor zip-tied to a sprinkler pipe in the room.

2. During an observation on 6/27/2022 at 1:28 p.m., there were two directional sprinkler heads in the kitchen storage room, there were no spare directional heads in the spare box at the standpipe which feeds that part of the sprinkler system.

3. During an observation on 6/27/2022 at 1:33 p.m., the freezers were inspected. The escutcheon rings were missing on two of the heads in the freezers.

4. During an observation on 6/27/22 at 1:56 p.m., the data center was inspected. There were several holes in the ceiling tiles in the room.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

Findings include:

1. During an observation on 6/28/22 at 10:10 a.m., the OR recovery area was inspected. There was a rolling chair sitting in front of the portable fire extinguisher in the area.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1. This deficiency affects 1 of 8 smoke compartments.

Findings include:

1. During an observation on 6/29/22 at 10:18 a.m. There was a portable extinguisher by the door which was blocked from immediate access.

Based on observation, the facility failed to:

a) install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1.

b) inspect portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 7.2.1.2.
Findings include:
1. During an observation on 6/27/22 at 1:35 p.m., the kitchen ABC fire extinguisher was inspected, it was found to be mounted 67" above the floor.

2. During an observation on 6/27/22 at 1:59 p.m., the data center portable extinguisher was inspected. It was missing all inspections since December of 2021.

3. During an observation on 6/28/22 at 9:43 a..m., OB OR prep fire extinguisher was inspected, it was found to be mounted 64" above the floor.

Based on observation, the facility failed to ensure the door can be closed by either pulling or pushing in accordance with NFPA 101-2012, Section 19.3.6.3.10.

Findings include:

1. During an observation on 6/28/22 at 1:15 p.m., the ante-room to patient room 3224 was inspected. It was found to be over full of equipment used to getting vitals on patients. The equipment was blocking the door from being closed.

Based on observation, the facility failed to ensure fire/smoke barrier doors located in the fire/smoke partitions were maintained per NFPA 101-2012, Section 19.3.7.8.

Findings include:

1. During an observation on 6/28/22 at 7:38 a.m., the double door smoke/fire doors by the hospital supervisor's office were inspected. The left leaf of the doors failed to close and latch when exercised.

2. During an observation on 6/28/22 at 8:55 a.m., the cross-corridor doors near the oxygen storage were exercised. The left leaf would not close and latch.

Based on observation, the facility failed to ensure fire/smoke barrier doors located in the fire/smoke partitions were maintained per NFPA 101-2012, Section 8.4.3.4 and NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, Section 6.3.1.7.1.

Findings include:

1. During an observation on 6/28/22 at 11:08 a.m., the fire doors from West to pre-op were exercised. The doors were not tight enough when closed. The gap between the doors was at least 1/4" wide. Doors cannot have a gap of more than 1/8" when closed.

Based on record review and interview, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6.

Findings include:

1. Review of facility documents and staff interview regarding fire drills for the last year reflected this building was mistakenly only getting one fire drill per year, until the second quarter of this year.