HospitalInspections.org

Based on observation and documentation review the facility fails to assure that
building construction type and height meets one of the following: 19.1.6.2., 19.1.6.3, 19.1.6.4, 19.3.5.1

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the following is noted:

1) Throughout 3rd floor SFRM of different types are applied together.
2) Wall and ceiling penetrations are noted in the following areas: 1720, 1801, 4012A, 6115, 6412, 6414, 6413, 6037, 6612, 6629, 6317, 6309, 6339, 6017, Closet across from stair 3 on 2nd floor, telecom room across from 5009,
3) Expandable foam is used as a penetration sealant in room 4012A.
3) Ceiling tiles are missing or out of place in the following locations: telecom by 1016,
4) Ductwork through a ceiling in room 1228B from a portable air conditioner is not attached at the ceiling.
5) Delamination of SFRM on beams in chase 6030
6) Unsealed penetration around black and white piping in the tank room B701b.
7) Missing ceiling tiles in the police dispatch area and in the telecommunication room B706b.
8) Missing ceiling tile in the squadron room B703.
9) Unsealed penetrations around pipe and conduit in the MRI riser room B12.
10) There is a penetration around a pipe in the 3-hour rated wall at Dock 1 of the B700 Loading Dock.
11) There are unsealed penetrations in 2 open wire chases in the west and south 3-hour rated fire barrier walls and an unsealed hole above the exit door from the room in the Heart Hospital Basement Tele Data Room.
12) There are damaged ceiling tiles and gaps between ceiling tiles and grids in the Bell Hospital Basement Pharmacy (B400-24).
13) There is an unsealed penetration around a pipe in Chase Room 7 at Level 1 in the Bell Hospital.
14) The fireproofing is delaminating from the structural beam in the interstitial space in Stairway 7 in the Bell Hospital.

Hospital staff were present and are aware of these findings.

Based on observation and documentation review the facility fails to assure that
building construction type and height meets one of the following: 19.1.6.2., 19.1.6.3, 19.1.6.4, 19.3.5.1

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the following is noted:

1) The building is not protected with
an automatic sprinkler system, corridor
walls terminate at a non-rated ceiling.
The area above ceiling is an open plenum
with transfer grills common to patient
rooms on each side and the corridor.
The area above the non-rated ceiling is
serving as a common HVAC return. The
building is a Type II (222) according to
the code footprint.
2) The ceiling is 1/2" sheet rock
throughout.
3) Non-rated above-ceiling access
panels are noted throughout the building
in rooms and corridors.

ON 10/19/2010 AT 2:55 PM THE IMMEDIATE JEOPARDY IS ABATED DUE TO THE FACILITY ESTABLISHING AN APPROVED FIREWATCH UNTIL ALL OF THE CONDITIONS ARE CORRECTED.

Based on observation and document review
the facility fails to assure that
Interior finish for corridors and
exitways, including exposed interior
surfaces of buildings such as fixed or
movable walls, partitions, columns, and
ceilings has a flame spread rating of
Class A or Class B

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) Corridor walls throughout have
carpet on the lower half of the walls
and the facility cannot produce
documentation of flame spread rating.

Hospital staff were present and are aware of these findings.

Based on observation and document review
the facility fails to assure that
Interior finish for corridors and
exitways, including exposed interior
surfaces of buildings such as fixed or
movable walls, partitions, columns, and
ceilings has a flame spread rating of
Class A or Class B

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) Corridor walls throughout have
carpet on the lower half of the walls
and the facility cannot produce
documentation of flame spread rating.

Staff was present and are aware of these
findings.

Based on observation and review of records , it is determined that the facility failed to assure that all rooms have at least a Class A or B in non sprinklered buildings and a Class A, B, or C in sprinkled buildings.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) The following rooms are provided with combustible wall finish and no documentation is provided to assure Class A or B flame spread rating: 1801,1463, 6018, 6412, 6629, 6317, 6339.

Hospital staff were present and are aware of these findings.

Based on observation, the facility failed to assure that all corridors have proper separation from use areas.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) Room 5253 in Unit 52 of the Bell Hospital is open to the corridor through an opening in the glass. There is no smoke detection in the room.
2) No smoke detection is provided within the same day waiting room located in room 2002.

Hospital staff were present and are aware of these findings.

Based on observation and staff interview the facility fails to assure that corridor doors close tightly and positive latch to prevent the spread of smoke and fire.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 - 10/8/2010 the following is noted:

1) Double doors are noted with manual latching devices in the following areas: HC1822, 5324, 5327, 5333, 6115, 6413, 6414, throughout units 51, 53 and 55, 6037, 6612, 6308, 5009, telecom room across from stair 2 on 6th floor,
2) Patient room doors fail to positive latch into their frames throughout units 51, 53 and 55.
3) Electrical room 4236 fails to positive latch into its frame.
4) Room 2500E - door is held open by an oxygen storage cart.
5) The corridor door at the Bell Hospital Orthopedic Spine Exam Suite 1 does not positively latch.

Hospital staff is present and are aware of these findings.

Based on observation the facility fails to assure that stairway doors positively latch into their frames.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) The east door for Stairway 5 at the Ground Floor of Bell Hospital fails to positively latch.

Hospital staff were present and are aware of these findings.

Based on observation, the facility failed to assure that all exit paths are properly marked.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) 2nd Floor Heart Center link, Exits signs not readily visible from both directions.
2) 5th floor of heart hospital has two exit sign in use, one exit is provided with a directional arrow that directs you into a waiting room transgressing pass stairwell number 2.
3) Room B313 does not have exit signs above the exit doors showing where the exits are located.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails
to assure that smoke compartments, as
shown on the code footprint, seal to
resist the passage of smoke

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) The corridor ceiling is not rated
and the wall at the smoke barrier does
not extend to the deck above the smoke
barrier doors.

Staff were present and are aware of
these findings.

ON 10/19/2010 AT 2:55 PM THE IMMEDIATE JEOPARDY IS ABATED DUE TO THE FACILITY ESTABLISHING AN APPROVED FIREWATCH UNTIL ALL OF THE CONDITIONS ARE CORRECTED.

Based on observation and staff interview, the facility failed to assure that smoke barrier walls in the attic are properly sealed, failing to provide the proper separation in order to prevent the spread of smoke and fire.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) 6th floor SE smoke barrier wall by 6013 open penetration around wires, and/or conduit's.
2) 6th floor NE smoke barrier wall by 6034 open penetration around wires, and/or conduit's.
3) Smoke barrier wall by BH5009 open penetration around wires, and / or conduit's.
4) Smoke barrier wall by 4507 has open penetrations around wires, and / or conduit's.
5) Heart Hospital by 5820 has open penetrations around wires, and / or conduit's.
6) The double doors in the burn unit suite boundary wall are not provided with self or automatic closures and will not seal to resist the passage of smoke.

Hospital staff were present and are aware of these findings.

Based on observation and staff interviews, the facility does not assure that barrier doors are provided a suitable means for keeping the smoke doors tightly closed, without gaps that would allow the passage of smoke. This deficient practice fails to prevent the spread of fire and smoke.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) The smoke barrier doors do not positively latch at 5H26 in Bell Hospital.
2) There is a gap between the double doors at the entrance to Unit 63 Transplant ICU of Bell Hospital that will not resist the passage of smoke.
3) There is a gap in the 6th Floor northwest smoke barrier doors at Bell Hospital that will not resist the passage of smoke.
4) There is a gap between the double doors at the entrance to Unit 65 Medical ICU at Bell Hospital that will not resist the passage of smoke.
5) The double doors at the entrance to Unit 65 Medical ICU at Bell Hospital don't positively latch.
6) The wall separating the Bell Hospital Ground Floor Gift Shop from the Gift Shop Storage Room is a 30-minute smoke barrier. The self-closing fire-rated door was held open by a wooden wedge.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails
to assure that one hour fire rated
construction (with 3/4 hour fire-rated
doors) or an approved automatic fire
extinguishing system in accordance with
8.4.1 and/or 19.3.5.4 protects hazardous
areas.

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) An office has been converted to a storage room with no automatic door closure and penetrations through the ceiling in room 1223B.
2) Room 1554, soiled lined is not smoke tight and penetrations are noted around the edge of the ceiling.
3) Room 4658 is a storage room and is not provided with an automatic door closure.
4) Room 4651 is utilized as a storage room and is not provided with a door.
5) Room 4249 and 4250 are rated as 2-hour assembly on footprint and are equipped with 20-minute rated doors.
6) Room 2646 is rated as 1-hour on footprint and is equipped with a 20-minute door.
7) Room 5152 is a storage room and is not equipped with a door.
8) Red bag holding room (bio room) is open to the corridor and is sheeted with wood finish walls.
9) Mechanical room 6506 has a 3" penetration in the wall.
10) Room 1711 is a conference room being utilized for storage.
11) Chemical storage 1444 failed to positive latch into its frame.
12) Room 6024 has an approximately 8" penetration in the wall.
13) Electrical room across from room G539 has gaps in the ceiling tiles around all conduit piping.
14) The Biohazard Room in the Heart Hospital Parking Garage has a mechanically powered ventilator and a louvered grill with no marked rating.
15) The door from the Biohazard Room in the Heart Hospital Parking Garage is not self-closing.
16) There are multiple screws missing from the fire-rated door assembly at the Basement Dock east door negating the fire rating of the door.
17) The Materials Management Distribution east door to the corridor was blocked open by a wedge and a trash can.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails to assure that one hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with
8.4.1 and/or 19.3.5.4 protects hazardous areas.

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the following is noted:

1) One room on each floor is being utilized as a soiled linen room and is not provided with 1-hour fire protection, automatic sprinkler system, or self or automatic closing doors.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails
to assure that stairways and smoke proof
towers used as exits are in accordance
with 7.2.

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) An open chase is noted in the wall
of the stairwell by 3052. The distance of travel is between the 2nd and 3rd floor.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails to assure that stairways and smoke proof towers used as exits are in accordance with 7.2.

FINDINGS INCLUDE:

1) Stair 3 - roof access has a 2" diameter penetration in the wall.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails
to assure that exit access is so
arranged that exits are readily
accessible at all times in accordance
with 7.1.

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) Patient room corridor doors and
bathroom doors in patient rooms are
equipped with keyed both side deadbolt
locks. This could result in patients
being locked into a room with no means
of escape.
2) The magnetic locks on all of the
building exits are not arranged to
automatically release upon activation of
the fire alarm, are not provided with
delayed egress and no emergency release
is provided at the supervising nurse's
station.

Hospital staff were present and are aware of these findings.

ON 10/19/2010 AT 2:55 PM THE IMMEDIATE JEOPARDY IS ABATED DUE TO THE FACILITY ESTABLISHING AN APPROVED FIREWATCH UNTIL ALL OF THE CONDITIONS ARE CORRECTED.

Based on observation the facility fails
to assure that emergency lighting of at
least 1 1/2 hour duration is provided in
accordance with 7.9.

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the following is noted:

1) No emergency lighting is provided in
the two med rooms.

Hospital staff were present and are aware of these findings.

Based on review of records and observation it is determined that the facility failed to assure that the fire alarm system is installed and maintained in accordance with NFPA 70 and NFPA 72.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) There is no smoke detection provided at the fire pump controller at the Energy Center.
2) Room 5544 in the Maternal Child Unit at Bell Hospital is being used for staff sleeping. There is no smoke detection and no fire alarm annunciator.
3) Fire alarm AV devices are obstructed by trees in 1st floor Heart Hospital in HC1709.
4) A smoke detector is found laying on top of the ceiling tile above room 5234.


Hospital staff were present and are aware of these findings.

Based on observation the facility failed to assure that when a sprinkler system is installed it has to be installed and maintained in accordance with NFPA 13 and NFPA 25.

FINDINGS INCLUDE:

During the inspection conducted on 10/4/2010 - 10/8/2010 the following is noted:

1) The following areas are not provided with automatic sprinkler protection: walk-in cooler next to 1426A, storage closet next to 1202D and 1202A, Room 4646, 2646A, Alcove by 2431, 5324, 5327,
2) Rooms 1213 and 4603 have sprinkler obstruction due to a non-compliant curtain.
3) Closets with no sprinkler protection are noted in Units 51, 53 and 55.
4) 6224 has a sprinkler obstruction due to a ceiling light.
5) 2252 has sprinkler obstruction due to storage too high.
6) Stairwells throughout are not provided with complete automatic sprinkler protection.
7) An IV pole is found hanging from a sprinkler pipe in the red bag holding room 6018.

Hospital staff were present and are aware of these findings.

Based on observation and staff interview, the facility failed to assure that required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) Missing escutcheon plates are noted in the following locations: top of escalator (2), 2500E.
2) Sprinkler escutcheon ring missing in the Hot Lab room B701a.
3) Sprinkler escutcheon ring missing in the Cyclotron room B701.
4) Room B703 has a sprinkler approximately 1 foot from another sprinkler.
5) Room B705 north bathroom has corrosion on the sprinkler.
6) Several sprinklers have lint buildup on the deflector in the ground level cafeteria kitchen.
7) Labeling for materials that is hung above storage shelves is obstructing sprinkler head spray pattern in the area of aisles marked DA and FE in Materials Management Distribution at Bell Hospital.
8) There are items stored within 18 inches of the sprinkler head in the Bell Hospital Ground Floor Gift Shop Storage Room.

Hospital staff were present and are aware of this finding.

Based on observation and review of records, the facility failed to assure that all fire extinguishers are maintained and serviced in accordance with NFPA 10.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) A fire extinguisher is obstructed by carts by room 1223 and 1214A
2) Fire extinguisher next to 5660C is mounted too high.
3) The monthly inspection of the portable fire extinguisher located at the east stair of the Energy Center is past due. The last monthly inspection recorded on the extinguisher tag is August 31, 2010.
4) Bio service dock B700 has a fire extinguisher that is not mounted.
5) Room B511 has a fire extinguisher sitting on top of a cabinet not mounted.
6) The portion of the tag indicating the date of the last annual maintenance has been removed from the portable fire extinguisher outside Room B810 at Bell Hospital.
7) There is a trash can blocking the fire extinguisher in the Bell Hospital Sterile Leach Room. The can was removed at the time of survey.

Hospital staff were present and aware of the findings.

Based on review of service records and observation the facility failed to assure the kitchen hood and suppression system is installed, maintained, and tested in accordance with NFPA 96.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) The deep fat fryer located in the ground level cafeteria kitchen has grease buildup on the interior lining of the hood.
2) A fryer is not protected by the hood suppression system due to the fryers placement under the hood.

Hospital staff were present and are aware of these findings.

Based on observation, the facility failed to assure that all exit paths are free of obstructions at all times

FINDINGS INCLUDE:

During the inspection conducted between 10/04/2010 - 10/8/2010 the following is noted:

1) Storage of beds, carts and other medical equipment is noted in the corridor by room HC1928 and HC1822, NICU unit, chairs by room 2201-2247, misc. storage throughout Unit 46 on the 4th floor, misc storage and portable air conditioning units between Units, 51, 53 and 55, Corridor 1H24 has storage throughout, file cabinets in corridor by 1336, 1H52 has storage throughout.
2) Room B312 exit access to the SE exit is obstructed by boxes, equipment, supplies and hospital beds being stored in the aisle within the room.
3) NW exit in room B312 has ladders being stored in the corridor within the room.
4) Room B12 (MRI) has multiple chairs and a infectious waste container being stored in the back corridor within the suite.
5) Multiple highchairs are being stored in the cafeteria corridor between the Wyandotte room and stairwell #2.
6) Room 200c exit access is obstructed by boxes and carts.
7) Fuel cans, a trash can, and other miscellaneous equipment were located next to the exit door from inside the Basement Generator Room at Heart Hospital.
8) There are 16 wooden pallets stored in the corridor outside Room B601.
9) There is an unattended trash cart outside Room B416.
10) There are boxes obstructing aisles in the storage area of the Basement Pharmacy.
11) There is a roller cart obstructing access to an interior exit door from the Basement Pharmacy.
12) There is a pallet of boxes in the corridor outside Room 1224.

Oncology:

1) At the Nurses station located in the corridor a copy/fax and small desk are reducing the corridor width.

Hospital staff were present and are aware of these findings.

Based on observation and review of records, the facility failed to provide proper documentation of window coverings in the facility in accordance with NFPA 701.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) Rooms 1809-1832 are equipped with approximately 9" mesh at the tops of the curtains.

Hospital staff were present and are aware of these findings.

Based on observation and staff interview, the facility failed to assure that medical gas storage is protected in accordance with NFPA 99, including the storage of combustible items within the location of the oxygen storage area.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) Unsecured oxygen or other gas storage is noted in the following locations: 1804.

Hospital staff were present and are aware of these findings:

(State Requirement)FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the following is noted:

1) The sleeping room doors throughout are not provided with automatic door closures and the building is not protected with an automatic sprinkler system.

Staff was present and are aware of these findings

DIALYSIS CENTER - BUSINESS OCCUPANCY:

K.S.A. 44-924(b)

A current boiler certificate, no more than 18 months beyond expiration date, shall be posted. This is required for all boilers, all water heaters with a water capacity of 85 gallons or greater, and all water heaters rated for more than 200,000 BTU's, regardless of size.

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

FINDINGS INCLUDE:

1) Two 119 Gallon hot water heaters located in mechanical room, no Initial Boiler Inspection ever done.

Hospital staff were present and are aware of these findings.

KU MED WESTWOOD - BUSINESS OCCUPANCY:

NFPA 13/8.7.6

Storage of all materials must be kept at least 18" below the sprinkler heads. Storage of materials shall not obstruct access to risers.

FINDINGS INCLUDE:

1) 3RD Floor Storage closets east bldg. NO sprinkler head clearance, storage to high and too close to the sprinkler head. Numerous individual department storage closet almost all with storage too high.

Hospital staff were present and are aware of these findings.

91-101/31-1.3.6
UFC 1001.5

Where provided, automatic sprinkler systems shall be maintained in operating condition. Control valves are checked monthly to verify that they are open. Valves shall be supervised by either:
a) a lock and chain, or
b) a locked room or area, or
c) electronically UNLESS specific occupancy has more restrictive requirements.

FINDINGS INCLUDE:

1) Sprinkler head 3rd floor hall way outside restrooms east bldg. have dropped down approximately 2 to 3 inches below the ceiling level.

Hospital staff were present and are aware of these findings.

91-101/7-6.3
UFC 1007.3.3.3.1

A fire alarm system, when provided, shall be audible throughout the entire building.

See Fire Fact 031

FINDINGS INCLUDE:

1) East bldg. Mechancial area lower level in the restrooms no fire alarm AV device found.
2) Westside dock lower level in the restrooms no fire alarm AV device found.

Hospital staff were present and are aware of these findings.

91-101/7-1.2
UFC 8506
NFPA 70

Use of temporary wiring or wiring which is not protected for permanent or long term use is prohibited. Wiring must comply with NFPA 70.

FINDINGS INCLUDE:

1) East bldg. Suite 208 break area powerstrip being used in conjunction with kitchen appliances.

Hospital staff were present and are aware of these findings.

Miscelaneous FINDINGS INCLUDE:

1) East bldg. receiving dock wall penetrations conduit, and sprinkler piping penetration not sealed.
2) 2 hour separation wall between East and West bldg. penetrations not sealed completely.
3) West side dock switchgear room 2' x4" penetration with multi electrical conduit piping not sealed.

Hospital staff were present and are aware of these findings.

Based on observation and staff interview the facility fails to assure that electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) Powerstrips are plugged into other powerstrips in the following locations: HC1807, 1212,
2) A toaster is found powered by a hanging powerstrip in room 1212.
3) Extension cords are found in use in the following locations: 2644 microwave oven,
4) NICU unit has an unsecured electrical panel (LC13A-BCE5--551) in the corridor.
5) Room 1228 has 2 full sized refrigerators plugged into powerstrips.
6) Open junction boxes are noted in the following locations: 6th floor - chase 5.
7) Open junction box in the tank room B701b.
8) Room B706b has a ladder obstructing the electrical panel.
9) Room B003 has an open electrical panel with the cover sitting on the floor leaning up against the panel.
10) The panel cover was open in the Heart Hospital Basement Elevator Mechanical Room.
11) The dishwasher wiring is exposed in the Bell Hospital Basement Kitchen.
12) There is an extension cord running above the ceiling tiles to a sump pump in the Bell Hospital Basement Kitchen.
13) The fire alarm junction box in the Bell Hospital Ground Floor Chase 8 is open.

Oncology:

1) Open junction box located at G038 in the tele-data closet.

Hospital staff is present and are aware of these findings.

Based on observation, the facility failed to assure that alcohol based hand gel containers placed in proper locations.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) Alcohol Based Hand Rub is within close proximity to a light switch in room B505.

Hospital staff were present and are aware of these findings.

Based on observation and documentation review the facility fails to assure that
building construction type and height meets one of the following: 19.1.6.2., 19.1.6.3, 19.1.6.4, 19.3.5.1

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the following is noted:

1) Throughout 3rd floor SFRM of different types are applied together.
2) Wall and ceiling penetrations are noted in the following areas: 1720, 1801, 4012A, 6115, 6412, 6414, 6413, 6037, 6612, 6629, 6317, 6309, 6339, 6017, Closet across from stair 3 on 2nd floor, telecom room across from 5009,
3) Expandable foam is used as a penetration sealant in room 4012A.
3) Ceiling tiles are missing or out of place in the following locations: telecom by 1016,
4) Ductwork through a ceiling in room 1228B from a portable air conditioner is not attached at the ceiling.
5) Delamination of SFRM on beams in chase 6030
6) Unsealed penetration around black and white piping in the tank room B701b.
7) Missing ceiling tiles in the police dispatch area and in the telecommunication room B706b.
8) Missing ceiling tile in the squadron room B703.
9) Unsealed penetrations around pipe and conduit in the MRI riser room B12.
10) There is a penetration around a pipe in the 3-hour rated wall at Dock 1 of the B700 Loading Dock.
11) There are unsealed penetrations in 2 open wire chases in the west and south 3-hour rated fire barrier walls and an unsealed hole above the exit door from the room in the Heart Hospital Basement Tele Data Room.
12) There are damaged ceiling tiles and gaps between ceiling tiles and grids in the Bell Hospital Basement Pharmacy (B400-24).
13) There is an unsealed penetration around a pipe in Chase Room 7 at Level 1 in the Bell Hospital.
14) The fireproofing is delaminating from the structural beam in the interstitial space in Stairway 7 in the Bell Hospital.

Hospital staff were present and are aware of these findings.

Based on observation and documentation review the facility fails to assure that
building construction type and height meets one of the following: 19.1.6.2., 19.1.6.3, 19.1.6.4, 19.3.5.1

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the following is noted:

1) The building is not protected with
an automatic sprinkler system, corridor
walls terminate at a non-rated ceiling.
The area above ceiling is an open plenum
with transfer grills common to patient
rooms on each side and the corridor.
The area above the non-rated ceiling is
serving as a common HVAC return. The
building is a Type II (222) according to
the code footprint.
2) The ceiling is 1/2" sheet rock
throughout.
3) Non-rated above-ceiling access
panels are noted throughout the building
in rooms and corridors.

ON 10/19/2010 AT 2:55 PM THE IMMEDIATE JEOPARDY IS ABATED DUE TO THE FACILITY ESTABLISHING AN APPROVED FIREWATCH UNTIL ALL OF THE CONDITIONS ARE CORRECTED.

Based on observation and document review
the facility fails to assure that
Interior finish for corridors and
exitways, including exposed interior
surfaces of buildings such as fixed or
movable walls, partitions, columns, and
ceilings has a flame spread rating of
Class A or Class B

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) Corridor walls throughout have
carpet on the lower half of the walls
and the facility cannot produce
documentation of flame spread rating.

Hospital staff were present and are aware of these findings.

Based on observation and document review
the facility fails to assure that
Interior finish for corridors and
exitways, including exposed interior
surfaces of buildings such as fixed or
movable walls, partitions, columns, and
ceilings has a flame spread rating of
Class A or Class B

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) Corridor walls throughout have
carpet on the lower half of the walls
and the facility cannot produce
documentation of flame spread rating.

Staff was present and are aware of these
findings.

Based on observation and review of records , it is determined that the facility failed to assure that all rooms have at least a Class A or B in non sprinklered buildings and a Class A, B, or C in sprinkled buildings.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) The following rooms are provided with combustible wall finish and no documentation is provided to assure Class A or B flame spread rating: 1801,1463, 6018, 6412, 6629, 6317, 6339.

Hospital staff were present and are aware of these findings.

Based on observation, the facility failed to assure that all corridors have proper separation from use areas.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) Room 5253 in Unit 52 of the Bell Hospital is open to the corridor through an opening in the glass. There is no smoke detection in the room.
2) No smoke detection is provided within the same day waiting room located in room 2002.

Hospital staff were present and are aware of these findings.

Based on observation and staff interview the facility fails to assure that corridor doors close tightly and positive latch to prevent the spread of smoke and fire.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 - 10/8/2010 the following is noted:

1) Double doors are noted with manual latching devices in the following areas: HC1822, 5324, 5327, 5333, 6115, 6413, 6414, throughout units 51, 53 and 55, 6037, 6612, 6308, 5009, telecom room across from stair 2 on 6th floor,
2) Patient room doors fail to positive latch into their frames throughout units 51, 53 and 55.
3) Electrical room 4236 fails to positive latch into its frame.
4) Room 2500E - door is held open by an oxygen storage cart.
5) The corridor door at the Bell Hospital Orthopedic Spine Exam Suite 1 does not positively latch.

Hospital staff is present and are aware of these findings.

Based on observation the facility fails to assure that stairway doors positively latch into their frames.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) The east door for Stairway 5 at the Ground Floor of Bell Hospital fails to positively latch.

Hospital staff were present and are aware of these findings.

Based on observation, the facility failed to assure that all exit paths are properly marked.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) 2nd Floor Heart Center link, Exits signs not readily visible from both directions.
2) 5th floor of heart hospital has two exit sign in use, one exit is provided with a directional arrow that directs you into a waiting room transgressing pass stairwell number 2.
3) Room B313 does not have exit signs above the exit doors showing where the exits are located.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails
to assure that smoke compartments, as
shown on the code footprint, seal to
resist the passage of smoke

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) The corridor ceiling is not rated
and the wall at the smoke barrier does
not extend to the deck above the smoke
barrier doors.

Staff were present and are aware of
these findings.

ON 10/19/2010 AT 2:55 PM THE IMMEDIATE JEOPARDY IS ABATED DUE TO THE FACILITY ESTABLISHING AN APPROVED FIREWATCH UNTIL ALL OF THE CONDITIONS ARE CORRECTED.

Based on observation and staff interview, the facility failed to assure that smoke barrier walls in the attic are properly sealed, failing to provide the proper separation in order to prevent the spread of smoke and fire.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) 6th floor SE smoke barrier wall by 6013 open penetration around wires, and/or conduit's.
2) 6th floor NE smoke barrier wall by 6034 open penetration around wires, and/or conduit's.
3) Smoke barrier wall by BH5009 open penetration around wires, and / or conduit's.
4) Smoke barrier wall by 4507 has open penetrations around wires, and / or conduit's.
5) Heart Hospital by 5820 has open penetrations around wires, and / or conduit's.
6) The double doors in the burn unit suite boundary wall are not provided with self or automatic closures and will not seal to resist the passage of smoke.

Hospital staff were present and are aware of these findings.

Based on observation and staff interviews, the facility does not assure that barrier doors are provided a suitable means for keeping the smoke doors tightly closed, without gaps that would allow the passage of smoke. This deficient practice fails to prevent the spread of fire and smoke.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) The smoke barrier doors do not positively latch at 5H26 in Bell Hospital.
2) There is a gap between the double doors at the entrance to Unit 63 Transplant ICU of Bell Hospital that will not resist the passage of smoke.
3) There is a gap in the 6th Floor northwest smoke barrier doors at Bell Hospital that will not resist the passage of smoke.
4) There is a gap between the double doors at the entrance to Unit 65 Medical ICU at Bell Hospital that will not resist the passage of smoke.
5) The double doors at the entrance to Unit 65 Medical ICU at Bell Hospital don't positively latch.
6) The wall separating the Bell Hospital Ground Floor Gift Shop from the Gift Shop Storage Room is a 30-minute smoke barrier. The self-closing fire-rated door was held open by a wooden wedge.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails
to assure that one hour fire rated
construction (with 3/4 hour fire-rated
doors) or an approved automatic fire
extinguishing system in accordance with
8.4.1 and/or 19.3.5.4 protects hazardous
areas.

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) An office has been converted to a storage room with no automatic door closure and penetrations through the ceiling in room 1223B.
2) Room 1554, soiled lined is not smoke tight and penetrations are noted around the edge of the ceiling.
3) Room 4658 is a storage room and is not provided with an automatic door closure.
4) Room 4651 is utilized as a storage room and is not provided with a door.
5) Room 4249 and 4250 are rated as 2-hour assembly on footprint and are equipped with 20-minute rated doors.
6) Room 2646 is rated as 1-hour on footprint and is equipped with a 20-minute door.
7) Room 5152 is a storage room and is not equipped with a door.
8) Red bag holding room (bio room) is open to the corridor and is sheeted with wood finish walls.
9) Mechanical room 6506 has a 3" penetration in the wall.
10) Room 1711 is a conference room being utilized for storage.
11) Chemical storage 1444 failed to positive latch into its frame.
12) Room 6024 has an approximately 8" penetration in the wall.
13) Electrical room across from room G539 has gaps in the ceiling tiles around all conduit piping.
14) The Biohazard Room in the Heart Hospital Parking Garage has a mechanically powered ventilator and a louvered grill with no marked rating.
15) The door from the Biohazard Room in the Heart Hospital Parking Garage is not self-closing.
16) There are multiple screws missing from the fire-rated door assembly at the Basement Dock east door negating the fire rating of the door.
17) The Materials Management Distribution east door to the corridor was blocked open by a wedge and a trash can.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails to assure that one hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with
8.4.1 and/or 19.3.5.4 protects hazardous areas.

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the following is noted:

1) One room on each floor is being utilized as a soiled linen room and is not provided with 1-hour fire protection, automatic sprinkler system, or self or automatic closing doors.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails
to assure that stairways and smoke proof
towers used as exits are in accordance
with 7.2.

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) An open chase is noted in the wall
of the stairwell by 3052. The distance of travel is between the 2nd and 3rd floor.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails to assure that stairways and smoke proof towers used as exits are in accordance with 7.2.

FINDINGS INCLUDE:

1) Stair 3 - roof access has a 2" diameter penetration in the wall.

Hospital staff were present and are aware of these findings.

Based on observation the facility fails
to assure that exit access is so
arranged that exits are readily
accessible at all times in accordance
with 7.1.

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the
following is noted:

1) Patient room corridor doors and
bathroom doors in patient rooms are
equipped with keyed both side deadbolt
locks. This could result in patients
being locked into a room with no means
of escape.
2) The magnetic locks on all of the
building exits are not arranged to
automatically release upon activation of
the fire alarm, are not provided with
delayed egress and no emergency release
is provided at the supervising nurse's
station.

Hospital staff were present and are aware of these findings.

ON 10/19/2010 AT 2:55 PM THE IMMEDIATE JEOPARDY IS ABATED DUE TO THE FACILITY ESTABLISHING AN APPROVED FIREWATCH UNTIL ALL OF THE CONDITIONS ARE CORRECTED.

Based on observation the facility fails
to assure that emergency lighting of at
least 1 1/2 hour duration is provided in
accordance with 7.9.

FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the following is noted:

1) No emergency lighting is provided in
the two med rooms.

Hospital staff were present and are aware of these findings.

Based on review of records and observation it is determined that the facility failed to assure that the fire alarm system is installed and maintained in accordance with NFPA 70 and NFPA 72.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) There is no smoke detection provided at the fire pump controller at the Energy Center.
2) Room 5544 in the Maternal Child Unit at Bell Hospital is being used for staff sleeping. There is no smoke detection and no fire alarm annunciator.
3) Fire alarm AV devices are obstructed by trees in 1st floor Heart Hospital in HC1709.
4) A smoke detector is found laying on top of the ceiling tile above room 5234.


Hospital staff were present and are aware of these findings.

Based on observation the facility failed to assure that when a sprinkler system is installed it has to be installed and maintained in accordance with NFPA 13 and NFPA 25.

FINDINGS INCLUDE:

During the inspection conducted on 10/4/2010 - 10/8/2010 the following is noted:

1) The following areas are not provided with automatic sprinkler protection: walk-in cooler next to 1426A, storage closet next to 1202D and 1202A, Room 4646, 2646A, Alcove by 2431, 5324, 5327,
2) Rooms 1213 and 4603 have sprinkler obstruction due to a non-compliant curtain.
3) Closets with no sprinkler protection are noted in Units 51, 53 and 55.
4) 6224 has a sprinkler obstruction due to a ceiling light.
5) 2252 has sprinkler obstruction due to storage too high.
6) Stairwells throughout are not provided with complete automatic sprinkler protection.
7) An IV pole is found hanging from a sprinkler pipe in the red bag holding room 6018.

Hospital staff were present and are aware of these findings.

Based on observation and staff interview, the facility failed to assure that required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) Missing escutcheon plates are noted in the following locations: top of escalator (2), 2500E.
2) Sprinkler escutcheon ring missing in the Hot Lab room B701a.
3) Sprinkler escutcheon ring missing in the Cyclotron room B701.
4) Room B703 has a sprinkler approximately 1 foot from another sprinkler.
5) Room B705 north bathroom has corrosion on the sprinkler.
6) Several sprinklers have lint buildup on the deflector in the ground level cafeteria kitchen.
7) Labeling for materials that is hung above storage shelves is obstructing sprinkler head spray pattern in the area of aisles marked DA and FE in Materials Management Distribution at Bell Hospital.
8) There are items stored within 18 inches of the sprinkler head in the Bell Hospital Ground Floor Gift Shop Storage Room.

Hospital staff were present and are aware of this finding.

Based on observation and review of records, the facility failed to assure that all fire extinguishers are maintained and serviced in accordance with NFPA 10.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) A fire extinguisher is obstructed by carts by room 1223 and 1214A
2) Fire extinguisher next to 5660C is mounted too high.
3) The monthly inspection of the portable fire extinguisher located at the east stair of the Energy Center is past due. The last monthly inspection recorded on the extinguisher tag is August 31, 2010.
4) Bio service dock B700 has a fire extinguisher that is not mounted.
5) Room B511 has a fire extinguisher sitting on top of a cabinet not mounted.
6) The portion of the tag indicating the date of the last annual maintenance has been removed from the portable fire extinguisher outside Room B810 at Bell Hospital.
7) There is a trash can blocking the fire extinguisher in the Bell Hospital Sterile Leach Room. The can was removed at the time of survey.

Hospital staff were present and aware of the findings.

Based on review of service records and observation the facility failed to assure the kitchen hood and suppression system is installed, maintained, and tested in accordance with NFPA 96.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) The deep fat fryer located in the ground level cafeteria kitchen has grease buildup on the interior lining of the hood.
2) A fryer is not protected by the hood suppression system due to the fryers placement under the hood.

Hospital staff were present and are aware of these findings.

Based on observation, the facility failed to assure that all exit paths are free of obstructions at all times

FINDINGS INCLUDE:

During the inspection conducted between 10/04/2010 - 10/8/2010 the following is noted:

1) Storage of beds, carts and other medical equipment is noted in the corridor by room HC1928 and HC1822, NICU unit, chairs by room 2201-2247, misc. storage throughout Unit 46 on the 4th floor, misc storage and portable air conditioning units between Units, 51, 53 and 55, Corridor 1H24 has storage throughout, file cabinets in corridor by 1336, 1H52 has storage throughout.
2) Room B312 exit access to the SE exit is obstructed by boxes, equipment, supplies and hospital beds being stored in the aisle within the room.
3) NW exit in room B312 has ladders being stored in the corridor within the room.
4) Room B12 (MRI) has multiple chairs and a infectious waste container being stored in the back corridor within the suite.
5) Multiple highchairs are being stored in the cafeteria corridor between the Wyandotte room and stairwell #2.
6) Room 200c exit access is obstructed by boxes and carts.
7) Fuel cans, a trash can, and other miscellaneous equipment were located next to the exit door from inside the Basement Generator Room at Heart Hospital.
8) There are 16 wooden pallets stored in the corridor outside Room B601.
9) There is an unattended trash cart outside Room B416.
10) There are boxes obstructing aisles in the storage area of the Basement Pharmacy.
11) There is a roller cart obstructing access to an interior exit door from the Basement Pharmacy.
12) There is a pallet of boxes in the corridor outside Room 1224.

Oncology:

1) At the Nurses station located in the corridor a copy/fax and small desk are reducing the corridor width.

Hospital staff were present and are aware of these findings.

Based on observation and review of records, the facility failed to provide proper documentation of window coverings in the facility in accordance with NFPA 701.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) Rooms 1809-1832 are equipped with approximately 9" mesh at the tops of the curtains.

Hospital staff were present and are aware of these findings.

Based on observation and staff interview, the facility failed to assure that medical gas storage is protected in accordance with NFPA 99, including the storage of combustible items within the location of the oxygen storage area.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) Unsecured oxygen or other gas storage is noted in the following locations: 1804.

Hospital staff were present and are aware of these findings:

(State Requirement)FINDINGS INCLUDE:

During the inspection on 10/4/2010 - 10/8/2010 the following is noted:

1) The sleeping room doors throughout are not provided with automatic door closures and the building is not protected with an automatic sprinkler system.

Staff was present and are aware of these findings

DIALYSIS CENTER - BUSINESS OCCUPANCY:

K.S.A. 44-924(b)

A current boiler certificate, no more than 18 months beyond expiration date, shall be posted. This is required for all boilers, all water heaters with a water capacity of 85 gallons or greater, and all water heaters rated for more than 200,000 BTU's, regardless of size.

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

FINDINGS INCLUDE:

1) Two 119 Gallon hot water heaters located in mechanical room, no Initial Boiler Inspection ever done.

Hospital staff were present and are aware of these findings.

KU MED WESTWOOD - BUSINESS OCCUPANCY:

NFPA 13/8.7.6

Storage of all materials must be kept at least 18" below the sprinkler heads. Storage of materials shall not obstruct access to risers.

FINDINGS INCLUDE:

1) 3RD Floor Storage closets east bldg. NO sprinkler head clearance, storage to high and too close to the sprinkler head. Numerous individual department storage closet almost all with storage too high.

Hospital staff were present and are aware of these findings.

91-101/31-1.3.6
UFC 1001.5

Where provided, automatic sprinkler systems shall be maintained in operating condition. Control valves are checked monthly to verify that they are open. Valves shall be supervised by either:
a) a lock and chain, or
b) a locked room or area, or
c) electronically UNLESS specific occupancy has more restrictive requirements.

FINDINGS INCLUDE:

1) Sprinkler head 3rd floor hall way outside restrooms east bldg. have dropped down approximately 2 to 3 inches below the ceiling level.

Hospital staff were present and are aware of these findings.

91-101/7-6.3
UFC 1007.3.3.3.1

A fire alarm system, when provided, shall be audible throughout the entire building.

See Fire Fact 031

FINDINGS INCLUDE:

1) East bldg. Mechancial area lower level in the restrooms no fire alarm AV device found.
2) Westside dock lower level in the restrooms no fire alarm AV device found.

Hospital staff were present and are aware of these findings.

91-101/7-1.2
UFC 8506
NFPA 70

Use of temporary wiring or wiring which is not protected for permanent or long term use is prohibited. Wiring must comply with NFPA 70.

FINDINGS INCLUDE:

1) East bldg. Suite 208 break area powerstrip being used in conjunction with kitchen appliances.

Hospital staff were present and are aware of these findings.

Miscelaneous FINDINGS INCLUDE:

1) East bldg. receiving dock wall penetrations conduit, and sprinkler piping penetration not sealed.
2) 2 hour separation wall between East and West bldg. penetrations not sealed completely.
3) West side dock switchgear room 2' x4" penetration with multi electrical conduit piping not sealed.

Hospital staff were present and are aware of these findings.

Based on observation and staff interview the facility fails to assure that electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code.

FINDINGS INCLUDE:

During the inspection between 10/4/2010 and 10/8/2010 the following is noted:

1) Powerstrips are plugged into other powerstrips in the following locations: HC1807, 1212,
2) A toaster is found powered by a hanging powerstrip in room 1212.
3) Extension cords are found in use in the following locations: 2644 microwave oven,
4) NICU unit has an unsecured electrical panel (LC13A-BCE5--551) in the corridor.
5) Room 1228 has 2 full sized refrigerators plugged into powerstrips.
6) Open junction boxes are noted in the following locations: 6th floor - chase 5.
7) Open junction box in the tank room B701b.
8) Room B706b has a ladder obstructing the electrical panel.
9) Room B003 has an open electrical panel with the cover sitting on the floor leaning up against the panel.
10) The panel cover was open in the Heart Hospital Basement Elevator Mechanical Room.
11) The dishwasher wiring is exposed in the Bell Hospital Basement Kitchen.
12) There is an extension cord running above the ceiling tiles to a sump pump in the Bell Hospital Basement Kitchen.
13) The fire alarm junction box in the Bell Hospital Ground Floor Chase 8 is open.

Oncology:

1) Open junction box located at G038 in the tele-data closet.

Hospital staff is present and are aware of these findings.