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A) Based upon random observation throughout the Hospital, based on document review and/or the lack of documentation and based on personnel interview of the Regional Director of Facilities and the Manager of Facilities, the surveyor finds that portions of the Hospital are Type II (000) Construction, as defined by NFPA 220. The Hospital is a five story building that does not comply with the minimum construction type requirements of 19.1.6.2:

Finding include but are not limited to:

1) The provider lacks detailed information that includes the construction type (as defined by NFPA 220) and the UL Floor/ceiling (or Roof/ceiling) Assembly Numbers (or equivalent) for each project and each addition spanning over a period of 67 years. The surveyors observed a number of variations of reinforced concrete construction.

a) Some of this was clearly fire rated for two hours or more. However, portions of the building have ribbed slab concrete construction. Some but not all of this ribbed slab construction has been fire proofed. The provider also has information (recent FSES by Rolf Jensen) that indicates that portions of the building have concrete floor assemblies that are not at least two hour construction. This information was conveyed verbally but was not shown to the surveyors.

example: 4th Floor Environmental Services closet opposite Room 409 has a plaster ceiling with holes and at least one duct penetration. There is concrete ribbed slab construction above this ceiling. A UL Design Number identifying this area with a two hour floor/ceiling assembly was not available.

b) Portions of the building have steel structural members. Some of this structure is protected as a fire rated assembly with monolithic ceilings. UL numbers for these systems were not available. Portions of the Main Building have been fire proofed via a project that was not completed. U DL Design Numbers for the systems used for this project were not submitted to the Department and were not available on site. Portions of the building have structural steel elements that are unprotected (see below).

c) It was not possible to investigate this condition in most patient rooms. Most of the patients rooms were occupied and access was limited.

2) While portions of the 4th Floor have fire proofed steel above lay-in ceilings and/or monolithic ceilings protecting structural steel above. The north end of the 4th Floor corridor up to the four hour vestibule was observed, with the Manager of Facilities present to be unprotected steel structural elements above a lay-in ceiling. This observation constitutes Type II (000) Construction. Roughly 40' of the north end of this corridor was not sprinklered in an otherwise sprinklered fire compartment.

a) A project submitted to the Department to provide sprinkler protection and fire proofing was terminated in 2012 by the Department due to lack of activity and lack of response to Department letters.

3) Tunnels and Crawl spaces - Larry's Pit: There are underground spaces under the north wings of the Hospital. Portions of this space are used as storage spaces. These spaces are not sprinklered and are not separated from other portions of this underground space (mostly crawl space).

a) The crawl spaces and other tunnels are open to a tunnel space that runs along the outside north wall of the Hospital. This tunnel is directly under the Hospital's side walk on the north side of the building. The side walk is also part of the Hospital's means of egress. The concrete above this tunnel is supported by unprotected steel columns and beams. This tunnel is not separated from the Hospital by two hour barriers; the Hospital is therefore Type II (000) construction as defend by NFPA 220.

b) The surveyor observed that a portion of the North Wing is supported by unprotected steel columns and beams that were observed from the east extension of the side walk tunnel, looking south.

c) The extent of the above condition (item "b") is not known and could not be explored due to height of space limitations.

4) Air handling Unit S-11 is located in a separate room on the south side of the building that is only accessible from outside. The sheets of plywood on top of the air handling unit are not compatible with Type I or Type II construction.

Failure to install and maintain fire rated structural assemblies could result in a failure of the building structure during a fire.


16339

Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect all patients, as well as staff and visitors due to required fire resistive construction requirements that are not completely protected to prevent the spread of fire from these areas.

Findings include:

A. In the afternoon of December 19, 2012, Main Building - First Floor, Old Radiology Department -The designated 4 - Hour Building fire separation near the Radiology Supervisor Office (second door from the exit) was observed with unprotected steel beam which does not comply with 19.1.6.2, NFPA 220 1999 3-1.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect any building occupants in the exit access corridors adjacent to the rooms listed, because smoke and fire could pass from them into the corridors.

Findings include:

A. Main Building - Third Floor - Nurse Station NW was observed to be open and not separated from the exit access corridor. The nurse's station was vacant and lacks smoke detection to comply with 19.3.6.1, exception # 1.

B. Main Building - Fifth Floor - G.I. Lab Procedure Room 2 (non-sprinklered compartment) : The required one hour corridor wall was observed with penetrations above the ceiling that are not sealed to comply with 19.3.6.2.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that the doors to exit access corridors do not always have positive latching hardware in accordance with 19.3.6.3.2.

Findings include:

1) 2nd Floor Surgery Building: The corridor T2116 extends south to a surgical suite boundary. The pair of auto-open doors at this suite boundary lack functioning positive latching hardware. The surveyor also notes from fire alarm testing on the morning of 12/19/12 that the auto-open function on these doors is not disabled from fire alarm activation.

2) 2nd Floor Surgery Building: Lobby T2112 has a surgical suite boundary identified in the east side of this Lobby. The pair of doors into the surgical suite lack functioning positive latching hardware. The surveyor also notes from fire alarm testing on the morning of 12/19/12 that the auto-open function on these doors is not disabled from fire alarm activation.

3) 2nd Floor Surgery Building: The PACU Recovery area is identified as a suite. This suite has two pairs of doors at each end. Both pairs of doors lack functioning positive latching hardware. The surveyor also notes from fire alarm testing on the morning of 12/19/12 that the auto-open function on these doors is not disabled from fire alarm activation.

4) 2nd Floor Northwest Wing - ICU Suite: One pair of opposite swinging doors to this suite has one door that does not latch due to air pressure.

5) 3rd Floor Northwest Wing: The pair of auto -open doors to the C-section unit lack functioning positive latching hardware. The surveyor also notes from fire alarm testing on the morning of 12/19/12 that the auto-open function on these doors is not disabled from fire alarm activation.

Failure to maintain corridor doors in accordance with code could allow fire and smoke to spread to corridors in a fire emergency.







16339

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by allowing smoke to pass from the building's exit access corridors to rooms housing them.

Findings include:

A. Main Building - In the afternoon of December 17, 2012, the pair of doors to the Third Floor C-Section Suite, was observed to not be positive latching as required by 19.3.6.3.2.

B. Main Building - Third Floor: Doors in corridors were observed that are being equipped with surface mounted dead bolts on the door. Surveyor observed locking devices in addition to the door hardware set, these doors when locked from the outside of the room will not allow egress from the room during emergency situation to comply with 7.2.1.5.4. Location observed:

1. Med / Surg Unit - Example: Patient Room 322

2. 3-South-Post OP / Inpatient Unit.

A) Based on observation and based upon the lack of documentation, the surveyor finds that vertical openings are not protected in accordance with 8.2. of NFPA 101 - 2000 and/or NFPA 90A - 1999.

Findings include:

1) South Penthouse: Multiple ducts penetrate the fire rated floor assembly without fire dampers installed at the top of each shaft in accordance with NFPA 90A. The room at the top of the shafts referenced has too many many uses including as kitchen exhaust fan, elevator equipment, air compressors etc. all of which conflict with the room as part of the vertical shaft enclosures below

This includes the duct penetration for E64 along with all duct penetrations near E10.

2) 4th Floor Elevator Foyer east of Elevators # 4 and # 5 - there is a closet with a vertical duct shaft in this foyer:

a) (K076) An unsecured oxygen tank was found in the elevator foyer on Monday afternoon.

b) (K056) The elevator foyer lacks sprinkler protection in an otherwise sprinklered zone

c) Two ducts penetrate the west wall of the shaft (one is a black iron kitchen exhaust duct) (the other is a stainless steel dishwasher exhaust duct). There is a void around the ducts in the shaft wall where the ducts penetrate the shaft; the shaft is open to the ceiling cavity of the elevator foyer and the 4th Floor corridor.

d) One or both ducts lack fire dampers where they penetrate the fire rated shaft wall in accordance with NFPA 90A or) one or both ducts lack continuously wrapper fire blanket (or other approved continuous shaft enclosure) from the point that they leave the shaft to the point that they penetrate into the floor above (somewhere above the corridor)

e) One or more electrical junction boxes were screwed into the black iron duct. This duct is not maintained as a seamless welded grease tight duct in accordance with NFPA 96 - 1998.

3) 4th Floor Stair # 6:

a) There is a vertical shaft on the east side of this stair. The shaft enclosure has combustible wood planks in the shaft. This material is not compatible with Type I or Type II construction. The combustible material is not permitted within the shaft enclosure. The shaft is not sprinklered (for concealed spaces with combustibles) in accordance with NFPA 13.

b) The west wall of the shaft, above the access panel has unsealed penetrations.

4) 4th Floor Northwest Wing - there is a two hour shaft enclosure shown on drawings south of the Linen Chute at the corner of the corridors. Almost no access was provided to this shaft; however the surveyor observed, with the Director of Facilities and the Safety Manager present, the walls to this shaft do not extend to the deck above in accordance with 8.2 of NFPA 101.

5) The Patient Rooms on the 4th Floor of the Southwest Wing are typical of many rooms on many floors (but not all rooms) for the southern portion of the building.

a) The patient room window walls have induction units that are not installed in accordance with NFPA 90A - 1975.

i) The vertical risers for the induction units are not enclosed as fire rated shafts from deck to deck. Fire ratings for the shaft enclosures were not available and the shaft terminate above the ceilings.

i) The duct feeds from the vertical risers into the induction units are 3" to 4" in diameter. The provider was not able to demonstrate that this duct feeds at sealed at the shaft enclosure in accordance with the original design requirements from NFPA 90A. Almost every room if not all rooms were patient occupied - access for inspection was extremely limited.

b) Although some of the patient rooms have bathroom exhaust duct runs that extend to shafts with fire dampers, a number of rooms typically at the end of the Southeast and Southwest wings have vertically exhaust ducts that extend to the room, that are not enclosure in fire rate shaft enclosures and that also lack fire dampers where the ducts penetrate required shaft enclosures.

c) Similar conditions to those cited above were observed in the 2nd Floor South Wing patient rooms.

d) Based on observation on two patient floors. Based upon the limited information available from the provider and based upon very limited access to patient rooms for inspection, the surveyors find that the patient rooms on the 3rd and 5th Floor as similar or the same as those observed on the 4th and 2nd Floors and the same deficiencies are expected as those cited under "a" and "b" above.

6) There is an elevator foyer at the west end of 4 Southwest. This elevator has an interstitial space that wraps around the east and north side of the elevator shaft. A large duct extends from the elevator shaft without a fire damper, through the north exterior wall. With this arrangement the interstitial space is part of the elevator shaft enclosure.

a) This interstitial space is not sprinklered

b) The access panel to this interstitial space is not fire rated (not a 1 1/2 hour opening protective).

7) 4th Floor Environmental Services closet opposite Room 409 provides access to a vertical shaft enclosure with multiple systems, ducts, conduit and a kitchen exhaust duct. The provider did not know what was in this shaft and was not able to identify how the kitchen exhaust duct is permitted in this shaft in accordance with NFPA 96.

a) This shaft when viewed from the 4th Floor appears to be open (and not enclosed in a fire rated enclosure) to a portion of the th Floor.

b) One insulted ducts runs horizontally through the shaft and has a fire damper. The west side of the shaft has a duct penetration for which a fire damper was not found.

8) 2nd Floor - Clean Supply Room opposite Room 209: There is a vertical shaft enclosure with a kitchen exhaust duct inside.

a) The shaft access door is damaged and will not close to a latched position.

b) A duct penetrates this shaft horizontally with a fire damper. The provider is not able to demonstrate how this kitchen duct is permitted in the same shaft with other ductwork in accordance with NFPA 90A and NFPA 96.

9) The plans identify a 1st Floor Mechanical Room T1246 near the Main Lobby with a two hour fire rated enclosure.

a) The surveyor finds that this mechanical space is open basement level tunnel spaces below and vertical chases above. Plans are not available for the basement level crawl spaces and connecting tunnels. This mechanical room is not separated from such spaces.

b) The mechanical room and shaft above are open to adjacent ceiling spaces. Duct penetrate the Mechanical Room and shaft above; fire dampers were not found. Access is very limited.

Failure to provide and maintain fire rated shaft enclosures and fire dampers at shaft penetrations will allow fire to spread from floor to floor in a fire emergency.


16339

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.
These deficiencies could affect any patients in the facility, as well as any staff and visitors present, because the lack of proper installation of shaft could result in smoke or fire to migrate from one floor to another.

Findings include:

A. Main Building - 5th Floor Level - Stair #6: Access Panel to shaft enclosure is broken and does not self-close to comply with 8.2.3.2.1.

B. Main Building - 5th Floor Level - Stair #7: The designated two hour fire rated exit stair wall was observed with two duct penetrations with fire dampers that are installed without retaining angles to comply with 7.1. and NFPA 90A.

C. Main Building - Third Floor/Med Surge Unit: The Life Safety drawings indicated two hour shaft walls near the Stair #1 by Patient Room 322 and based upon observation the shaft walls are not two hour fire rated to comply with 19.3.1.1. in accordance with 8.2.5. Also, the shaft above the ceiling contain a hole that is not fire sealed to comply with 8.2.3.2.3.

A) Based on random observation with the Director of Facilities and the Safety Manager present on 12/ 19/12, the surveyor observed that fire doors do not automatically close upon activation of the fire alarm system in accordance with 7.2.1.8. Based on fire alarm testing conducted on the morning of 12/19/12. the surveyor observed:

1) 3rd Floor Northwest Wing - two pairs of fire doors failed to close to a latched position during fire alarm testing. Air pressure prevented the door from closing.

2) The 1st Floor Gift Shop storage room door was wedged open

3) 1st Floor Storage Room 1630 has two pairs of fire doors with magnetic hold open devices. Smoke detection on both sides of the doors installed in accordance with NFPA 72 are not provide in compliance with 7.2.1.8 of NFPA 101.

Failure to close fire or smoke doors in a fire emergency will allow fire to spread to multiple areas.

A) Based on random observation, with the Manager of Facilities present, the surveyor finds that fire doors are held open by means that does not comply with 7.2.1.8:

Findings include:

1) The Northeast Building corridor door to a receiving area has a pair of doors with magnetic hold open devices. Smoke detection on both sides of the doors are not provided in accordance with NFPA 72 and 7.2.1.8 of NFPA 101. One smoke detector is installed 20 feet below the deck above and not in accordance with NFPA 72.

Failure to close fire doors in a fire emergency will allow fire and smoke to spread.

Based on observation, it was determined that the facility failed to provide /maintain properly constructed smoke barriers to meet at least 30 minutes fire resistance rating in accordance with LSC, Sections 8.3 and 19.3.7.3. Locations include:

1. Main Building - Third Floor: Wiring penetrations at a designated smoke barrier wall by Patient Rooms 314 and 319 South were observed that are not sealed to provide a smoke tight wall to comply with Section 8.3.

A) Based on random observation with the the Safety Manager present on 12/18/12, the surveyor observed that hazardous areas are not enclosed in accordance with 19.3.2.1.

Findings include:

1) 5th Floor Southwest: The corridor is used as a holding space for palleted supplies and is not separated from all other others in accordance with 19.3.2.1.

2) Materials Management Room 234 is a hazardous storage area. The corridor door to this space is not fire rated and lacks self closing hardware.

3) 2nd Floor Surgical Building - Surgical Suite:

a) The door to the Clean Equipment Holding Room was taped so that the latch set would not function.

b) Procedure Room # 8 has been converted to a storage use. The door to the room was propped open. The door is also not fire rated and lacks self closing hardware.

c) "Maxwell Street" storage room: The inactive leaf lacks automatic latching hardware (has manual flush bolt instead) and lacks self closing hardware.

4) 1st Floor Kitchen - the east path out of the Kitchen is used as a materials holding or storage area. This area is open to the Kitchen and makes the entire Kitchen a hazardous storage area. The Kitchen will be evaluated as a hazardous area.

Failure to maintain the enclosure of hazardous areas will increase the fuel load in a fire emergency and allow smoke and fire to spread into the corridors that are necessary from movement or evacuation.




16339

Based upon random observation, the surveyor finds that hazardous locations do not comply with 19.3.2.1. These deficiencies could affect all patients, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous areas into the building's exit access corridors.

Findings include:

A. Sprinklered hazardous areas are not provided with smoke-resistant enclosure including self-closing, positive latching doors to comply with the requirements of 19.3.2.1. Locations include:

1. Main Building - Fifth Floor, Wellness Center Testing Office was observed as being used for storage and the door to this room is not self-closing.

A) Based on random observation, with the Manager of Facilities present, the surveyor finds that hazardous areas are not separated from all other portions of the building in accordance with 39.3.2.1.

Findings include:

1) On the afternoon of December 17, 2012, the 3rd Floor corridors were observed to be used as a holding space for: cardboard waste, palleted supplies and large waste carts with bagged waste. This floor is not fully sprinklered and a smoke tight separation was not provided between the corridor and the hazardous storage.

2) Basement Level - The fire door to the Painters Room door does not close to latch.

3) Basement Level - The fire doors to the Bed Storage area were tied open and do not comply with 7.2.1.8 of NFPA 101.

Failure to maintain required separations for hazardous areas could allow fire to spread beyond such areas in a fire emergency.

A) Based on observation with the Director of Facilities and the Safety Manager present, the surveyor finds that required exit enclosures are not installed and maintained in accordance with 7.1 and 8.2 of NFPA 101.

Findings include but are not limited to

1) Stair # 13 serves as a two story exit for the Surgery Building Addition. It is identified on plans as a two hour fire rated enclosure and with a two hour enclosed exit corridor between the East Building and the Surgery Building at the 1st Floor, discharging to the South.

a) Plans fail to this 1st Floor corridor as a
required Exit Passageway.

b) Multiple ducts penetrate the two hour
wall at the 1st Floor between the exit
passageway and the Outpatient Lab and
lack fire dampers and/or fire damper
access panels.

2) The south side of the Hospital has a two story foyer east of the Main Lobby. This foyer has a two story stair that connects the Hospital via a bridge across the street to a medical office building to the south. This two story foyer is identified on plans with a two hour fire rated separation between the foyer and the Hospital.

a) The stair in this foyer lacks an exit
discharge in accordance with 7.7.1
or 7.7.2.

b) A duct penetrates the two hour wall above
the fire doors at the 1st Floor without a
fire damper in accordance with 7.1 and
8.2 of NFPA 101.

3) 1st Floor Stair # 6: The exit enclosure has a fire door that does not latch.

4) The room numbers on plans do not match the actual room numbers used. The following citations were observed in either the exit passageway for Stair # 5 or Stair # 6.

a) The fire doors to Office 1718 has an
unapproved hold open device (device
that does not comply with 7.2.1.8 of
NFPA 101.

b) The fire door to Room 1715 was tied
open.

c) The fire door to Room 1716 had a
closing device that was disabled.

5) Stair # 4 has a side-lite type panel in a steel frame next to the fire door on each floor. The provider is not able to identify how this thin panel at the stair enclosure is part of a two hour fire separation.

6) Stair # 4 serves as a required means of egress for four floors above the 1st Floor. The stair lacks an exit discharge in accordance with 7.7.1 or 7.7.2.

7) Stair # 2 discharges into the 1st Floor corridor; an exit passageway is not identified on any plans for this discharge although two hour walls are provided. One round duct penetration of the two hour west wall of a bathroom lacks a fire damper.

8) The 2nd Floor Design and Construction Office is located directly above the surgery generator. The only exit path from this 2nd Floor space is via a stair to the 1st Floor that is not separated and not provided from storage area that is discharges through.

Failure to maintain exits could result in injury or death to staff and patients in a fire emergency.


16339

Based upon random observation the surveyor finds that exits are not enclosed and maintained as protected path to a public way to comply with Chapter 7 of NFPA 101. These deficiencies could affect any patients from this building and
as well as any staff and visitors because designated exit stairs are not protected against fire or smoke conditions to comply with 8.2.5.2.

Findings include:

1. Main Building - Stair #5 discharges at the First floor through a required exit passageway. This exit passageway is not identified on any facility plans as an exit passageway. This exit passageway does not comply with 7.1.3.2.2 due to the following:

a. Automatic Linen Dispenser was
observed stored within the exit
passageway.

b. An unoccupied Electrical Closet opens
into the exit passageway which does not
comply with 7.1.3.2.1 (d).

2. Main Building - Stair #6 discharges at the First floor through a required exit passageway. This exit passageway is not identified on any facility plans as an exit passageway. This exit passageway does not comply with 7.1.3.2.2 due to the following:

a. The passageway lacks a continuous
protected path to an exit discharge in
accordance with 7.7.1. Surveyor
noted that the passageway contains
ductwork penetrations that are not
dampered, piping and other systems
which do not serve the passageway.

b. Electrical Closet deemed hazardous
opens into the exit passageway which
does not comply with 7.1.3.2.1 (d). This
closet contain two (2) ductwork
penetrations that lack fire dampers.

3. Main Building - Stair #3 discharges at the First Floor. The surveyor finds that the building is not fully sprinklered. The stair discharge does not comply with 7.7.1 or 7.7.2.

4. Main Building - Third Floor Stair #7: Based on observation, the surveyor finds that the stair wall has a gap above the ceiling that is not fire sealed to comply with 7.1.3.2.1.

5. Main Building - First Floor, Stair #1: Based on observation the surveyor finds that an exit discharge enclosure (that serve a 5 story exit stair) does not provide a continuous protected path of escape to comply with 19.3.2. An exit stair enclosure was observed that does not comply with 7.1.3.2.1.(e) except #1. The designated 2-hour fire rated exit passageway lacked separation and protection due to the following:

a. The Exit Discharge of Stair #1 appears
to utilizes an exit passageway. The exit
passageway is not identified on any
plans.

The enclosure contains an elevator
which is open to an exit passageway and
does not meet NFPA 101 2000 -
7.1.3.2.1(d).

b. A duct was observed penetrating
the fire rated walls above the double
doors to E.D. suite which is part of the
exit passageway, and it was observed
to lack a fire damper .

A) Based on random observation, with the Manager of Facilities present, the surveyor finds that exit stair enclosures are not installed and maintained as a continuously protected path in accordance with Chapter 7 and 8 of NFPA 101.

Findings include:

1) Stair # 9 is a required exit stair for Floor 1 - 5 of the Northeast Building.

a) A bicycle was found stored at the 1st Floor landing of Stair 9 on the afternoon of December 17, 2012. (7.1.3.2.3).

b) The Stair Vestibule at the 1st Floor is not identified on Life Safety Plans as a two hour fire rated enclosure. Although other plans identify two hour walls, the Life Safety Plans identify no rating to the north and they identify a one hour wall at the Telecom Closet. Two round duct penetrations of this vestibule were observed with no fire dampers in accordance with NFPA 90A and 7.1.3.2.1 e) exception # 1.

Failure to maintain required exit enclosures could result in injury or death to staff and patients in a fire emergency.

A) Based on observation, with the Manager of Facilities present, the surveyor finds that exits are not maintained as a protected path of travel in accordance with 7.1 of NFPA 101. The surveyor also notes that the Northeast Building is not fully sprinklered.

Findings include:

1) The North Exit Stair (Stair 8) of the East Building is also identified as an exit for the Basement and 2nd Floor of the Northeast Building. The 2nd Floor of the Northeast Building is also an identified exit path for the Hospital. Stair # 8 discharges into a 1st Floor corridor of the Northeast Building and lacks are exit discharge in accordance with 7.7.1 or 7.7.2 of NFPA 101.

Lack of complying exits could result in injury or death the staff and patients in a fire emergency.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that required means of egress are not maintained as a continuously protected path to the outside in accordance with Chapter 7 and 8.2 of NFPA 101.

Findings include:

1) The surveyor finds that patient rooms have latch sets and single cylinder deadbolt locks. The deadbolt locks do not operated in one single motion to release the lock upon operation of the latch set. The deadbolt locks have not been permanently disabled (keys will still operate the locks).. Access to patient rooms was very limited (almost all of them were occupied with patients). This condition applies to all patient rooms (all floors) with door hardware similar to Room 445.

2) The 3rd Floor Northwest Wing has an obstetrics unit with a bracelet security system that also involves electronic locking hardware on exit doors. On 12/19/12, between 11:30 AM and Noon, with multiple security, engineering and 3rd Floor nursing staff present, the provider attempted to demonstrate how this bracelet system worked, how delayed egress locking was provided in accordance with 7.2.1.6.1 and how activation of the fire alarm system releases any locked doors in accordance with 7.2.1.6.1.

After multiple attempts the provider was not able to automatically lock the doors with the security system, was not able to demonstrate that the doors release in 15 seconds and release from activation of the fire alarm system when the doors are electronically locked.

The surveyor further noted that the secured doors did go into alarm but did not necessarily trigger a "code pink" alarm condition that was called for by the provider.

3) 2nd Floor Surgery Building addition: Elevator Lobby T2112 is part of a required exit access corridor. This corridor space lacks two remote paths of egress in accordance 19.2.5.9. Exit signs direct portions of the means of egress into the suites to the south and east which does not comply with 19.2.5.9. The only complying exit paths from this space (a horizontal exit and a exit stair) are next to each other and are not remote.

4) 2nd Floor Southeast Wing: There is an existing pair of cross corridor doors in the corridor with exit signs on both sides of the doors. These doors are not identified as smoke doors or doors in fire barriers. The exit path in both directions are required, however the doors only swing in one direction and do not comply with 7.2.1.4.2.

5) 2nd Floor Surgery Building: The Pre-op area, Recovery area and surgical unit all have pair of doors with automatic openings functions. These doors when opened manually require too much force to open that doors and do not comply with 7.2.1.4.5.

6) 1st Floor Dietary area: The Food Serving area is separated by two fire shutters from the Dining Room. These fire shutters do not show up on the Life Safety Plans. The provider was not able to identify when and how they close

a) An exit path with illuminated exit signs is not provided from all portions of the Servery and from all portions of the Dining Room. Existing exit signs are not always visible from the Dining Room. The Servery has no exit paths without going under the fire shutters and into the Dining Room. The exit path through the Kitchen has been identified as a hazardous area and is not permitted.

7) The 1st Floor Loading Dock receiving area has an exit sign directing an exit path to the Loading Dock. A safe path is not defined by barriers at the loading dock and the drop off at the loading dock lacks barriers to prevent falls.

Failure to provide and maintain adequate means of egress could result in injury or death to staff and patients in a fire emergency.



16339

Based on random observation during the survey walk-through, not all designated exit accesses are properly maintained and arranged to ensure the dependability of evacuation selected so that exits are readily accessible at all times in accordance with 19.2.1, 19.7.3. These deficiencies could affect patients, staff and any visitors because exit access are not being maintained, and tested that exits are not readily accessible especially under fire conditions at any time.

Findings include:

1. Main Building - Third Floor, OB Unit: In the morning of 12/19/12: Designated Exit stair door equipped with magnetic hardware and secured with an electronic card reader is not available to pass through in case of fire or other emergency situation to comply with 19.7.3 and 7.2.1.6.1 Subpart (d). This exit egress door lacks a readily visible signage "PUSH UNTIL ALARM SOUNDS, DOOR CAN BE OPENED IN 15 SECONDS". This deficiency could affect Post Partum Patients patients because this locked door is not being maintained, tested and that this exit egress door is available especially under fire conditions at any time.

2. Main Building - First Floor, Utility Room across CT Procedure: The door to this room protrudes more than 7" into the corridor during it's swing which does not comply with 7.2.1.4.4.

3. Main Building - First Floor, Radiology Suite: Based on observation the exterior door for the Radiology Suite is being provided with a delayed egress lock but lack signage to comply with 7.2.1.6.1. Subpart (d).

4. Main Building - First Floor: Identified Office T1200 near the Women's Dressing Room for the Ultrasound Suite does not have a direct connection to an egress corridor or to an exit when the fire shutter closed to comply with 19.2.5.1. The door to this room was provided with a fire shutter as part of the 4-hour fire separation which closes during fire condition and the occupant(s) from this room would not have any means of egress to exit out of the room.

A. Based on observation, the surveyors finds that designated outpatient suites do not appear to have two remote exit access doors to comply with 19.2.5.2. Example location observed:

1. Main Building - First Floor, Cardiac Cath Lab Suite (identified 3,301 square feet in the Life Safety Plan): The suite is in excess of 2,500 square feet and lacks two remote exit paths to comply with 19.2.5.3.

2. Main Building - First Floor, Ultra Sound Suite: The suite is indicated to be 3,607 square feet with only a single compliant exit access to the corridor which does not comply with 19.2.5.2. An exit sign is directed through the 4 hour vestibule which passes through a second intervening hazardous construction staging area and does not comply with 19.2.5.5.

3. Main Building - Fifth Floor, Central Services Suite: The suite is identified to be 3,168 square feet does not have two remote exit access doors to a corridor to comply with 19.2.5.2.

A) Based on document review and random observation with the Regional VP, Director of Facilities and the Safety Manager present, the surveyors observed two, three and four hour fire barriers are provided throughout the building and multiple four hour Chicago Vestibules are installed on each floor but no always at the same location on each floor. While these Chicago Vestibules could comply as horizontal exit, there is not information available that clearly indicates that they are used as such, that they are required by NFPA 101 and/or how they comply with 19.2.2.5. The surveyor notes that these fire barriers and Chicago Vestibule also defined required smoke compartments; however this information is missing - see K048.

Based on random observation, the surveyor finds that some of these fire barriers are deficient as fire barriers and/or smoke barriers and do not comply with Chapter 8 of NFPA 101.

Findings include

1) Ice Machine Alcove T4037 is defined on some plans with a four hour fire barrier on the west side of the space and with fire barriers on all sides on other plans.

a) There is an existing fire shutter on the east side of the space with a fusible link. The shutter is not designed to close in accordance with 7.2.1.8 and the space has not exit path is the shutter closes.

b) The designed four hour fire barrier at the west side of this space is four inches of pyrobar with voids in the barrier above the ceiling. This condition does not constitute a two hour or a four hour fire barrier.

2) Similar conditions were observed at the same location on the 2nd Floor except that a duct penetration through the designed fire barrier on the 2nd Floor lacks a fire damper.

3) Similar of the same conditions are expected at the 3rd Floor.

Failure to maintain fire barriers will allow smoke and fire to spread to other compartments.





16339


Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies as required by NFPA 101, 8.2.3.2.4.1&2. Findings include:

1. Main Building, Fifth Floor: Designated 4 hour Chicago Vestibule near the Nurse Education Room is a required smoke barrier in addition to a fire barrier. The surveyor observed a duct penetration that is not fire and smoke dampered.

2. Main Building - Third Floor near the Nursery Suite: In the afternoon of 12/18/2012, the designated four (4) hour Chicago Vestibule / fire separation wall near the Nursery Suite was observed with conduit penetrations (2) that are not sealed against fire to comply with 8.2.3.4.4.2.

3. Main Building - First Floor, Emergency Department Suite: In the morning of 12/19/12, the designated two hour fire wall was observed with a duct penetration that is not fire dampered. Location observed above the SE pair of doors to the ED Suite.

4. Main Building - First Floor near the NE Emergency Department Suite: In the morning of 12/19/2012, the designated four (4) hour Chicago Vestibule / fire separation wall near the Nurse Station I and by the Decontamination Room was observed with duct penetrations (2) that are not dampered.

5. Main Building - First Floor - ED: The pair of doors label to the ED Suite (Southeast ) were observed to have been painted over, the Life Safety Plan indicated a 2 hour fire resistance rating wall.

Based on random observation during the survey walk through while accompanied by the senior electrician and the coordinator of building operations, not all exit discharge locations are provided with illumination to comply with NFPA-101, Sections 18.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

1. Exit discharge from some exits use HID type light fixtures that require a warmup period before the lights operate which does not meet the requirements of NFPA-101, Section 7.9.1.2, for lighting to be of instantaneous operation so as not to leave the exit path in darkness.

A) Based on random observation and the lack of full documentation, the surveyor finds that some battery operated emergency lights are not tested and maintained monthly and annually in accordance with 7.9.3 of NFPA 101.

Findings include:

1) Documentation for annual testing was not available.

2) The label on the battery operated light at the end of 4 West indicates that it was last monthly tested in October 2012.

Failure to maintain battery operated lighting could result in failure.


17659


Based on random observation during the survey walk through while accompanied by the senior electrician and the coordinator of building operations, not all portions of the emergency lighting are installed and tested in accordance with NFPA-70, 99, and 101. These deficiencies could affect all persons in the facility required to utilize battery lighting in operating rooms and procedure rooms by leaving surgical staff in the dark during a power outage, and in exit passage ways by preventing safe and unimpeded access to the public way.

Findings include:

1. Records were not kept of the testing of battery lighting in accordance with NFPA-99, Section 3-4.4.2. Records are not maintained for monthly battery lighting tests, (include the location of each battery lighting unit).

2. Records were not kept of the testing of battery lighting in accordance with NFPA-101, Section 7.9.3. Records are not maintained for the 90 minute annual test, (include the location of each battery lighting unit).

A) Based on random observation, with the Manager of Facilities present, the surveyor observed that the NE Building has emergency lighting and exit signs with battery back-up. The provider does not have an itemized list identifying each location. Instead, monthly testing is documented by a date and initials of the tester on each device. The surveyor finds that some devices have not been tested since August of 2012. The Provider could not demonstrate monthly and annual testing of the devices in accordance with 7.9.3 of NFPA 101.

Findings include multiple locations in the NE Building, including but not limited to:

1) Monthly testing - all devices and all levels in Stair 9

2) Annual testing - all devices

Failure to test and maintain emergency lighting may result in failure during normal power loss.

A) Based on random observation, with the Manager of Facilities present, the surveyor finds that exit signs do not always identify a complying exit path.

Findings include:

1) The 2nd Floor corridor of Northeast Building has an exit sign above the door to Stair 8 while the signs above the door to Stair 9 indicates "STAIRS".

Failure to properly identify exit may confuse staff and patients during an emergency.

Based on random observation during the survey walk-through, exit signs were not installed in accordance with 7.10. This deficiency could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

1. Sleep Center, an exit sign was observed that was not properly installed because it appears to direct occupants into a room.

Based on random observation during the survey walk-through, exit signs were not provided or were not fully visible to designate the path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

1. Main Building - Fifth Floor, Stairwell exit sign in the Central Services is not continuously illuminated to comply with 7.10.5.2.

2.Main Building - Fifth Floor, Physical Medicine Suite: Exit signs are not provided to identify egress paths to comply with 7.10.1.1.

3. Main Building - First Floor: The exit sign at the exit access corridor by Room 1209 leads occupants into the Ultrasound Suite.

4. Main Building - Designated exit signs reads "STAIR" and not "EXIT" to comply with 7.10.1.3. Locations observed include:

a. Penthouse exit sign

b. Fifth Floor - Stairs #3 and #4

5. Main Building - First Floor, near Radiology Department Suite: The exit sign by the exit Stair #1 is aimed an incorrect egress path which does not comply with 7.10.1.1.

A) Based on random observation, with the Manager of Facilities present, the surveyor finds that the provider's written fire plan does not comply with 19.7.1.1. Although an abbreviated version of R A C E is posted throughout the facility, the written fire plan indicates that all doors are to be closed before the fire alarm system is to be activated, during a fire.

This difference in fire plans could result in poor staff performance during a fire emergency.

B) All Exit Passageways are not identified on the Life Safety Plans dated February 2012; the provider is not able to demonstrate how most exit discharges comply with 7.7.1 or 7.7.2

C) Underground spaces, crawl spaces and underground tunnels along with the accesses to such spaces are not identified on the Life Safety Plans dated February 2012. The surveyor observes that a portion of this space is used for storage and that the storage use is open to the entire crawl space. The surveyor also observes that a portion of this space may be sprinklered, however there are no barriers that separate the sprinklered area from the unsprinklered area.




16339

Based on the review of the facilities documents it was determined that the facility failed to maintain a written plan for the protection of residents to provide a prompt and effective response in the event of a fire emergency in accordance with LSC, Section 19.7.2.1.

Findings include:

A. Main Building- First Floor, Radiology Suite: In the afternoon of 12/18/12 it was observed that the posted Evacuation Plan near the CT Procedure for the facility was not accurately drawn and the information about the nearest location of exit is not correct.

B. The provider lacks a comprehensive Life Safety Code Master Plan for each floor. The information provided for this survey was not accurate and did not correctly show the buildings conditions observed.

1. Exit Passageways were not indicated, however, the facility representative stated that certain areas were indeed exit passageways, however, during the walk through they were found to be deficient.

2. The size and boundary of each smoke compartment is not identified on plan.

3. Travel distances in suites is not clearly documented.

4. Areas identified on the Life Safety Plan drawings no longer exist. Example: MRI T1223, Control Room T1222 and Mechanical Room T1221.

The surveyor finds that the provider cannot comply with 19.1.1.3 without the information identified above.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that the fire alarm system is not installed in accordance with NFPA 72 - 1999.

Findings include:

1) 1st Floor Fire Alarm Panel Closet between Main Lobby and South Bridge: The fire alarm panel is not continuously attended and the closet lacks a smoke detector above the panel in accordance with NFPA 72, Section 1-5.6.

2) 1st Floor Surgery Building Fire Alarm Panel in closet. This space has a heat detector and not a smoke detector in accordance with NFPA 72.

3) Based on testing on the morning of 12/19/12, the surveyors find that the fire alarm system is not audible through out all area were personnel work and are expected to respond, in accordance with the 5db/10db/15db rules of NFPA 72:

a) 5th Floor Surgery Building Elevator Foyer

b) 5th Floor Southwest Wing include Decontamination and Central Services

Failure to install and maintain the fire alarm system in accordance with code could prevent the fire alarm system from detecting fires and notifying staff and fire rescue personnel.



16339


A. Based on random observation during the survey walk-through and staff interview, not all portions of the building fire alarm system are installed in accordance with 19.3.4 findings include:

1. Second Floor - In the morning of 12/19/12, the fire alarm system within the adjacent Medical Office Building was activated. It is noted that the first primary set of doors between the hospital and the business occupancy did not close during the fire alarm test. The Life Safety Plan identified the two hour fire rated occupancy separation. The surveyor observed that the 4 hour Chicago Vestibule doors and the hold-open door to the Solarium did not close as well during this test with the activation of the smoke detector.

2. Main Building, Second Floor (ICU Suite): Pair of double doors (hold-open) to the ICU Suite near the Stairwell #6 did not close to latch during the activation of the fire alarm system.




17659


Based on random observation during the survey walk through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

1. Panel IR-LRP-CR-1B, and panel LP-3W-C2 have circuits marked as feeding fire alarm that are not marked in red and equipped with a locking device as required by NFPA-72, Section 1-5.2.5.2.

2. The Fire Alarm Control Panels are not labeled with the electrical panel designation and circuit number as required by NFPA 72, Section 1-5.2.5.

3. The fire alarm panels were in areas that were not continuously occupied and did not have a smoke detector above the panel as required by NFPA-72, Section 1-5.6.

A. Sleep Center: The surveyor finds from observation and staff interview that the building has a fire alarm system. Documentation that identifies how the system are tested, service and maintained in accordance with NFPA 72 - 1999 was not available onsite. This could affect all building occupants if the fire alarm system does not initiate an alarm without delay or the components can not be located during a fire emergency.

Failure to maintain the fire alarm systems could result in failure to notify occupants and the fire department in a fire emergency.

A. Wound Care Center: The surveyor finds from observation and staff interview that the building has a fire alarm system. Documentation that identifies how the system are tested, service and maintained in accordance with NFPA 72 - 1999 was not available onsite. This could affect all building occupants if the fire alarm system does not initiate an alarm without delay or the components can not be located during a fire emergency.

Failure to maintain the fire alarm systems could result in failure to notify occupants and the fire department in a fire emergency.

A) Based on random observation with the Director of Facilities and the Safety Manager present the surveyor finds that the sprinkler system is not installed and maintained in accordance with NFPA 13 -1999:

Findings include but are not limited to:

Note: The surveyors find that the building is not fully sprinklered and therefore does not qualify for any exceptions under NFPA 101 for fully sprinklered buildings. The surveyors further observe that no floor is fully sprinklered and that in some cases some smoke or fire compartments are not fully sprinklered.

1) Janitor's Closet 452A is not sprinklered in an otherwise sprinklered area.

2) 4 Center: an ice machine obstructs the sprinkler protection in this area.

3) 4th Floor - Northwest Wing has an assisted bathing area with one toilet room with missing ceiling tiles. The missing ceiling tiles compromises the sprinkler protection in this space.

5) 4th Floor - Northwest Wing - there is a janitor's closet with a sprinkler drain that lacks identifying of what it is, in accordance with NFPA 13.

6) 2nd Floor Equipment Storage Room 235 has a missing ceiling tile which compromises the sprinkler protection in this space.

7) 2nd Floor Southwest Wing: The ice machine alcove is not sprinkler protected in an otherwise sprinklered area.

8) Boiler Room - Fire Pump: access to the fire pump controller and the fire pump, in addition to any switchgear, was blocked by storage in this room.

9) The 1st Floor Cashier's Area is not sprinkler protected in an otherwise sprinklered zone.

10) 1st Floor - Room 1715 (Old Security Area) was under construction and had no ceiling. The sprinkler protection in this area was compromised; the provider was not able to identify what if any interim life safety measures were implemented.

Failure to install and maintain sprinkler protection could result in partial coverage and spread of fire and smoke in a fire emergency.


16339


A. Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.These deficiencies could affect all patients, staff and any visitors due to improper installation of the sprinkler system which can fail to activate under fire conditions.

Findings include:

1. Main Building - First Floor Old fast Track ED: Sprinkler escutcheon plates are missing in the Waiting Area and by the Vending Machine Area.

2. Main Building - Fifth Floor - 4 Hour Chicago vestibule near the Nurse Education Room an escutcheon plate is missing.

3. Main Building - Third Floor, Environmental Services across Patient Room 309: Inspector's Test Pipe drain is not installed to simulate the flow of one sprinkler head in accordance with NFPA 13.

4. Main Building - Third Floor North, OB Linen Chute: Sprinkler head is not installed in the chute in a sprinklered smoke compartment.

A) The surveyor observes that the NE Building is partially sprinklered; however, based on random observation with the Manager of Facilities present, the surveyor finds that the sprinklered areas have sprinkler heads that are not installed in accordance with NFPA 13:

Findings include:

1) 2nd Floor IT Rooms are protected by a drypipe/pre-actions sprinklered system. The sprinkler heads to two of two rooms are partially obstructed by the equipment in the rooms.

2) The Basement Level at the northeast corner has sprinklered heads installed below ribbed slab construction with the head at 12" or more below the lowest structural member. The sprinkler heads are not installed at " or less below structural members in accordance with 5-6.4.1.2 of NFPA 13 - 1999. Other portions of the Basement should be reviewed for compliance.

Failure to install sprinkler protection in accordance with code will result in poor performance in a fire.

A. Sleep Center: The surveyor finds that sprinkler documentation for this building was not available on site. Documentation was not available for

1. Quarterly flow testing

2) Annual testing, service and maintenance of the sprinkler system in accordance with NFPA 25

A. Wound Care Center: The surveyor finds that sprinkler documentation for this building was not available on site. Documentation was not available for

1. Quarterly flow testing

2) Annual testing, service and maintenance of the sprinkler system in accordance with NFPA 25

1. 6th floor Mechanical Room (T6003). By direct observation in the company of the Coordinator of Building Operations the surveyor could not determine that all duct penetrations through floor or shaft enclosures contain fire damper at the following locations.

a. Shaft (T6008) next to the elevator shafts, the supply duct penetrations (2).

b. Floor penetration in the maintenance shop space (T6011) East and South of the elevator shafts.

2. 6th floor Mechanical Room (T6015).

a. Floor penetration for exhaust fan E62.

b. Floor penetration for exhaust fan E63.

c. Floor penetration for what appears to be dishwasher exhaust East of the kitchen exhaust fans.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that kitchen hood suppression systems are not installed and maintained in accordance with NFPA 17 and 96.

Findings include:

1) The 1st Floor Dietary main cooking line has a hood with grease filters that do not fit tightly together, that are gaps in the filters that allow grease to bypass the filters.

2) The cooking equipment, the walls next to the cooking equipment and the floors under the cooking equipment are all coated with grime, grease and food product. The surveyor notes that this is a potential health hazard but also finds that it constitutes a potential fire hazard.

Failure maintain kitchen hood suppression system and the environment near such could result in a fire.






14416

6th floor mechanical room (T6015 ) contain equipment for elevators No. 1 & 2 and exhaust fans. By direct observation the afternoon of 12/17/12 while in the company of the Coordinator of Building Operations,

a. The surveyor finds the duct connections to the two utility fan set for the first floor kitchen grease hood exhaust are not by way of flanges and bolted in compliance with NFPA 96, 1998, 5-1.3. The connections are by way of fabric collars and do not appear to be listed devices. The fan and duct assemblies appear to contain fusible fire link guillotine type dampers. Through staff interview this could not be confirmed and that these dampers were still active.

A) Based on random observation with the Safety Manager present on 12/18/12, the surveyor observed that portable electric heaters are used that have heating elements that exceed 212 degrees F and that do not comply with the requirements of 19.7.8.

Findings include but are not limited to:

1) Portable heater in Room 1718

2) Portable heater in Room 1716

Use of unapproved portable heating devices could cause a fire.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/17/12 - 12/19/12, the surveyor observed that exit access corridors were obstructed and are not maintained in accordance with 7.1.10 and 19.3.6.1.

Findings include:

1) 4th Floor - Northeast Wing: The corridor was continuously (reduced in width to less than 8'-0") by unattended computers on wheels and isolation carts. This was in addition to cleaning equipment, food service carts and laundry hampers that were moving around and more or less attended (and are therefore permitted).

2) 2nd Floor - Surgery Building Corridor T2116: On 12/18/12, with the Director of Facilities present, the surveyor observed that this designated exit access corridor was substantially obstructed to 4'-0" or less. The coat rack, supplies, equipment, carts, etc. in this corridor constitute an unenclosed hazardous area that does not comply with 19.3.2.1 and/or 19.3.6.1. Immediate correction was required. The same condition was observed on 12/19/12.

3) 2nd Floor - Surgery Building Recover area. The corridor to the south out of this space was obstructed by a gurney and by empty blue linen carts.

Failure to maintain the means of egress will delay movement or evacuation in an emergency.



16339

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. This deficient practice could effect all patients and staff as well as visitors who must utilize the exit access corridors because means of egress are not continuously maintained.

Findings include:

A. Main Building, Fifth Floor - G.I. equipment and Scrubs / Aprons Rack were observed stored in exit access corridor that obstruct egress, and the required 8'-0" corridor width is not being maintained to comply with 19.2.3.3. and 7.1.10.1.

B. Main Building - Third Floor, OB Unit: In the morning of 12/17/12 it was observed that the corridor ceiling in the 3rd floor OB department was not at the minimum 7'-6" height required by 7.1.5. Height was approximately 7'-2". This deficient practice could effect all patients and staff as well as visitors who must utilize the exit access corridors.

C. Main Building - First Floor, E.D. NE corner of the Old fast track was being obstructed with chairs and reduce the required aisle width.

D. Main Building - First Floor, E.D: Exit access corridor near the ED Staff Lounge behind the Old Fast Track was being obstructed with Linen Carts and Medical Equipment.

A) Based on random observation with the Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that oxygen storage does not always comply with NFPA 99. The 2nd Floor Surgery Building "Maxwell Street" storage room was observed to have oxygen tanks stored directly under a wood cabinet and with combustible storage that was too close to the oxygen tanks.

Failure to properly store oxygen tanks could result in a fire that is aggravated by an oxygen source.

Based on direct observation, the surveyor finds the facility failed to provide separation by an intervening wall between the medical gas zone valves and the outlets they serve to comply with NFPA 99, 1999, 4-3.1.2.3 (d). These deficiencies could pose a potential hazard to patients if medical gas zone valves are not installed properly in accordance with NFPA 99.

A. In the morning of 12/19/12, by direct observation the surveyor finds that not all medical gas zone valves are separated from the outlets/inlets they serve. This does not comply with NFPA 99, 1999, 4-3.1.2.3. Locations observed:

1. Main Building - First Floor, E. R. Suite, E.R. Examination Bays (A, B, C, D,E, and F):

2. Main Building - First Floor, E. R. Suite serving bays D, E, F, G, and H

3. Main - First Floor, Radiology Suite for Prep/Recovery Bays

4. Main Building - First Floor, Ultrasound Suite

5. Main Building - First Floor, Cardiac Cath Suite

6. Main/Surgery Building - Second Floor, Post/OP Recovery Area

A) From random observation the surveyor finds that the building is not fully sprinklered and smoke dampers are not installed at designated smoke barriers in accordance with 8.3.6 of NFPA 101.

Findings include but are not limited to:

1) 3rd Floor Southeast Wing: The four hour vestibule between 3 SE and the Surgery Building addition to the east is a required smoke barrier. It is not identified as a smoke barrier on plans. Both smoke compartments lack sprinkler protection; one duct penetration lacks a smoke damper in accordance with 8.3.6 of NFPA 101 and in accordance with NFPA 90.

2) 3rd Floor Southeast Wing: The four hour vestibule between 3 SE and the Recovery Room of Surgery Building addition to the east is a required smoke barrier. It is not identified as a smoke barrier on plans. Both smoke compartments lack sprinkler protection; one duct penetration has a fire damper but lacks a smoke damper in accordance with 8.3.6 of NFPA 101 and in accordance with NFPA 90.

Failure to provide and maintain smoke dampers in unsprinklered buildings will allow smoke to spread to multiple areas in a fire emergency.

Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.


Findings include:

1. The surgery building emergency generator did not have remote shut down switches to comply with NFPA-110, Section 3-5.5.6.

2. Three of three emergency generators did not have a remote annunciators or a derangement signal at a 24 hour staffed location to meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

The facilities emergency power system is not installed and maintained in accordance with the 1999 Editions of NFPA 70, 99 and 110, in accordance with 21.2.9 NFPA 101- 2000.

1) The documentation of monthly load testing of the generators does not include amperage readings of all three phases.

Failure to test and maintain the emergency generator could result in failure during a loss of normal power to the facility.

Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panels EP-4W-1, LP-3W-C, LP-3W-C2, LP621, CLP-2W-2, ER-CP1, 1R-LRP-CR-1B, and 1-CLR-3 had circuits feeding the fire alarm panels, med gas alarm panels, and elevator cab lighting (these items should be served from the life safety panel). This does not meet the requirements of NFPA-70, Section 517-32 and 33.

2. Life safety panel EMLP-4 is serving a cardiac monitor and panel EM-L11 is serving the operating rooms on the fifth floor, (should be served by the critical branch), which does not meet the requirements of NFPA-70, Section 517-32.

A) Based on random observation with the Manager of Facilities present the surveyor finds that electrical installations and materials do not comply with NFPA 70-1999:

Findings include but are not limited to:

1) Electrical rooms are not sprinklered in the NE Building but are used for combustible storage;

a) Two 3rd Floor Electrical Rooms are used for combustible storage but are not sprinklered.

b) A large 3rd Floor switchgear room is used for combustible storage. The room is not sprinklered and the storage blocks access to electrical gear. 3'-0" is not maintained in front of panels and switchgear.

c) The 1st Floor Electrical Room next to the Trash Compactor Room is used for combustible storage and the room is not sprinklered. One of two doors to this room was blocked shut, in spite of sign on door that indicates "do not block."

2) Electrical extension cords are in use

a) 2nd Floor Respiratory Care has an extension cord that runs through a door opening.

b) 2nd Floor Solarium - Christmas Tree on an extension cord

c) Basement Painters Room - orange extension cord.

3) 1st Floor Maintenance Shop - 2 x 4 light fixtures have storage on top of the suspended fixtures.

Failure to maintain electrical rooms could reduce access in an emergency. Use of extension cords for permanent installations could cause a fire. Improper storage on top of electrical fixtures could cause a fire.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present, the surveyor observed that electrical installations, equipment and materials are not installed and maintained in accordance with NFPA 70 - 1999.

Findings include:

1) Access to electrical panels and switchgear is blocked; 36" of clear space and a clear path are not provided and maintained.

a) 2nd Floor Elevator Foyer east of Elevator 4 and 5 - access to panels is blocked by gurneys.

b) 2nd Floor Surgical Suite - aisle in front of Cysto Room access is blocked to electrical panels

c) 2nd Floor Surgical Suite - Closet with Panel 2-LR-2

i) The room is used for storage but lacks sprinkler protection in accordance with NFPA 13.

ii) Storage items block access to panels

d) 2nd Floor Surgical Suite opposite O R # 1 - access to panels is blocked by supply carts.

e) Boiler Room East Wall - access to panels and switches is blocked by storage.

2) Electrical extension cords are used for permanent installations; electrical wiring does not comply with NFPA 70:

a) 1st Floor Kitchen - Ice Cream Chest has an orange extension cord.

b) Air handling Unit S-11 is located in a separate room on the south side of the building that is only accessible from outside. A yellow electrical cord in permanent use is not wiring in conduit in accordance with NFPA 70 and multiple junction boxes lack covers.

c) 1st Floor Gift Shop - the cashiers' area has multiple extension cords.

d) The 1st Floor Nursing Administration House Managers Office has multiple plug strips that are plugged in in series.

Failure to install and maintain electrical systems in accordance with code could cause a fire.


16339

Based on random observation during the survey walk-through, not all portions of the facility's electrical system are installed in accordance with NFPA 70.

Findings include:

A. Main Building - Fifth Floor - : The Electrical panel directories are not updated and or labeled accurately as to what circuits they serves. These deficiencies could affect any patients being treated in the Physical Rehab and Cardiac Rehab because power and light may not always be available to provide treatment. Location observed:

1. Physical Medicine - LP-5NW-S.

2. Electrical Closet near the Chemistry lab - LP-5W-1-ESS and
LP-5W-2-ESS

B. Main Building - 5th Floor Lab: In the morning of 12/18/12 electrical panel was observed at which a clear working space of 3'-0" in front of the panel is not maintained as required by NFPA 70 1999 110-26(a). Locations observed include:

1. Utility Closet - Electrical Panel LP-5E-3-ESS is being blocked with trash carts.

C. Main Building - Third Floor NW, Electrical Closet was observed with stored ceiling panels and staff gowns, the 3'-0" required clearance in front of the panel is not being maintained.

D. Electrical junction boxes were observed that are not equipped with cover plates required by NFPA 70 1999 370-25. Locations observed include:

1. Main Building - Third Floor, above ceiling in the Clean Utility Room.

2. Main Building - First Floor, ED Suite: above ceiling in the Equipment Room




17659


Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Normal power receptacles were not provided in operating rooms on the second floor, in the patient rooms on the second floor, in the ICU, the GI unit operating rooms, recovery rooms, and patient rooms on the fifth floor, as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

2. Bonding of the piping for the medical gas system could not be located by staff as required by NFPA-70, Section 250-104(c). This could cause a potential difference between med gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

3. Emergency receptacles in the operating rooms on the fifth floor, and other patient bed locations were not all identified as emergency receptacles. All receptacles or cover plates served by critical power shall have a distinctive color or marking so as to be readily identifiable in accordance with NFPA-99, Section 3-4.2.2.4(a)2, and NFPA-70, Section 517-19(a). This could cause confusion during a power outage trying to locate an emergency receptacle for critical care equipment.

4. The operating rooms were not equipped with battery lights to comply with NFPA-99, Section 3-3.2.1.2(a)5e.

By direct observation the afternoon of 12/18/12 in the company of the Coordinator of Building Operations, the surveyor finds that sprinkler protection is provided in the penthouse elevator machine room (located at the fifth floor level of Stair Tower No. 1) for the elevator identified in the machine room as Elevator No.1, however heat detectors are not provided or install within 2 feet of each sprinkler head for elevator shut down prior to the discharge of water as required by NFPA 72, 1999 3-9.4 & ANSI/ASME A17.1, 102.2, c, .3).

A) Based on observation with the Director of Facilities and the Safety Manager present, the surveyor observed that the existing dumbwaiter shaft opposite room 431 has a dumbwaiter door that will open without the dumbwaiter present. This was observed on Tuesday 12/18/12 and it does not comply with ANSI A17.3.

This condition could cause serious harm to anyone that opens the dumbwaiter door.


17659


Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. The surveyor did not find a single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation of each elevator as required by NFPA-70, Section 620-53.

2. The surveyor did not find that the disconnect for the emergency lighting and controls for each elevator was fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

A) Based upon random observation throughout the Hospital, based on document review and/or the lack of documentation and based on personnel interview of the Regional Director of Facilities and the Manager of Facilities, the surveyor finds that portions of the Hospital are Type II (000) Construction, as defined by NFPA 220. The Hospital is a five story building that does not comply with the minimum construction type requirements of 19.1.6.2:

Finding include but are not limited to:

1) The provider lacks detailed information that includes the construction type (as defined by NFPA 220) and the UL Floor/ceiling (or Roof/ceiling) Assembly Numbers (or equivalent) for each project and each addition spanning over a period of 67 years. The surveyors observed a number of variations of reinforced concrete construction.

a) Some of this was clearly fire rated for two hours or more. However, portions of the building have ribbed slab concrete construction. Some but not all of this ribbed slab construction has been fire proofed. The provider also has information (recent FSES by Rolf Jensen) that indicates that portions of the building have concrete floor assemblies that are not at least two hour construction. This information was conveyed verbally but was not shown to the surveyors.

example: 4th Floor Environmental Services closet opposite Room 409 has a plaster ceiling with holes and at least one duct penetration. There is concrete ribbed slab construction above this ceiling. A UL Design Number identifying this area with a two hour floor/ceiling assembly was not available.

b) Portions of the building have steel structural members. Some of this structure is protected as a fire rated assembly with monolithic ceilings. UL numbers for these systems were not available. Portions of the Main Building have been fire proofed via a project that was not completed. U DL Design Numbers for the systems used for this project were not submitted to the Department and were not available on site. Portions of the building have structural steel elements that are unprotected (see below).

c) It was not possible to investigate this condition in most patient rooms. Most of the patients rooms were occupied and access was limited.

2) While portions of the 4th Floor have fire proofed steel above lay-in ceilings and/or monolithic ceilings protecting structural steel above. The north end of the 4th Floor corridor up to the four hour vestibule was observed, with the Manager of Facilities present to be unprotected steel structural elements above a lay-in ceiling. This observation constitutes Type II (000) Construction. Roughly 40' of the north end of this corridor was not sprinklered in an otherwise sprinklered fire compartment.

a) A project submitted to the Department to provide sprinkler protection and fire proofing was terminated in 2012 by the Department due to lack of activity and lack of response to Department letters.

3) Tunnels and Crawl spaces - Larry's Pit: There are underground spaces under the north wings of the Hospital. Portions of this space are used as storage spaces. These spaces are not sprinklered and are not separated from other portions of this underground space (mostly crawl space).

a) The crawl spaces and other tunnels are open to a tunnel space that runs along the outside north wall of the Hospital. This tunnel is directly under the Hospital's side walk on the north side of the building. The side walk is also part of the Hospital's means of egress. The concrete above this tunnel is supported by unprotected steel columns and beams. This tunnel is not separated from the Hospital by two hour barriers; the Hospital is therefore Type II (000) construction as defend by NFPA 220.

b) The surveyor observed that a portion of the North Wing is supported by unprotected steel columns and beams that were observed from the east extension of the side walk tunnel, looking south.

c) The extent of the above condition (item "b") is not known and could not be explored due to height of space limitations.

4) Air handling Unit S-11 is located in a separate room on the south side of the building that is only accessible from outside. The sheets of plywood on top of the air handling unit are not compatible with Type I or Type II construction.

Failure to install and maintain fire rated structural assemblies could result in a failure of the building structure during a fire.


16339

Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect all patients, as well as staff and visitors due to required fire resistive construction requirements that are not completely protected to prevent the spread of fire from these areas.

Findings include:

A. In the afternoon of December 19, 2012, Main Building - First Floor, Old Radiology Department -The designated 4 - Hour Building fire separation near the Radiology Supervisor Office (second door from the exit) was observed with unprotected steel beam which does not comply with 19.1.6.2, NFPA 220 1999 3-1.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect any building occupants in the exit access corridors adjacent to the rooms listed, because smoke and fire could pass from them into the corridors.

Findings include:

A. Main Building - Third Floor - Nurse Station NW was observed to be open and not separated from the exit access corridor. The nurse's station was vacant and lacks smoke detection to comply with 19.3.6.1, exception # 1.

B. Main Building - Fifth Floor - G.I. Lab Procedure Room 2 (non-sprinklered compartment) : The required one hour corridor wall was observed with penetrations above the ceiling that are not sealed to comply with 19.3.6.2.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that the doors to exit access corridors do not always have positive latching hardware in accordance with 19.3.6.3.2.

Findings include:

1) 2nd Floor Surgery Building: The corridor T2116 extends south to a surgical suite boundary. The pair of auto-open doors at this suite boundary lack functioning positive latching hardware. The surveyor also notes from fire alarm testing on the morning of 12/19/12 that the auto-open function on these doors is not disabled from fire alarm activation.

2) 2nd Floor Surgery Building: Lobby T2112 has a surgical suite boundary identified in the east side of this Lobby. The pair of doors into the surgical suite lack functioning positive latching hardware. The surveyor also notes from fire alarm testing on the morning of 12/19/12 that the auto-open function on these doors is not disabled from fire alarm activation.

3) 2nd Floor Surgery Building: The PACU Recovery area is identified as a suite. This suite has two pairs of doors at each end. Both pairs of doors lack functioning positive latching hardware. The surveyor also notes from fire alarm testing on the morning of 12/19/12 that the auto-open function on these doors is not disabled from fire alarm activation.

4) 2nd Floor Northwest Wing - ICU Suite: One pair of opposite swinging doors to this suite has one door that does not latch due to air pressure.

5) 3rd Floor Northwest Wing: The pair of auto -open doors to the C-section unit lack functioning positive latching hardware. The surveyor also notes from fire alarm testing on the morning of 12/19/12 that the auto-open function on these doors is not disabled from fire alarm activation.

Failure to maintain corridor doors in accordance with code could allow fire and smoke to spread to corridors in a fire emergency.







16339

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by allowing smoke to pass from the building's exit access corridors to rooms housing them.

Findings include:

A. Main Building - In the afternoon of December 17, 2012, the pair of doors to the Third Floor C-Section Suite, was observed to not be positive latching as required by 19.3.6.3.2.

B. Main Building - Third Floor: Doors in corridors were observed that are being equipped with surface mounted dead bolts on the door. Surveyor observed locking devices in addition to the door hardware set, these doors when locked from the outside of the room will not allow egress from the room during emergency situation to comply with 7.2.1.5.4. Location observed:

1. Med / Surg Unit - Example: Patient Room 322

2. 3-South-Post OP / Inpatient Unit.

A) Based on observation and based upon the lack of documentation, the surveyor finds that vertical openings are not protected in accordance with 8.2. of NFPA 101 - 2000 and/or NFPA 90A - 1999.

Findings include:

1) South Penthouse: Multiple ducts penetrate the fire rated floor assembly without fire dampers installed at the top of each shaft in accordance with NFPA 90A. The room at the top of the shafts referenced has too many many uses including as kitchen exhaust fan, elevator equipment, air compressors etc. all of which conflict with the room as part of the vertical shaft enclosures below

This includes the duct penetration for E64 along with all duct penetrations near E10.

2) 4th Floor Elevator Foyer east of Elevators # 4 and # 5 - there is a closet with a vertical duct shaft in this foyer:

a) (K076) An unsecured oxygen tank was found in the elevator foyer on Monday afternoon.

b) (K056) The elevator foyer lacks sprinkler protection in an otherwise sprinklered zone

c) Two ducts penetrate the west wall of the shaft (one is a black iron kitchen exhaust duct) (the other is a stainless steel dishwasher exhaust duct). There is a void around the ducts in the shaft wall where the ducts penetrate the shaft; the shaft is open to the ceiling cavity of the elevator foyer and the 4th Floor corridor.

d) One or both ducts lack fire dampers where they penetrate the fire rated shaft wall in accordance with NFPA 90A or) one or both ducts lack continuously wrapper fire blanket (or other approved continuous shaft enclosure) from the point that they leave the shaft to the point that they penetrate into the floor above (somewhere above the corridor)

e) One or more electrical junction boxes were screwed into the black iron duct. This duct is not maintained as a seamless welded grease tight duct in accordance with NFPA 96 - 1998.

3) 4th Floor Stair # 6:

a) There is a vertical shaft on the east side of this stair. The shaft enclosure has combustible wood planks in the shaft. This material is not compatible with Type I or Type II construction. The combustible material is not permitted within the shaft enclosure. The shaft is not sprinklered (for concealed spaces with combustibles) in accordance with NFPA 13.

b) The west wall of the shaft, above the access panel has unsealed penetrations.

4) 4th Floor Northwest Wing - there is a two hour shaft enclosure shown on drawings south of the Linen Chute at the corner of the corridors. Almost no access was provided to this shaft; however the surveyor observed, with the Director of Facilities and the Safety Manager present, the walls to this shaft do not extend to the deck above in accordance with 8.2 of NFPA 101.

5) The Patient Rooms on the 4th Floor of the Southwest Wing are typical of many rooms on many floors (but not all rooms) for the southern portion of the building.

a) The patient room window walls have induction units that are not installed in accordance with NFPA 90A - 1975.

i) The vertical risers for the induction units are not enclosed as fire rated shafts from deck to deck. Fire ratings for the shaft enclosures were not available and the shaft terminate above the ceilings.

i) The duct feeds from the vertical risers into the induction units are 3" to 4" in diameter. The provider was not able to demonstrate that this duct feeds at sealed at the shaft enclosure in accordance with the original design requirements from NFPA 90A. Almost every room if not all rooms were patient occupied - access for inspection was extremely limited.

b) Although some of the patient rooms have bathroom exhaust duct runs that extend to shafts with fire dampers, a number of rooms typically at the end of the Southeast and Southwest wings have vertically exhaust ducts that extend to the room, that are not enclosure in fire rate shaft enclosures and that also lack fire dampers where the ducts penetrate required shaft enclosures.

c) Similar conditions to those cited above were observed in the 2nd Floor South Wing patient rooms.

d) Based on observation on two patient floors. Based upon the limited information available from the provider and based upon very limited access to patient rooms for inspection, the surveyors find that the patient rooms on the 3rd and 5th Floor as similar or the same as those observed on the 4th and 2nd Floors and the same deficiencies are expected as those cited under "a" and "b" above.

6) There is an elevator foyer at the west end of 4 Southwest. This elevator has an interstitial space that wraps around the east and north side of the elevator shaft. A large duct extends from the elevator shaft without a fire damper, through the north exterior wall. With this arrangement the interstitial space is part of the elevator shaft enclosure.

a) This interstitial space is not sprinklered

b) The access panel to this interstitial space is not fire rated (not a 1 1/2 hour opening protective).

7) 4th Floor Environmental Services closet opposite Room 409 provides access to a vertical shaft enclosure with multiple systems, ducts, conduit and a kitchen exhaust duct. The provider did not know what was in this shaft and was not able to identify how the kitchen exhaust duct is permitted in this shaft in accordance with NFPA 96.

a) This shaft when viewed from the 4th Floor appears to be open (and not enclosed in a fire rated enclosure) to a portion of the th Floor.

b) One insulted ducts runs horizontally through the shaft and has a fire damper. The west side of the shaft has a duct penetration for which a fire damper was not found.

8) 2nd Floor - Clean Supply Room opposite Room 209: There is a vertical shaft enclosure with a kitchen exhaust duct inside.

a) The shaft access door is damaged and will not close to a latched position.

b) A duct penetrates this shaft horizontally with a fire damper. The provider is not able to demonstrate how this kitchen duct is permitted in the same shaft with other ductwork in accordance with NFPA 90A and NFPA 96.

9) The plans identify a 1st Floor Mechanical Room T1246 near the Main Lobby with a two hour fire rated enclosure.

a) The surveyor finds that this mechanical space is open basement level tunnel spaces below and vertical chases above. Plans are not available for the basement level crawl spaces and connecting tunnels. This mechanical room is not separated from such spaces.

b) The mechanical room and shaft above are open to adjacent ceiling spaces. Duct penetrate the Mechanical Room and shaft above; fire dampers were not found. Access is very limited.

Failure to provide and maintain fire rated shaft enclosures and fire dampers at shaft penetrations will allow fire to spread from floor to floor in a fire emergency.


16339

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.
These deficiencies could affect any patients in the facility, as well as any staff and visitors present, because the lack of proper installation of shaft could result in smoke or fire to migrate from one floor to another.

Findings include:

A. Main Building - 5th Floor Level - Stair #6: Access Panel to shaft enclosure is broken and does not self-close to comply with 8.2.3.2.1.

B. Main Building - 5th Floor Level - Stair #7: The designated two hour fire rated exit stair wall was observed with two duct penetrations with fire dampers that are installed without retaining angles to comply with 7.1. and NFPA 90A.

C. Main Building - Third Floor/Med Surge Unit: The Life Safety drawings indicated two hour shaft walls near the Stair #1 by Patient Room 322 and based upon observation the shaft walls are not two hour fire rated to comply with 19.3.1.1. in accordance with 8.2.5. Also, the shaft above the ceiling contain a hole that is not fire sealed to comply with 8.2.3.2.3.

A) Based on random observation with the Director of Facilities and the Safety Manager present on 12/ 19/12, the surveyor observed that fire doors do not automatically close upon activation of the fire alarm system in accordance with 7.2.1.8. Based on fire alarm testing conducted on the morning of 12/19/12. the surveyor observed:

1) 3rd Floor Northwest Wing - two pairs of fire doors failed to close to a latched position during fire alarm testing. Air pressure prevented the door from closing.

2) The 1st Floor Gift Shop storage room door was wedged open

3) 1st Floor Storage Room 1630 has two pairs of fire doors with magnetic hold open devices. Smoke detection on both sides of the doors installed in accordance with NFPA 72 are not provide in compliance with 7.2.1.8 of NFPA 101.

Failure to close fire or smoke doors in a fire emergency will allow fire to spread to multiple areas.

A) Based on random observation, with the Manager of Facilities present, the surveyor finds that fire doors are held open by means that does not comply with 7.2.1.8:

Findings include:

1) The Northeast Building corridor door to a receiving area has a pair of doors with magnetic hold open devices. Smoke detection on both sides of the doors are not provided in accordance with NFPA 72 and 7.2.1.8 of NFPA 101. One smoke detector is installed 20 feet below the deck above and not in accordance with NFPA 72.

Failure to close fire doors in a fire emergency will allow fire and smoke to spread.

Based on observation, it was determined that the facility failed to provide /maintain properly constructed smoke barriers to meet at least 30 minutes fire resistance rating in accordance with LSC, Sections 8.3 and 19.3.7.3. Locations include:

1. Main Building - Third Floor: Wiring penetrations at a designated smoke barrier wall by Patient Rooms 314 and 319 South were observed that are not sealed to provide a smoke tight wall to comply with Section 8.3.

A) Based on random observation with the the Safety Manager present on 12/18/12, the surveyor observed that hazardous areas are not enclosed in accordance with 19.3.2.1.

Findings include:

1) 5th Floor Southwest: The corridor is used as a holding space for palleted supplies and is not separated from all other others in accordance with 19.3.2.1.

2) Materials Management Room 234 is a hazardous storage area. The corridor door to this space is not fire rated and lacks self closing hardware.

3) 2nd Floor Surgical Building - Surgical Suite:

a) The door to the Clean Equipment Holding Room was taped so that the latch set would not function.

b) Procedure Room # 8 has been converted to a storage use. The door to the room was propped open. The door is also not fire rated and lacks self closing hardware.

c) "Maxwell Street" storage room: The inactive leaf lacks automatic latching hardware (has manual flush bolt instead) and lacks self closing hardware.

4) 1st Floor Kitchen - the east path out of the Kitchen is used as a materials holding or storage area. This area is open to the Kitchen and makes the entire Kitchen a hazardous storage area. The Kitchen will be evaluated as a hazardous area.

Failure to maintain the enclosure of hazardous areas will increase the fuel load in a fire emergency and allow smoke and fire to spread into the corridors that are necessary from movement or evacuation.




16339

Based upon random observation, the surveyor finds that hazardous locations do not comply with 19.3.2.1. These deficiencies could affect all patients, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous areas into the building's exit access corridors.

Findings include:

A. Sprinklered hazardous areas are not provided with smoke-resistant enclosure including self-closing, positive latching doors to comply with the requirements of 19.3.2.1. Locations include:

1. Main Building - Fifth Floor, Wellness Center Testing Office was observed as being used for storage and the door to this room is not self-closing.

A) Based on random observation, with the Manager of Facilities present, the surveyor finds that hazardous areas are not separated from all other portions of the building in accordance with 39.3.2.1.

Findings include:

1) On the afternoon of December 17, 2012, the 3rd Floor corridors were observed to be used as a holding space for: cardboard waste, palleted supplies and large waste carts with bagged waste. This floor is not fully sprinklered and a smoke tight separation was not provided between the corridor and the hazardous storage.

2) Basement Level - The fire door to the Painters Room door does not close to latch.

3) Basement Level - The fire doors to the Bed Storage area were tied open and do not comply with 7.2.1.8 of NFPA 101.

Failure to maintain required separations for hazardous areas could allow fire to spread beyond such areas in a fire emergency.

A) Based on observation with the Director of Facilities and the Safety Manager present, the surveyor finds that required exit enclosures are not installed and maintained in accordance with 7.1 and 8.2 of NFPA 101.

Findings include but are not limited to

1) Stair # 13 serves as a two story exit for the Surgery Building Addition. It is identified on plans as a two hour fire rated enclosure and with a two hour enclosed exit corridor between the East Building and the Surgery Building at the 1st Floor, discharging to the South.

a) Plans fail to this 1st Floor corridor as a
required Exit Passageway.

b) Multiple ducts penetrate the two hour
wall at the 1st Floor between the exit
passageway and the Outpatient Lab and
lack fire dampers and/or fire damper
access panels.

2) The south side of the Hospital has a two story foyer east of the Main Lobby. This foyer has a two story stair that connects the Hospital via a bridge across the street to a medical office building to the south. This two story foyer is identified on plans with a two hour fire rated separation between the foyer and the Hospital.

a) The stair in this foyer lacks an exit
discharge in accordance with 7.7.1
or 7.7.2.

b) A duct penetrates the two hour wall above
the fire doors at the 1st Floor without a
fire damper in accordance with 7.1 and
8.2 of NFPA 101.

3) 1st Floor Stair # 6: The exit enclosure has a fire door that does not latch.

4) The room numbers on plans do not match the actual room numbers used. The following citations were observed in either the exit passageway for Stair # 5 or Stair # 6.

a) The fire doors to Office 1718 has an
unapproved hold open device (device
that does not comply with 7.2.1.8 of
NFPA 101.

b) The fire door to Room 1715 was tied
open.

c) The fire door to Room 1716 had a
closing device that was disabled.

5) Stair # 4 has a side-lite type panel in a steel frame next to the fire door on each floor. The provider is not able to identify how this thin panel at the stair enclosure is part of a two hour fire separation.

6) Stair # 4 serves as a required means of egress for four floors above the 1st Floor. The stair lacks an exit discharge in accordance with 7.7.1 or 7.7.2.

7) Stair # 2 discharges into the 1st Floor corridor; an exit passageway is not identified on any plans for this discharge although two hour walls are provided. One round duct penetration of the two hour west wall of a bathroom lacks a fire damper.

8) The 2nd Floor Design and Construction Office is located directly above the surgery generator. The only exit path from this 2nd Floor space is via a stair to the 1st Floor that is not separated and not provided from storage area that is discharges through.

Failure to maintain exits could result in injury or death to staff and patients in a fire emergency.


16339

Based upon random observation the surveyor finds that exits are not enclosed and maintained as protected path to a public way to comply with Chapter 7 of NFPA 101. These deficiencies could affect any patients from this building and
as well as any staff and visitors because designated exit stairs are not protected against fire or smoke conditions to comply with 8.2.5.2.

Findings include:

1. Main Building - Stair #5 discharges at the First floor through a required exit passageway. This exit passageway is not identified on any facility plans as an exit passageway. This exit passageway does not comply with 7.1.3.2.2 due to the following:

a. Automatic Linen Dispenser was
observed stored within the exit
passageway.

b. An unoccupied Electrical Closet opens
into the exit passageway which does not
comply with 7.1.3.2.1 (d).

2. Main Building - Stair #6 discharges at the First floor through a required exit passageway. This exit passageway is not identified on any facility plans as an exit passageway. This exit passageway does not comply with 7.1.3.2.2 due to the following:

a. The passageway lacks a continuous
protected path to an exit discharge in
accordance with 7.7.1. Surveyor
noted that the passageway contains
ductwork penetrations that are not
dampered, piping and other systems
which do not serve the passageway.

b. Electrical Closet deemed hazardous
opens into the exit passageway which
does not comply with 7.1.3.2.1 (d). This
closet contain two (2) ductwork
penetrations that lack fire dampers.

3. Main Building - Stair #3 discharges at the First Floor. The surveyor finds that the building is not fully sprinklered. The stair discharge does not comply with 7.7.1 or 7.7.2.

4. Main Building - Third Floor Stair #7: Based on observation, the surveyor finds that the stair wall has a gap above the ceiling that is not fire sealed to comply with 7.1.3.2.1.

5. Main Building - First Floor, Stair #1: Based on observation the surveyor finds that an exit discharge enclosure (that serve a 5 story exit stair) does not provide a continuous protected path of escape to comply with 19.3.2. An exit stair enclosure was observed that does not comply with 7.1.3.2.1.(e) except #1. The designated 2-hour fire rated exit passageway lacked separation and protection due to the following:

a. The Exit Discharge of Stair #1 appears
to utilizes an exit passageway. The exit
passageway is not identified on any
plans.

The enclosure contains an elevator
which is open to an exit passageway and
does not meet NFPA 101 2000 -
7.1.3.2.1(d).

b. A duct was observed penetrating
the fire rated walls above the double
doors to E.D. suite which is part of the
exit passageway, and it was observed
to lack a fire damper .

A) Based on random observation, with the Manager of Facilities present, the surveyor finds that exit stair enclosures are not installed and maintained as a continuously protected path in accordance with Chapter 7 and 8 of NFPA 101.

Findings include:

1) Stair # 9 is a required exit stair for Floor 1 - 5 of the Northeast Building.

a) A bicycle was found stored at the 1st Floor landing of Stair 9 on the afternoon of December 17, 2012. (7.1.3.2.3).

b) The Stair Vestibule at the 1st Floor is not identified on Life Safety Plans as a two hour fire rated enclosure. Although other plans identify two hour walls, the Life Safety Plans identify no rating to the north and they identify a one hour wall at the Telecom Closet. Two round duct penetrations of this vestibule were observed with no fire dampers in accordance with NFPA 90A and 7.1.3.2.1 e) exception # 1.

Failure to maintain required exit enclosures could result in injury or death to staff and patients in a fire emergency.

A) Based on observation, with the Manager of Facilities present, the surveyor finds that exits are not maintained as a protected path of travel in accordance with 7.1 of NFPA 101. The surveyor also notes that the Northeast Building is not fully sprinklered.

Findings include:

1) The North Exit Stair (Stair 8) of the East Building is also identified as an exit for the Basement and 2nd Floor of the Northeast Building. The 2nd Floor of the Northeast Building is also an identified exit path for the Hospital. Stair # 8 discharges into a 1st Floor corridor of the Northeast Building and lacks are exit discharge in accordance with 7.7.1 or 7.7.2 of NFPA 101.

Lack of complying exits could result in injury or death the staff and patients in a fire emergency.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that required means of egress are not maintained as a continuously protected path to the outside in accordance with Chapter 7 and 8.2 of NFPA 101.

Findings include:

1) The surveyor finds that patient rooms have latch sets and single cylinder deadbolt locks. The deadbolt locks do not operated in one single motion to release the lock upon operation of the latch set. The deadbolt locks have not been permanently disabled (keys will still operate the locks).. Access to patient rooms was very limited (almost all of them were occupied with patients). This condition applies to all patient rooms (all floors) with door hardware similar to Room 445.

2) The 3rd Floor Northwest Wing has an obstetrics unit with a bracelet security system that also involves electronic locking hardware on exit doors. On 12/19/12, between 11:30 AM and Noon, with multiple security, engineering and 3rd Floor nursing staff present, the provider attempted to demonstrate how this bracelet system worked, how delayed egress locking was provided in accordance with 7.2.1.6.1 and how activation of the fire alarm system releases any locked doors in accordance with 7.2.1.6.1.

After multiple attempts the provider was not able to automatically lock the doors with the security system, was not able to demonstrate that the doors release in 15 seconds and release from activation of the fire alarm system when the doors are electronically locked.

The surveyor further noted that the secured doors did go into alarm but did not necessarily trigger a "code pink" alarm condition that was called for by the provider.

3) 2nd Floor Surgery Building addition: Elevator Lobby T2112 is part of a required exit access corridor. This corridor space lacks two remote paths of egress in accordance 19.2.5.9. Exit signs direct portions of the means of egress into the suites to the south and east which does not comply with 19.2.5.9. The only complying exit paths from this space (a horizontal exit and a exit stair) are next to each other and are not remote.

4) 2nd Floor Southeast Wing: There is an existing pair of cross corridor doors in the corridor with exit signs on both sides of the doors. These doors are not identified as smoke doors or doors in fire barriers. The exit path in both directions are required, however the doors only swing in one direction and do not comply with 7.2.1.4.2.

5) 2nd Floor Surgery Building: The Pre-op area, Recovery area and surgical unit all have pair of doors with automatic openings functions. These doors when opened manually require too much force to open that doors and do not comply with 7.2.1.4.5.

6) 1st Floor Dietary area: The Food Serving area is separated by two fire shutters from the Dining Room. These fire shutters do not show up on the Life Safety Plans. The provider was not able to identify when and how they close

a) An exit path with illuminated exit signs is not provided from all portions of the Servery and from all portions of the Dining Room. Existing exit signs are not always visible from the Dining Room. The Servery has no exit paths without going under the fire shutters and into the Dining Room. The exit path through the Kitchen has been identified as a hazardous area and is not permitted.

7) The 1st Floor Loading Dock receiving area has an exit sign directing an exit path to the Loading Dock. A safe path is not defined by barriers at the loading dock and the drop off at the loading dock lacks barriers to prevent falls.

Failure to provide and maintain adequate means of egress could result in injury or death to staff and patients in a fire emergency.



16339

Based on random observation during the survey walk-through, not all designated exit accesses are properly maintained and arranged to ensure the dependability of evacuation selected so that exits are readily accessible at all times in accordance with 19.2.1, 19.7.3. These deficiencies could affect patients, staff and any visitors because exit access are not being maintained, and tested that exits are not readily accessible especially under fire conditions at any time.

Findings include:

1. Main Building - Third Floor, OB Unit: In the morning of 12/19/12: Designated Exit stair door equipped with magnetic hardware and secured with an electronic card reader is not available to pass through in case of fire or other emergency situation to comply with 19.7.3 and 7.2.1.6.1 Subpart (d). This exit egress door lacks a readily visible signage "PUSH UNTIL ALARM SOUNDS, DOOR CAN BE OPENED IN 15 SECONDS". This deficiency could affect Post Partum Patients patients because this locked door is not being maintained, tested and that this exit egress door is available especially under fire conditions at any time.

2. Main Building - First Floor, Utility Room across CT Procedure: The door to this room protrudes more than 7" into the corridor during it's swing which does not comply with 7.2.1.4.4.

3. Main Building - First Floor, Radiology Suite: Based on observation the exterior door for the Radiology Suite is being provided with a delayed egress lock but lack signage to comply with 7.2.1.6.1. Subpart (d).

4. Main Building - First Floor: Identified Office T1200 near the Women's Dressing Room for the Ultrasound Suite does not have a direct connection to an egress corridor or to an exit when the fire shutter closed to comply with 19.2.5.1. The door to this room was provided with a fire shutter as part of the 4-hour fire separation which closes during fire condition and the occupant(s) from this room would not have any means of egress to exit out of the room.

A. Based on observation, the surveyors finds that designated outpatient suites do not appear to have two remote exit access doors to comply with 19.2.5.2. Example location observed:

1. Main Building - First Floor, Cardiac Cath Lab Suite (identified 3,301 square feet in the Life Safety Plan): The suite is in excess of 2,500 square feet and lacks two remote exit paths to comply with 19.2.5.3.

2. Main Building - First Floor, Ultra Sound Suite: The suite is indicated to be 3,607 square feet with only a single compliant exit access to the corridor which does not comply with 19.2.5.2. An exit sign is directed through the 4 hour vestibule which passes through a second intervening hazardous construction staging area and does not comply with 19.2.5.5.

3. Main Building - Fifth Floor, Central Services Suite: The suite is identified to be 3,168 square feet does not have two remote exit access doors to a corridor to comply with 19.2.5.2.

A) Based on document review and random observation with the Regional VP, Director of Facilities and the Safety Manager present, the surveyors observed two, three and four hour fire barriers are provided throughout the building and multiple four hour Chicago Vestibules are installed on each floor but no always at the same location on each floor. While these Chicago Vestibules could comply as horizontal exit, there is not information available that clearly indicates that they are used as such, that they are required by NFPA 101 and/or how they comply with 19.2.2.5. The surveyor notes that these fire barriers and Chicago Vestibule also defined required smoke compartments; however this information is missing - see K048.

Based on random observation, the surveyor finds that some of these fire barriers are deficient as fire barriers and/or smoke barriers and do not comply with Chapter 8 of NFPA 101.

Findings include

1) Ice Machine Alcove T4037 is defined on some plans with a four hour fire barrier on the west side of the space and with fire barriers on all sides on other plans.

a) There is an existing fire shutter on the east side of the space with a fusible link. The shutter is not designed to close in accordance with 7.2.1.8 and the space has not exit path is the shutter closes.

b) The designed four hour fire barrier at the west side of this space is four inches of pyrobar with voids in the barrier above the ceiling. This condition does not constitute a two hour or a four hour fire barrier.

2) Similar conditions were observed at the same location on the 2nd Floor except that a duct penetration through the designed fire barrier on the 2nd Floor lacks a fire damper.

3) Similar of the same conditions are expected at the 3rd Floor.

Failure to maintain fire barriers will allow smoke and fire to spread to other compartments.





16339


Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies as required by NFPA 101, 8.2.3.2.4.1&2. Findings include:

1. Main Building, Fifth Floor: Designated 4 hour Chicago Vestibule near the Nurse Education Room is a required smoke barrier in addition to a fire barrier. The surveyor observed a duct penetration that is not fire and smoke dampered.

2. Main Building - Third Floor near the Nursery Suite: In the afternoon of 12/18/2012, the designated four (4) hour Chicago Vestibule / fire separation wall near the Nursery Suite was observed with conduit penetrations (2) that are not sealed against fire to comply with 8.2.3.4.4.2.

3. Main Building - First Floor, Emergency Department Suite: In the morning of 12/19/12, the designated two hour fire wall was observed with a duct penetration that is not fire dampered. Location observed above the SE pair of doors to the ED Suite.

4. Main Building - First Floor near the NE Emergency Department Suite: In the morning of 12/19/2012, the designated four (4) hour Chicago Vestibule / fire separation wall near the Nurse Station I and by the Decontamination Room was observed with duct penetrations (2) that are not dampered.

5. Main Building - First Floor - ED: The pair of doors label to the ED Suite (Southeast ) were observed to have been painted over, the Life Safety Plan indicated a 2 hour fire resistance rating wall.

Based on random observation during the survey walk through while accompanied by the senior electrician and the coordinator of building operations, not all exit discharge locations are provided with illumination to comply with NFPA-101, Sections 18.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

1. Exit discharge from some exits use HID type light fixtures that require a warmup period before the lights operate which does not meet the requirements of NFPA-101, Section 7.9.1.2, for lighting to be of instantaneous operation so as not to leave the exit path in darkness.

A) Based on random observation and the lack of full documentation, the surveyor finds that some battery operated emergency lights are not tested and maintained monthly and annually in accordance with 7.9.3 of NFPA 101.

Findings include:

1) Documentation for annual testing was not available.

2) The label on the battery operated light at the end of 4 West indicates that it was last monthly tested in October 2012.

Failure to maintain battery operated lighting could result in failure.


17659


Based on random observation during the survey walk through while accompanied by the senior electrician and the coordinator of building operations, not all portions of the emergency lighting are installed and tested in accordance with NFPA-70, 99, and 101. These deficiencies could affect all persons in the facility required to utilize battery lighting in operating rooms and procedure rooms by leaving surgical staff in the dark during a power outage, and in exit passage ways by preventing safe and unimpeded access to the public way.

Findings include:

1. Records were not kept of the testing of battery lighting in accordance with NFPA-99, Section 3-4.4.2. Records are not maintained for monthly battery lighting tests, (include the location of each battery lighting unit).

2. Records were not kept of the testing of battery lighting in accordance with NFPA-101, Section 7.9.3. Records are not maintained for the 90 minute annual test, (include the location of each battery lighting unit).

A) Based on random observation, with the Manager of Facilities present, the surveyor observed that the NE Building has emergency lighting and exit signs with battery back-up. The provider does not have an itemized list identifying each location. Instead, monthly testing is documented by a date and initials of the tester on each device. The surveyor finds that some devices have not been tested since August of 2012. The Provider could not demonstrate monthly and annual testing of the devices in accordance with 7.9.3 of NFPA 101.

Findings include multiple locations in the NE Building, including but not limited to:

1) Monthly testing - all devices and all levels in Stair 9

2) Annual testing - all devices

Failure to test and maintain emergency lighting may result in failure during normal power loss.

A) Based on random observation, with the Manager of Facilities present, the surveyor finds that exit signs do not always identify a complying exit path.

Findings include:

1) The 2nd Floor corridor of Northeast Building has an exit sign above the door to Stair 8 while the signs above the door to Stair 9 indicates "STAIRS".

Failure to properly identify exit may confuse staff and patients during an emergency.

Based on random observation during the survey walk-through, exit signs were not installed in accordance with 7.10. This deficiency could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

1. Sleep Center, an exit sign was observed that was not properly installed because it appears to direct occupants into a room.

Based on random observation during the survey walk-through, exit signs were not provided or were not fully visible to designate the path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

1. Main Building - Fifth Floor, Stairwell exit sign in the Central Services is not continuously illuminated to comply with 7.10.5.2.

2.Main Building - Fifth Floor, Physical Medicine Suite: Exit signs are not provided to identify egress paths to comply with 7.10.1.1.

3. Main Building - First Floor: The exit sign at the exit access corridor by Room 1209 leads occupants into the Ultrasound Suite.

4. Main Building - Designated exit signs reads "STAIR" and not "EXIT" to comply with 7.10.1.3. Locations observed include:

a. Penthouse exit sign

b. Fifth Floor - Stairs #3 and #4

5. Main Building - First Floor, near Radiology Department Suite: The exit sign by the exit Stair #1 is aimed an incorrect egress path which does not comply with 7.10.1.1.

A) Based on random observation, with the Manager of Facilities present, the surveyor finds that the provider's written fire plan does not comply with 19.7.1.1. Although an abbreviated version of R A C E is posted throughout the facility, the written fire plan indicates that all doors are to be closed before the fire alarm system is to be activated, during a fire.

This difference in fire plans could result in poor staff performance during a fire emergency.

B) All Exit Passageways are not identified on the Life Safety Plans dated February 2012; the provider is not able to demonstrate how most exit discharges comply with 7.7.1 or 7.7.2

C) Underground spaces, crawl spaces and underground tunnels along with the accesses to such spaces are not identified on the Life Safety Plans dated February 2012. The surveyor observes that a portion of this space is used for storage and that the storage use is open to the entire crawl space. The surveyor also observes that a portion of this space may be sprinklered, however there are no barriers that separate the sprinklered area from the unsprinklered area.




16339

Based on the review of the facilities documents it was determined that the facility failed to maintain a written plan for the protection of residents to provide a prompt and effective response in the event of a fire emergency in accordance with LSC, Section 19.7.2.1.

Findings include:

A. Main Building- First Floor, Radiology Suite: In the afternoon of 12/18/12 it was observed that the posted Evacuation Plan near the CT Procedure for the facility was not accurately drawn and the information about the nearest location of exit is not correct.

B. The provider lacks a comprehensive Life Safety Code Master Plan for each floor. The information provided for this survey was not accurate and did not correctly show the buildings conditions observed.

1. Exit Passageways were not indicated, however, the facility representative stated that certain areas were indeed exit passageways, however, during the walk through they were found to be deficient.

2. The size and boundary of each smoke compartment is not identified on plan.

3. Travel distances in suites is not clearly documented.

4. Areas identified on the Life Safety Plan drawings no longer exist. Example: MRI T1223, Control Room T1222 and Mechanical Room T1221.

The surveyor finds that the provider cannot comply with 19.1.1.3 without the information identified above.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that the fire alarm system is not installed in accordance with NFPA 72 - 1999.

Findings include:

1) 1st Floor Fire Alarm Panel Closet between Main Lobby and South Bridge: The fire alarm panel is not continuously attended and the closet lacks a smoke detector above the panel in accordance with NFPA 72, Section 1-5.6.

2) 1st Floor Surgery Building Fire Alarm Panel in closet. This space has a heat detector and not a smoke detector in accordance with NFPA 72.

3) Based on testing on the morning of 12/19/12, the surveyors find that the fire alarm system is not audible through out all area were personnel work and are expected to respond, in accordance with the 5db/10db/15db rules of NFPA 72:

a) 5th Floor Surgery Building Elevator Foyer

b) 5th Floor Southwest Wing include Decontamination and Central Services

Failure to install and maintain the fire alarm system in accordance with code could prevent the fire alarm system from detecting fires and notifying staff and fire rescue personnel.



16339


A. Based on random observation during the survey walk-through and staff interview, not all portions of the building fire alarm system are installed in accordance with 19.3.4 findings include:

1. Second Floor - In the morning of 12/19/12, the fire alarm system within the adjacent Medical Office Building was activated. It is noted that the first primary set of doors between the hospital and the business occupancy did not close during the fire alarm test. The Life Safety Plan identified the two hour fire rated occupancy separation. The surveyor observed that the 4 hour Chicago Vestibule doors and the hold-open door to the Solarium did not close as well during this test with the activation of the smoke detector.

2. Main Building, Second Floor (ICU Suite): Pair of double doors (hold-open) to the ICU Suite near the Stairwell #6 did not close to latch during the activation of the fire alarm system.




17659


Based on random observation during the survey walk through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

1. Panel IR-LRP-CR-1B, and panel LP-3W-C2 have circuits marked as feeding fire alarm that are not marked in red and equipped with a locking device as required by NFPA-72, Section 1-5.2.5.2.

2. The Fire Alarm Control Panels are not labeled with the electrical panel designation and circuit number as required by NFPA 72, Section 1-5.2.5.

3. The fire alarm panels were in areas that were not continuously occupied and did not have a smoke detector above the panel as required by NFPA-72, Section 1-5.6.

A. Sleep Center: The surveyor finds from observation and staff interview that the building has a fire alarm system. Documentation that identifies how the system are tested, service and maintained in accordance with NFPA 72 - 1999 was not available onsite. This could affect all building occupants if the fire alarm system does not initiate an alarm without delay or the components can not be located during a fire emergency.

Failure to maintain the fire alarm systems could result in failure to notify occupants and the fire department in a fire emergency.

A. Wound Care Center: The surveyor finds from observation and staff interview that the building has a fire alarm system. Documentation that identifies how the system are tested, service and maintained in accordance with NFPA 72 - 1999 was not available onsite. This could affect all building occupants if the fire alarm system does not initiate an alarm without delay or the components can not be located during a fire emergency.

Failure to maintain the fire alarm systems could result in failure to notify occupants and the fire department in a fire emergency.

A) Based on random observation with the Director of Facilities and the Safety Manager present the surveyor finds that the sprinkler system is not installed and maintained in accordance with NFPA 13 -1999:

Findings include but are not limited to:

Note: The surveyors find that the building is not fully sprinklered and therefore does not qualify for any exceptions under NFPA 101 for fully sprinklered buildings. The surveyors further observe that no floor is fully sprinklered and that in some cases some smoke or fire compartments are not fully sprinklered.

1) Janitor's Closet 452A is not sprinklered in an otherwise sprinklered area.

2) 4 Center: an ice machine obstructs the sprinkler protection in this area.

3) 4th Floor - Northwest Wing has an assisted bathing area with one toilet room with missing ceiling tiles. The missing ceiling tiles compromises the sprinkler protection in this space.

5) 4th Floor - Northwest Wing - there is a janitor's closet with a sprinkler drain that lacks identifying of what it is, in accordance with NFPA 13.

6) 2nd Floor Equipment Storage Room 235 has a missing ceiling tile which compromises the sprinkler protection in this space.

7) 2nd Floor Southwest Wing: The ice machine alcove is not sprinkler protected in an otherwise sprinklered area.

8) Boiler Room - Fire Pump: access to the fire pump controller and the fire pump, in addition to any switchgear, was blocked by storage in this room.

9) The 1st Floor Cashier's Area is not sprinkler protected in an otherwise sprinklered zone.

10) 1st Floor - Room 1715 (Old Security Area) was under construction and had no ceiling. The sprinkler protection in this area was compromised; the provider was not able to identify what if any interim life safety measures were implemented.

Failure to install and maintain sprinkler protection could result in partial coverage and spread of fire and smoke in a fire emergency.


16339


A. Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999.These deficiencies could affect all patients, staff and any visitors due to improper installation of the sprinkler system which can fail to activate under fire conditions.

Findings include:

1. Main Building - First Floor Old fast Track ED: Sprinkler escutcheon plates are missing in the Waiting Area and by the Vending Machine Area.

2. Main Building - Fifth Floor - 4 Hour Chicago vestibule near the Nurse Education Room an escutcheon plate is missing.

3. Main Building - Third Floor, Environmental Services across Patient Room 309: Inspector's Test Pipe drain is not installed to simulate the flow of one sprinkler head in accordance with NFPA 13.

4. Main Building - Third Floor North, OB Linen Chute: Sprinkler head is not installed in the chute in a sprinklered smoke compartment.

A) The surveyor observes that the NE Building is partially sprinklered; however, based on random observation with the Manager of Facilities present, the surveyor finds that the sprinklered areas have sprinkler heads that are not installed in accordance with NFPA 13:

Findings include:

1) 2nd Floor IT Rooms are protected by a drypipe/pre-actions sprinklered system. The sprinkler heads to two of two rooms are partially obstructed by the equipment in the rooms.

2) The Basement Level at the northeast corner has sprinklered heads installed below ribbed slab construction with the head at 12" or more below the lowest structural member. The sprinkler heads are not installed at " or less below structural members in accordance with 5-6.4.1.2 of NFPA 13 - 1999. Other portions of the Basement should be reviewed for compliance.

Failure to install sprinkler protection in accordance with code will result in poor performance in a fire.

A. Sleep Center: The surveyor finds that sprinkler documentation for this building was not available on site. Documentation was not available for

1. Quarterly flow testing

2) Annual testing, service and maintenance of the sprinkler system in accordance with NFPA 25

A. Wound Care Center: The surveyor finds that sprinkler documentation for this building was not available on site. Documentation was not available for

1. Quarterly flow testing

2) Annual testing, service and maintenance of the sprinkler system in accordance with NFPA 25

1. 6th floor Mechanical Room (T6003). By direct observation in the company of the Coordinator of Building Operations the surveyor could not determine that all duct penetrations through floor or shaft enclosures contain fire damper at the following locations.

a. Shaft (T6008) next to the elevator shafts, the supply duct penetrations (2).

b. Floor penetration in the maintenance shop space (T6011) East and South of the elevator shafts.

2. 6th floor Mechanical Room (T6015).

a. Floor penetration for exhaust fan E62.

b. Floor penetration for exhaust fan E63.

c. Floor penetration for what appears to be dishwasher exhaust East of the kitchen exhaust fans.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that kitchen hood suppression systems are not installed and maintained in accordance with NFPA 17 and 96.

Findings include:

1) The 1st Floor Dietary main cooking line has a hood with grease filters that do not fit tightly together, that are gaps in the filters that allow grease to bypass the filters.

2) The cooking equipment, the walls next to the cooking equipment and the floors under the cooking equipment are all coated with grime, grease and food product. The surveyor notes that this is a potential health hazard but also finds that it constitutes a potential fire hazard.

Failure maintain kitchen hood suppression system and the environment near such could result in a fire.






14416

6th floor mechanical room (T6015 ) contain equipment for elevators No. 1 & 2 and exhaust fans. By direct observation the afternoon of 12/17/12 while in the company of the Coordinator of Building Operations,

a. The surveyor finds the duct connections to the two utility fan set for the first floor kitchen grease hood exhaust are not by way of flanges and bolted in compliance with NFPA 96, 1998, 5-1.3. The connections are by way of fabric collars and do not appear to be listed devices. The fan and duct assemblies appear to contain fusible fire link guillotine type dampers. Through staff interview this could not be confirmed and that these dampers were still active.

A) Based on random observation with the Safety Manager present on 12/18/12, the surveyor observed that portable electric heaters are used that have heating elements that exceed 212 degrees F and that do not comply with the requirements of 19.7.8.

Findings include but are not limited to:

1) Portable heater in Room 1718

2) Portable heater in Room 1716

Use of unapproved portable heating devices could cause a fire.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present on 12/17/12 - 12/19/12, the surveyor observed that exit access corridors were obstructed and are not maintained in accordance with 7.1.10 and 19.3.6.1.

Findings include:

1) 4th Floor - Northeast Wing: The corridor was continuously (reduced in width to less than 8'-0") by unattended computers on wheels and isolation carts. This was in addition to cleaning equipment, food service carts and laundry hampers that were moving around and more or less attended (and are therefore permitted).

2) 2nd Floor - Surgery Building Corridor T2116: On 12/18/12, with the Director of Facilities present, the surveyor observed that this designated exit access corridor was substantially obstructed to 4'-0" or less. The coat rack, supplies, equipment, carts, etc. in this corridor constitute an unenclosed hazardous area that does not comply with 19.3.2.1 and/or 19.3.6.1. Immediate correction was required. The same condition was observed on 12/19/12.

3) 2nd Floor - Surgery Building Recover area. The corridor to the south out of this space was obstructed by a gurney and by empty blue linen carts.

Failure to maintain the means of egress will delay movement or evacuation in an emergency.



16339

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. This deficient practice could effect all patients and staff as well as visitors who must utilize the exit access corridors because means of egress are not continuously maintained.

Findings include:

A. Main Building, Fifth Floor - G.I. equipment and Scrubs / Aprons Rack were observed stored in exit access corridor that obstruct egress, and the required 8'-0" corridor width is not being maintained to comply with 19.2.3.3. and 7.1.10.1.

B. Main Building - Third Floor, OB Unit: In the morning of 12/17/12 it was observed that the corridor ceiling in the 3rd floor OB department was not at the minimum 7'-6" height required by 7.1.5. Height was approximately 7'-2". This deficient practice could effect all patients and staff as well as visitors who must utilize the exit access corridors.

C. Main Building - First Floor, E.D. NE corner of the Old fast track was being obstructed with chairs and reduce the required aisle width.

D. Main Building - First Floor, E.D: Exit access corridor near the ED Staff Lounge behind the Old Fast Track was being obstructed with Linen Carts and Medical Equipment.

A) Based on random observation with the Director of Facilities and the Safety Manager present on 12/18/12, the surveyor observed that oxygen storage does not always comply with NFPA 99. The 2nd Floor Surgery Building "Maxwell Street" storage room was observed to have oxygen tanks stored directly under a wood cabinet and with combustible storage that was too close to the oxygen tanks.

Failure to properly store oxygen tanks could result in a fire that is aggravated by an oxygen source.

Based on direct observation, the surveyor finds the facility failed to provide separation by an intervening wall between the medical gas zone valves and the outlets they serve to comply with NFPA 99, 1999, 4-3.1.2.3 (d). These deficiencies could pose a potential hazard to patients if medical gas zone valves are not installed properly in accordance with NFPA 99.

A. In the morning of 12/19/12, by direct observation the surveyor finds that not all medical gas zone valves are separated from the outlets/inlets they serve. This does not comply with NFPA 99, 1999, 4-3.1.2.3. Locations observed:

1. Main Building - First Floor, E. R. Suite, E.R. Examination Bays (A, B, C, D,E, and F):

2. Main Building - First Floor, E. R. Suite serving bays D, E, F, G, and H

3. Main - First Floor, Radiology Suite for Prep/Recovery Bays

4. Main Building - First Floor, Ultrasound Suite

5. Main Building - First Floor, Cardiac Cath Suite

6. Main/Surgery Building - Second Floor, Post/OP Recovery Area

A) From random observation the surveyor finds that the building is not fully sprinklered and smoke dampers are not installed at designated smoke barriers in accordance with 8.3.6 of NFPA 101.

Findings include but are not limited to:

1) 3rd Floor Southeast Wing: The four hour vestibule between 3 SE and the Surgery Building addition to the east is a required smoke barrier. It is not identified as a smoke barrier on plans. Both smoke compartments lack sprinkler protection; one duct penetration lacks a smoke damper in accordance with 8.3.6 of NFPA 101 and in accordance with NFPA 90.

2) 3rd Floor Southeast Wing: The four hour vestibule between 3 SE and the Recovery Room of Surgery Building addition to the east is a required smoke barrier. It is not identified as a smoke barrier on plans. Both smoke compartments lack sprinkler protection; one duct penetration has a fire damper but lacks a smoke damper in accordance with 8.3.6 of NFPA 101 and in accordance with NFPA 90.

Failure to provide and maintain smoke dampers in unsprinklered buildings will allow smoke to spread to multiple areas in a fire emergency.

Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.


Findings include:

1. The surgery building emergency generator did not have remote shut down switches to comply with NFPA-110, Section 3-5.5.6.

2. Three of three emergency generators did not have a remote annunciators or a derangement signal at a 24 hour staffed location to meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

The facilities emergency power system is not installed and maintained in accordance with the 1999 Editions of NFPA 70, 99 and 110, in accordance with 21.2.9 NFPA 101- 2000.

1) The documentation of monthly load testing of the generators does not include amperage readings of all three phases.

Failure to test and maintain the emergency generator could result in failure during a loss of normal power to the facility.

Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panels EP-4W-1, LP-3W-C, LP-3W-C2, LP621, CLP-2W-2, ER-CP1, 1R-LRP-CR-1B, and 1-CLR-3 had circuits feeding the fire alarm panels, med gas alarm panels, and elevator cab lighting (these items should be served from the life safety panel). This does not meet the requirements of NFPA-70, Section 517-32 and 33.

2. Life safety panel EMLP-4 is serving a cardiac monitor and panel EM-L11 is serving the operating rooms on the fifth floor, (should be served by the critical branch), which does not meet the requirements of NFPA-70, Section 517-32.

A) Based on random observation with the Manager of Facilities present the surveyor finds that electrical installations and materials do not comply with NFPA 70-1999:

Findings include but are not limited to:

1) Electrical rooms are not sprinklered in the NE Building but are used for combustible storage;

a) Two 3rd Floor Electrical Rooms are used for combustible storage but are not sprinklered.

b) A large 3rd Floor switchgear room is used for combustible storage. The room is not sprinklered and the storage blocks access to electrical gear. 3'-0" is not maintained in front of panels and switchgear.

c) The 1st Floor Electrical Room next to the Trash Compactor Room is used for combustible storage and the room is not sprinklered. One of two doors to this room was blocked shut, in spite of sign on door that indicates "do not block."

2) Electrical extension cords are in use

a) 2nd Floor Respiratory Care has an extension cord that runs through a door opening.

b) 2nd Floor Solarium - Christmas Tree on an extension cord

c) Basement Painters Room - orange extension cord.

3) 1st Floor Maintenance Shop - 2 x 4 light fixtures have storage on top of the suspended fixtures.

Failure to maintain electrical rooms could reduce access in an emergency. Use of extension cords for permanent installations could cause a fire. Improper storage on top of electrical fixtures could cause a fire.

A) Based on random observation with the Regional VP, Director of Facilities and the Safety Manager present, the surveyor observed that electrical installations, equipment and materials are not installed and maintained in accordance with NFPA 70 - 1999.

Findings include:

1) Access to electrical panels and switchgear is blocked; 36" of clear space and a clear path are not provided and maintained.

a) 2nd Floor Elevator Foyer east of Elevator 4 and 5 - access to panels is blocked by gurneys.

b) 2nd Floor Surgical Suite - aisle in front of Cysto Room access is blocked to electrical panels

c) 2nd Floor Surgical Suite - Closet with Panel 2-LR-2

i) The room is used for storage but lacks sprinkler protection in accordance with NFPA 13.

ii) Storage items block access to panels

d) 2nd Floor Surgical Suite opposite O R # 1 - access to panels is blocked by supply carts.

e) Boiler Room East Wall - access to panels and switches is blocked by storage.

2) Electrical extension cords are used for permanent installations; electrical wiring does not comply with NFPA 70:

a) 1st Floor Kitchen - Ice Cream Chest has an orange extension cord.

b) Air handling Unit S-11 is located in a separate room on the south side of the building that is only accessible from outside. A yellow electrical cord in permanent use is not wiring in conduit in accordance with NFPA 70 and multiple junction boxes lack covers.

c) 1st Floor Gift Shop - the cashiers' area has multiple extension cords.

d) The 1st Floor Nursing Administration House Managers Office has multiple plug strips that are plugged in in series.

Failure to install and maintain electrical systems in accordance with code could cause a fire.


16339

Based on random observation during the survey walk-through, not all portions of the facility's electrical system are installed in accordance with NFPA 70.

Findings include:

A. Main Building - Fifth Floor - : The Electrical panel directories are not updated and or labeled accurately as to what circuits they serves. These deficiencies could affect any patients being treated in the Physical Rehab and Cardiac Rehab because power and light may not always be available to provide treatment. Location observed:

1. Physical Medicine - LP-5NW-S.

2. Electrical Closet near the Chemistry lab - LP-5W-1-ESS and
LP-5W-2-ESS

B. Main Building - 5th Floor Lab: In the morning of 12/18/12 electrical panel was observed at which a clear working space of 3'-0" in front of the panel is not maintained as required by NFPA 70 1999 110-26(a). Locations observed include:

1. Utility Closet - Electrical Panel LP-5E-3-ESS is being blocked with trash carts.

C. Main Building - Third Floor NW, Electrical Closet was observed with stored ceiling panels and staff gowns, the 3'-0" required clearance in front of the panel is not being maintained.

D. Electrical junction boxes were observed that are not equipped with cover plates required by NFPA 70 1999 370-25. Locations observed include:

1. Main Building - Third Floor, above ceiling in the Clean Utility Room.

2. Main Building - First Floor, ED Suite: above ceiling in the Equipment Room




17659


Based on random observation during the survey walk-through while accompanied by the senior electrician and the coordinator of building operations , the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Normal power receptacles were not provided in operating rooms on the second floor, in the patient rooms on the second floor, in the ICU, the GI unit operating rooms, recovery rooms, and patient rooms on the fifth floor, as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

2. Bonding of the piping for the medical gas system could not be located by staff as required by NFPA-70, Section 250-104(c). This could cause a potential difference between med gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

3. Emergency receptacles in the operating rooms on the fifth floor, and other patient bed locations were not all identified as emergency receptacles. All receptacles or cover plates served by critical power shall have a distinctive color or marking so as to be readily identifiable in accordance with NFPA-99, Section 3-4.2.2.4(a)2, and NFPA-70, Section 517-19(a). This could cause confusion during a power outage trying to locate an emergency receptacle for critical care equipment.

4. The operating rooms were not equipped with battery lights to comply with NFPA-99, Section 3-3.2.1.2(a)5e.

By direct observation the afternoon of 12/18/12 in the company of the Coordinator of Building Operations, the surveyor finds that sprinkler protection is provided in the penthouse elevator machine room (located at the fifth floor level of Stair Tower No. 1) for the elevator identified in the machine room as Elevator No.1, however heat detectors are not provided or install within 2 feet of each sprinkler head for elevator shut down prior to the discharge of water as required by NFPA 72, 1999 3-9.4 & ANSI/ASME A17.1, 102.2, c, .3).