HospitalInspections.org

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) Corrected 03/19/14

a) Deleted 03/19/14

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 L 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) Deleted 03/19/14

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) Deleted 03/19/14

3) Corrected 03/19/14

a) Corrected 03/19/14

4) Corrected 06/06/13.

5) Corrected 10/22/2014.

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



16339


Corrected 03/19/14

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) Corrected 10/22/2014

2) Corrected 10/22/2014

a) Corrected 06/06/13.

b) Corrected 03/19/14

c) Corrected 05/23/14 - Surveyor 07113 from project inspection IDPH # 9986

d) Corrected 05/23/14 - Surveyor 07113 from project inspection IDPH # 9986

e) Corrected 05/23/14 - Surveyor 07113 from project inspection IDPH # 9986

3) Corrected 06/06/13.

4) Corrected 10/22/2014

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) Corrected 10/22/2014

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.

10/22/2014 UPDATE: Kitchen exhaust duct portion of 7 corrected.

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 the Floor.

10/22/2014 UPDATE: Work described in PoC was not completed by date indicated.

b) Corrected 10/22/2014

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

a) Corrected 06/06/13.

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. This mechanical room is not separated from the tunnels and crawl 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.

10) Corrected 10/22/2014

11) Corrected 10/22/2014

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

Corrected 10/22/2014.

A) Corrected 10/22/2014

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. Corrected 03/19/14 - per Cat. Waiver

2. Corrected 10/22/2014

3. Corrected 10/22/2014

4. Corrected 06/06/13..

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 .

10/22/2014 UPDATE: Work described in PoC was not completed by date indicated.

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:

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.

a) NEW 10/22/2014: The PoC for 3) above created the second path of egress from Elevator Lobby T2112, but the cross corridor doors installed to restrict access to the egress corridor beyond are equipped with magnetic locks that are not equipped with delayed egress or access control hardware as required by the exceptions to 19.2.2.2.4.

4) Corrected 10/22/2014

5) Corrected 03/19/14

7) Corrected 03/19/14

8) Corrected 10/22/2014

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



16339


Corrected 03/19/14

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. Corrected 03/19/14

A) Corrected 10/22/2014
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. Corrected 10/22/2014

2. Corrected 06/06/13.

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. Corrected 10/22/2014

5. Corrected 06/06/13.

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) Corrected 03/19/14

7) Corrected 03/19/14

B) (New 03/20/14) Based on random observation with the Director of Facilities present on 3/19/13 - 3/20/14, the surveyor finds that rooms or spaces lack sprinkler protect in otherwise sprinklered areas or compartments. In some cases the lack sprinkler system does not comply with the exceptions under NFPA 13 -1999.

Locations include:

1. Corrected 10/22/2014

2. Corrected 10/22/2014

3. The Boiler Room is sprinklered. The Boiler Room is open to a Lower Level (which is more of a tunnel space and crawl space). The area is the Lower Level, near the Boiler Room opening is sprinklered; however all spaces, all tunnels and or crawlspace areas which are also open to the Boiler Room are sprinklered. There are no fire barriers in this Lower Level to limit what must be sprinklered.

4. Corrected 10/22/2014

5. Corrected 10/22/2014

6. Corrected 10/22/2014

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

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. Corrected 10/22/2014

2. Corrected 10/22/2014

A) Corrected 06/06/13.




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:

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.

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. Corrected 10/22/2014

6. Corrected 03/19/14

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.

3. (New 03/20/14): Panel IR-LRP-CR-1B, Panel LP-3W-C2 and/or Panel IR-LRP- IB all have conflicting panels schedules and they have circuits marked as feeding fire alarm system. These panels are identified at Critical Branch Panels of emergency power. The fire alarm panels are not supplied from the Life Safety Branch in accordance with 517-32.

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.

c) Corrected 10/22/2014

d) (New 03/20/14): 1st Floor Load Dock Receiving Room. On 03/19/14 with the Director of facilities present the surveyor observed at that access to the Generator Room door and access to an electrical room door was blocked by storage, even with signs in the space indicating that such access was not to be blocked. Adequate provisions to prevent re-occurrence have not been implemented.

10/22/2014 UPDATE: Work described in PoC was not completed by date indicated.

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. Corrected 03/19/14

B. Corrected 06/06/13.

C. Corrected 06/06/13.

D. Corrected 06/06/13.




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. Corrected 10/22/2014

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. Corrected 03/19/14

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).