HospitalInspections.org

Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight corridor frames. This deficiency occurred in 1 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

Based on a recent Verification Visit on 06/08/2016 at 11 am, it was observed on the 1st floor in the Visitors Lounge Room 1098, in the orange smoke compartment Zone 2, the door had a frame that would not resist the passage of smoke because the door frame was designed with no door frame 'butt' to stop the spread of smoke to the corridor. The room had no smoke detection if open to the corridor. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.6.3.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
______________________________________

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with properly rated door and frame assemblies, ducts in fire-rated wall assemblies with fire dampers and sealed floor or vertical shaft penetrations. These deficiencies occurred in 4 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

3. Based on a recent Verification Visit on 06/08/2016 at 11:30 am, it was observed on the 1st & Basement floors in the Stairwell 1090 in orange smoke compartment Zone 2, one or more air ducts penetrated the vertical shaft enclosure and could not be confirmed to have a properly installed fire damper. The mechanical duct penetrating the Stairwell 1090 was not fire-dampered and smoke-dampered. Under new construction requirements, ducts are not allowed to penetrate a Stairwell, if not serving the stairwell. Mechanical ducts must be outside the Stairwell unless serving it. This observed situation was not compliant with NFPA 90A (1999 ed.), section 3-3.4.

4. Based on a recent Verification Visit on 06/08/2016 at 11:40 am, it was observed on the 1st & Basement floors in the Stairwell 1090 at 1st floor landing in orange smoke compartment Zone 2, penetrations in a vertical shaft were not sealed according to an approved method. The deficiencies included multiple electrical conduits and wires not serving the Stairwell. The wiring was added after the original Stairs were constructed. Items are not allowed to enter a Stairwell unless serving the Stairwell. This observed situation was not compliant with NFPA 101 (2000 ed.), section 8.2.5.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
______________________________________

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated-wall construction, with incorrect fire-rated stenciling and sealed wall penetrations. These deficiencies occurred in 7 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

5. Based on a recent Verification Visit on 06/08/2016 at 12:15 pm, it was observed on the 1st floor in the Office Room 1162 in the orange smoke compartment Zone 1, that the smoke barrier wall was not constructed to a 60 minute fire resistance rating because the construction joints were not sealed where the wall met the deck above. At the time of construction (1993), the smoke barriers were required to meet a 60 minute fire-rating unless approved by the authority having jurisdiction (AHJ). This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

9. Based on a recent Verification Visit on 06/08/2016 at 12:18 pm, it was observed on the 1st floor in the spaces along the orange and yellow smoke compartment barrier, that the smoke barrier (wall) was not constructed to a 60 minute fire resistance rating because the construction joint was not sealed where the wall met the deck above. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

10. Based on a recent Verification Visit on 06/08/2016 at 12:21 pm, it was observed on the 1st floor in the Medical Records File Room 1023 in the red smoke compartment, that penetrations were not sealed according to an approved method. The deficiencies included multiple steel roof joists not properly fire-sealed where they penetrated the 1-hour and 2-hour stenciled fire and smoke barriers (walls) above the ceiling. The room straddled the smoke barrier separating the red from the yellow smoke compartments. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

11. Based on a recent Verification Visit on 06/08/2016 at 12:24 pm it was observed on the 1st floor in the Main East-West Corridor outside the Medical Records File Room in the yellow smoke compartment, the smoke barrier wall was not compliant. It was incorrectly identified as the wrong fire-rating stenciling. The stenciling above the ceiling in the corridor was incorrect. It was shown as a 2-hour wall assembly, but was not identified the same as the Life Safety Plans. The stenciling was incorrect according to an interview with staff A and staff B. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

12. Based on a recent Verification Visit on 06/08/2016 at 12:27 pm, it was observed on the 1st floor in the In North-South Corridor along 2-hour Smoke Barrier, across from Room 1074, penetrations were not sealed according to an approved method. The deficiency included a metal sleeve through the wall abocve the ceiling not fire-sealed. This situation was not compliant with NFPA 101 (2000 ed.), section 19.3.7.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
______________________________________

Based on observation, review of life safety plans, and interview, the facility did not enclose hazardous rooms (built in 1993 to the NFPA 101 (1991 ed.) Life Safety Code, section 12-3.2.1) with fire-rated wall construction, sealed wall penetrations, rated fire doors and closers on all hazardous room doors. Buildings cannot be down-graded from the level of original construction unless approved by the authority having jurisdiction (AHJ) per NFPA 101 (2000 ed.), section 4.6.7. These deficiencies occurred in 7 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. Based on a recent Verification Visit on 06/08/2016 at 12:30 pm, it was observed on the 1st floor in the Clean Supplies & Oxygen Cylinder Storage Room 1158, in the orange smoke compartment Zone 1, that the wall of this hazardous room was not constructed to the required fire resistance rating. Some of the construction joints were not sealed above the ceiling where the wall met the deck above. A (8" x 8") hole was observed at the South wall above-the-ceiling. The room was considered hazardous because it exceeded 100 square feet in area and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

2. Based on a recent Verification Visit on 06/08/2016 at 12:32 pm, it was observed on the 1st floor in the Clean Supplies & Oxygen Cylinder Storage Room 1158, in the orange smoke compartment Zone 1, that penetrations were not sealed according to an approved method. The deficiency included all pipes and flex ducts penetrating this 1-hour fire-rated room above the ceiling. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

3. Based on a recent Verification Visit on 06/08/2016 at 12:34 pm, it was observed on the 1st floor in the Clean Supplies & Oxygen Cylinder Storage Room 1158 in the orange smoke compartment Zone 1, that the fire barrier door or fire access door could not be verified to have the required rating. The hospital was built in 1993 and the NFPA 101 (2000 edition), section 4.6.7 does not allow a building to be down-graded from the level of original construction unless approved by the authority having jursidiction (AHJ) requiring hazardous rooms to be sprinkled and fire-rated if over 100 square feet at the time of construction for a Building Type II (000) Limited Combustible Construction. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

4. Based on a recent Verification Visit on 06/08/2016 at 12:36 pm, it was observed on the 1st floor in the Inpatient Laundry Room 1117 in the orange smoke compartment Zone 1, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall above the ceiling was not properly fire rated for this hazardous space based on the room being a laundry room with considerable linens and cotton products within the room. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), section 4.6.7.

5. Based on a recent Verification Visit on 06/08/2016 at 12:38 pm, it was observed on the 1st floor in the Soiled Linen Room 1116 & Soiled Utility Room 1115 in the orange smoke compartment Zone 1, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall above the ceiling was not constructed to a 1-hour fire-rated wall assembly based on missing taping at joints, screws not mudded and penetrations of conduits and wires not fire-sealed. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

7. Based on a recent Verification Visit on 06/08/2016 at 12:40 pm, it was observed on the 1st floor in the Supply Room 1113 in the orange smoke compartment Zone 1, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall above the ceiling was not constructed to a 1-hour fire-rated wall assembly based on missing taping at joints, screws not mudded and penetrations of conduits and wires not fire-sealed. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

10. Based on a recent Verification Visit on 06/08/2016 at 12:42 pm, it was observed on the 1st floor in the Loading Dock 1096, General Storage Room 1095 and Kitchen Storage Room 1088A in the orange smoke compartment Zone 2, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall in each room was not properly fire-rated. The seams were not taped and screws not mudded and top of wall not sealed to the deck above. Multiple penetrations were observed through the walls with no fire sealant or fire dampers where flex-duct was used. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

11. Based on a recent Verification Visit on 06/08/2016 at 12:44 pm, it was observed on the 1st floor in the Medical Records File Room 1023 in the red smoke compartment Zone 1, that penetrations were not sealed according to an approved method. The deficiency included two sleeves on both North and South Walls were not fire-sealed per the Life Safety Code requirements for a hazardous space exceeding 100 square feet. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

12. Based on a recent Verification Visit on 06/08/2016 at 12:46 pm, it was observed on the 1st floor in the Medical Records File Room 1023 in the red smoke compartment Zone 1, that the fire barrier door or fire access door could not be verified to have the required rating. The fire door protecting the Medical Records File Room was not labeled. The label was painted over or was missing. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101(2000 ed.), 4.6.7.

13. Based on a recent Verification Visit on 06/08/2016 at 12:48 pm, it was observed on the 1st floor in the Main East-West Corridor on opposite side of the Corridor from Medical Records File Room (Storage Room 1079) in the yellow smoke compartment, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was not fire-rated to 1-hour construction above the ceiling in the corner for a hazardous room. The room was considered hazardous because it was holding combustible elements. The corner construction was improperly installed per the listing agencies minimum requirements for a rated enclosure. The wall edge was not taped and screws were not mudded. The room was considered hazardous because it exceeded 100 square feet and contained a quantity of stored combustible materials considered hazardous. This situation was not compliant with NFPA 101 (2000 ed.), 4.6.7.

This condition was confirmed at the time of discovery by a concurrent observation, review of Life Safety Plans and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.), and staff C (Waukesha Co. MHC Administrator).
______________________________________

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 and to the Life Safety Code, section 9.6.1.4. These Codes require approval by the authority having jurisdiction (AHJ) in an existing healthcare facility when not installed in compliance with NFPA 72. The Centers for Medicare and Medicaid Services (CMS) have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self-preservation and rely on a highly reliable fire alarm system to defend-in-place. This is consistent with NFPA 72 (1999 edition) section 1-2.3, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a fire alarm system with smoke detectors at required locations and did not provide visual alarm notification at all required locations. These deficiencies occurred in 3 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. Based on a recent Verification Visit on 06/08/2016 at 12:51 pm, it was observed on the Penthouse floor, in the Mechanical Room for AHU #1, that the smoke detectors were not located in accordance with NFPA 72 requirements. The smoke detectors were located greater than 12 inches below the highest point of the roof. The smoke detectors were located at the bottom of the steel beams that appeared to be at least 20 - 24 inches in depth. This exceeds the maximum allowed distance from the highest point by the NFPA 72 (1999 edition) Fire Alarm Code. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

2. Based on a recent Verification Visit on 06/08/2016 at 12:53 pm, it was observed on the Mechanical Penthouse, above 1st Floor in the Mechanical Room for AHU #2, above the yellow smoke compartment, that the smoke detectors were not located in accordance with NFPA 72 requirements. Several smoke detectors were not located within 12 inches of the highest point of the ceiling and/or deck within the mechanical room. These detectors were located at the bottom of the steel beams and the beams were greater than 18 inches in depth. The mechanical room was separated from the 1st Floor by 2-hour floor decking. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

3. Based on a recent Verification Visit on 06/08/2016 at 12:54 pm, it was observed on the 1st floor in the Medical Records Office 1021 in red smoke compartment Zone 1, that the facility did not install a visual fire alarm notification device correctly for notification to staff in this space for a fire emergency. Private mode notification requires staff to be aware of all fire alarm situations including visual notification. The visual alarm notification device mounted on the North wall of this Room was blocked by a newly installed upper wall cabinets. The wall cabinets were mounted up-tight against the visual notification device on it's left. This was not to Code per NFPA 72 (1999 ed.). This situation was not compliant with NFPA 72 (1999 ed.), section 4-5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
______________________________________

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements and a compliant sprinkler support system. These deficiencies occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. Based on a recent Verification Visit on 06/08/2016 at 1:05 pm, it was observed on the 1st floor in the Inpatient Unit A & B at Entry Doors of Room 1150 & 1170, that the sprinkler pipe hangers and support system was not compliant. The sprinkler pipes were being used to hold-up the electrical wiring and conduits within this section of the space. Sprinkler pipes are not allowed to be holding any other equipment besides the pipes and heads that were designed as a system. This condition was found throughout the hospital, in all smoke compartments, and in both patient areas and non-patient areas. This situation was not compliant with NFPA 13 (1999 ed.), section 6-1.

2. Based on a recent Verification Visit on 06/08/2016 at 1:07 pm, it was observed on the 1st floor in the Room 1181 in the green smoke compartment of Inpatient Unit B, that the sprinkler pipe hangers and support system was not compliant. The sprinkler pipes were being used to hold-up the electrical wiring and conduits within this section of the space. Sprinkler pipes are not allowed to be holding any other equipment besides the pipes and heads that were designed as a system. Per NFPA 13, section 6-1.1.1, the components of hanger assemblies that directly attach to the pipe or to the building structure shall be 'listed'. This condition was throughout the hospital. This situation was not compliant with NFPA 13 (1999 ed.), section 6-1.

3. Based on a recent Verification Visit on 06/08/2016 at 1:09 pm, it was observed on the 1st floor in the Corridor 1171 in the orange smoke compartment Zone 1, that the sprinkler pipe hangers and support system was not compliant. The sprinkler pipes were being used to hold-up the electrical flex wiring and conduits within this section of the space. This situation was not compliant with NFPA 13 (1999 ed.), section 6-1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
______________________________________

Based on observation, record review and interview, the facility did not provide a ventilation system in accordance with the manufacturer specifications and NFPA 90A with required damper maintenance, compliant air distribution installation and compliant fire dampers. These deficiencies occurred in 7 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

3. Based on a recent Verification Visit on 06/08/2016 at 1:25 pm, it was observed on the 1st floor in the North-South Corridor and East-West Corridor of the smoke compartments yellow and red, at the 2-hour smoke barrier above the ceiling, fire dampers were not installed in air ducts that penetrated 2-hour fire-rated wall assemblies. 2-hour wall assemblies were confirmed via stenciling on the walls above the ceilings. These fire barriers (walls) were originally designed as a 2-hour separation walls, separating the Hospital Occupancy from the Business Occupancy. This situation has changed per interview with staff 'C' and both areas are now combined under the Hospital Occupancy. This same wall is now being used as a smoke barrier, separating the red from the yellow smoke compartments. A 2-hour wall assembly requires a fire damper where a duct passes though it. All ducts passing through this 2-hour wall assembly could not be proved to have fire dampers. This situation was not compliant with NFPA 101 (2000 ed.), section 19.5.2.1 and NFPA 90A (1999 ed.), section 3-3.1.

This condition was confirmed at the time of discovery by a concurrent observation, documentation review and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
______________________________________

Based on observation, staff interviews and review of facility documents, the facility did not have (1.) fire dampers through 2-hour fire-rated assemblies, (2.) proper separation of hazardous spaces to exit stairwells and (3.) a Fire Response Plan that contained all code-required elements including a written fire control plan with correct placement of fire extinguishers per the Life Safety Plan that contained provisions for access of extinguishers (portable fire extinguishers) to assist in putting out a small fires. The facility did not have a building that complied with regulations that were in effect at time of construction and approved to the federal standards. These deficiencies occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. Based on a recent Verification Visit on 06/08/2016 at 2:01 pm, it was observed on the 1st floor in the Main Electrical Vault Room 1093 in the orange smoke compartment Zone 2, that the two means of exit access were not provided at each end of the electrical working space, which had equipment rated at 1200 amperes or more or was 6' wide or more. The room had combined electrical panels that exceeded 1200 amps, requiring a minimum 1-hour room enclosure. The hospital elected to have a 2-hour enclosure to remove the fire protection system, so as not to mix water and electricity. This then requires any mechanical ducts going into the room to be fire/smoke dampered for a two-hour fire assembly. The fire/smoke dampers were missing. This situation was not compliant with NFPA 70 (1999 ed.), 110-26(c) and NFPA 101 (2000 ed.) section 8.2.3.2.4.1 Penetrations and Miscellaneous Openings to Fire Barriers and 9.2.1 HVAC systems.

This condition was confirmed at the time of discovery by a concurrent observation, review of Life Safety Plans and interview with staff A (Hosp. Maintenance Lead), staff B (Construction Project Sprvs.) and staff C (Waukesha Co. MHC Administrator).
______________________________________