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B) New 02/02/10: The surveyor finds that the 4th Floor Surgical Unit has an exit access corridor that runs through it. There is a scrub area and an office area that is open to the corridor. The office is not staffed 24/7 and is not separated from the corridor in accordance with 19.3.6.1.

The exit access corridor through the 4th Floor surgical unit is not clearly identified on the Life Safey Code Plans.




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A. The 1st Floor Main Lobby of the building was found to have miscellaneous opening in pass through windows. The aggregate open area of openings to the exit access corridor in unsprinklered building is permitted to be 20 square inches per room; and located at or below half the distance of the height from the floor to the ceiling of the room.

02/02/10: The window opening was not corrected in accordance with the last submitted PoC. The combined opening dimensions of the speaker hole and the pass through slot are clearly in excess of 20 square inches and do not comply with 19.3.6.5.

B) New 02/02/10: The surveyor finds that the 4th Floor Surgical Unit has an exit access corridor that runs through it. The operating rooms and other doors in this unit all have foot peg, hold open devices that prevent the door from being pulled closed in one simple motion in accordance with 19.3.6.3.3. This includes the door to the "Clean Room" and the "Decontamination Room."

C) New 02/02/10: The pair of doors to Operating Room # 2 have panic hardware. One of the doors failed to latch.

D) New 02/02/10: The pair of corridor doors to Recovery has one door of the two that lacks positive latching hardware.



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A) 1st Floor
1. Corrected 02/02/10

B) Basement
2. Corrected 02/02/10

C) New 02/02/10: Transfered from K032: The surveyor finds that the 4th Floor Surgical Unit is not a suite as defined by NFPA 101. An exit access corridor continues through this area to the exit stair the west. Operating Rooms typically have pairs of corridor doors with self closing hardware and panic hardware.

1) Most if not all of teh doors in this surgcail unit have "foot peg" hold devices on the foot of each door. This hardware does not allow each door to be closed readily without delay in accordance with NFPA 101. This includes both doors for each operating room.

2) O R # 2: One of two doors does not latch.

D) New 02/02/10: 4th Floor Outpatient Pre-op/Recovery. This room has two corridor doors. One is blocked off and latch with slide bolts. This door lacks postive latching hardware. Alternately, the door is not permenantly secured closed.

1. Modified 02/02/10: The provider has identified smoke barriers on Life Safety Code Plans. From random observation the surveyor finds that one hour smoke barriers are not constructed as one hour fire barriers to the deck above. See also K104.

Modified 02/11/10, after SOD was mailed - separate letter sent. Confirm which floors have 31 one sleeping patients/floor and which if any have previously identified smoke barriers. The size (in gross area) of each smoke compartment is not identified on plans.

Added on 02/11/10: The designated smoke barriers on the 2nd, 3rd and 4th Floors all have penetrations above the ceilings, through the smoke barrier, that are not sealed for one hour fire rated construction. Smoke dampers are also missing at the 2nd, 3rd and 4th Floors - see K104.

A) Modified 02/02/10: The 4th Floor Sterilizer Room behind the stair in the surgical area is not properly separated for the exit stair with fire rated construction and/or fire rated opening protectives.

a) (Original citation) The south wall of the sterilizer room is not constructed as a two hour fire barrier (unrated access panel, duct penetration with no fire damper, etc.).

The surveyor finds that the above barrier is not a barrier that is designed to separate the sterilizer room and the mechanical sysems in the interstitial space from the stair. The true separation wall is the wall inside the intersitial space between the stair and the insterstitial space (it has a U L rate access panel in the stair). (information only - item "a" is not a deficiency)

b) There is an interstitial space between the stair and the sterilizer room that must be separated from the exit stair. The concrete slab of the interstitial space and the fire rated wall inside appear to provide the required two hour separation from the stair.

i) The continuity of this fire barrier appears
to be incomplete. The ceiling cavity of
the stair is open to this
interstitial space at the top of the wall of
the stair It is not clear why the ceiling
cavity should not be separated from the
interstitial space by a vertical two hour
barrier or that the ceiling of the stair is
constructed as a horizontal two hour fire
barrier (w/ no support from above).

ii) There is a gap between the concrete slab
of the interstitial space and the lower
wall of the sterilizer room (with
plumbing in the gap). The provider
lacks information that demonstrates that
the remaining solid portion of the wall
separates the plumbing space from the
stair by two hour construction.

A) (New 02/02/10) 4th Floor West Stair: This exit stair from the surgical unit has two electrical transformers mounted on the wall, inside the stair, and does not comply with 7.1.3.2.1 and/or 7.2.2.5.3.


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A) Exits are not installed and maintained to provide a continuous protected path to a public way:

1) (Modified 02/02/10: The East Stair of the Hospital serves as a required exit for floors 1 through 4. This stair does not comply with Chapter 7 or NFPA 101:

a) There is an elevator opening within the exit stair enclosure on Floors 1 through 4. This deficiency includes the lack of separation at the 1st Floor Exit Passageway. The previously submitted PoC does not address the protection of the Exit Passageway.

The previously submitted PoC does not identify the IDPH Project Number that is part of the PoC for the above item.

b) There is an existing exit passageway at the 1st Floor that serves as the discharge for this stair (with a protected path to the exterior on the east side of the Building. The exit passageway is deficient:

i) The office area east of the stair has a
door into the exit passageway that is a
3/4 hour fire door. A 1 1/2 hour fire
doors is not provided. Further the
designated two hour west wall of the
office has one or more holes or
penetrations (above the ceiling) that are
not sealed for two hour fire rated
construction.

ii) The North wall of the office area is a
designated two hour fire barrier. The
glass block in this wall is not two hour
construction. Multiple louvers in the
wall are not protected for two hour
construction. Three "window" type air
conditioners penetrate this two hour
barrier - the wall is not two hour
construction and the exit passageway is
compromised. Also, two ducts penetrate the
designated two hour wall above the
ceiling without fire dampers.

iii) There is a fire door at the north end of
this exit passageway (next to the Hot
Lab). There is one or more holes in the
designated two hour barrier (above the
ceiling) above the fire door.

iv) The designated two hour walls at the Hot
Lab and Nuc Medicine have a duct that
runs across the exit passageway, above
the ceiling, that lack fire dampers.

v) Multiple doors that open into the exit
passageway have U L Labels that are
painted (1 1/2 fire doors could not be
verified).

Hot Lab

Nuclear Medicine

Pharmacy/lab

vi) There is an interstitial space just north of
the stair and west of the exit passageway.
The wall is a designated two hour
barrier. The access panel in the lower
part of the wall and the wall construction
behind the access panel are not two hour
construction. There is an opening in the
floor of this interstitial space into the
Basement below. The opening in the
floor is not protected as a two hour
penetration (vertical opening separation
in a two hour fire rated floor).

vii) The stair discharge only complies with
7.7.1 if a two hour Exit Passageway is
provided at the 1st Floor. This Exit
Passageway is not identified on the Life
Safety Code plans and does not comply
with 7.2.6, as indicated in item "a" and
"b" above.

Corrected 6/03/10 - plans show
exit passageway

viii) A ramped change of elevation occurs
in a portion of this exit passageway.
Details along with the exact slope of
this ramp are not provided.

Corrected 6/03/10 - plans show
ramp pitch

B) 1st floor

2. An exit discharge path from the ED and other parts of the hospital discharge into an outside area that is fenced and secured at night. The continuous path to a public way is not provided.

02/02/10 - The sliding gate installed in the fence is not chained and locked open permanently. The swinging door provided in this fence is closed and locked.

3. Corrected 02/02/10

4. Corrected 02/02/10

C) (New 2/02/10): The Northwest Stair from 2 North has a door to the outside at grade. This stair is identified as a fire escape; it is not a fire escape. It is a previously approved non-conforming enclosed exterior stair. (see K047)

1) On 2/02/10, the door required more than 50 pounds of force to push the door open. Immediate correction was required and was confirmed by the surveyor. The provider lacks adequate means to check all exit discharge doors for proper operation.

2 ) The stair has a handrail the is mounted to a masonry wall. The railing has an open end at the upper portion of the railing. This open railing does not extend to the top of the stair treads and lacks a railing termination in accordance with NFPA 101. The open end on the railing constitutes and unnecessary hazard in a mean of egress. (7.2.2.4.4)

B) (New 02/02/10): The 1st Floor North, one story, wing identified as Golden Light, is separated from the rest of the Hospital by two hour fire rated walls. The separation wall is deficient as a two hour barrier:

The concrete block wall above a pair of fire doors (opposite Room 133) has holes and voids above the ceiling that are not sealed for two hour construction.


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A) 1st Floor

1. Above the ceiling in the "Chicago Vestibule" by the ED, a fire damper in ductwork penetrating the wall was found to be closed. 02/02/10: This item was not corrected in accordance with the last submitted PoC.

2. Modified 02/02/10: Above the door in the dental exam room near the "Chicago Vestibule" in ED ductwork with fire damper and access door. Based upon the Life Safety Code plan, the fire damper is not required at this location. If it remains it must be maintained in accordance with NFPA 90. This item will be deleted on the next on site visit.

3. Corrected 02/02/10 - see K038

A) 4th Floor

1. Corrected 02/02/10

2) New 02/02/10: One of the exit paths for 2 North is directed to an outside stair that is identified with two illuminated signs that indicate "Fire Escape". Fire escapes are not permitted by NFPA 101 in health care occupancies. The surveyor finds that the stair is an existing exterior enclosed exit stair. Illuminated exit signs that indicate EXIT are not provided.

Basement
1. Corrected 02/02/10

2. (New 02/02/10): The sprinkler heads are obstructed be storage in one row of the large Basement Storage Room and in the area where the ceiling is much lower. Storage is not maintained at 18" below the sprinkler heads.

A) (New 02/02/10): The surveyor observed that Operating Room # 1 has a flex-duct hanging out of the ceiling. This duct was not connected to any equipment in the room.

Identify when and how this duct will be removed and how the ceiling and the duct connection will be repaired.


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Penthouse

1. The surgery air handling unit was found to have a unseled penetration at the units access door to the filters.



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a. Deleted 02/02/10 - see K104

b. Deleted 06/21/10

Modified 02/02/10: Based upon personnel interview, the surveyor finds that 2nd and 3rd Floor corridors have air handling systems that provide fresh air to the corridors. Some but not all patient rooms on the 2nd and 3rd Floor have bathroom exhaust and/or general exhausts in the patient rooms. The provider lacks documentation that demonstrates that the patient rooms with exhausts are not negative relative to the air pressure in the corridors and that the corridor is not being used as a fresh air plenum for patient rooms.

A) New 02/02/10: The surveyor finds that the 4th Floor Surgical Unit has an exit access corridor that runs through it to the West Stair.

1) Patient gurneys and waste containers are routinely left in the exit access corridor, obstructing the corridor width during surgical procedures.

B) (New 02/02/10): The provider has no information that identifies 2 North as a patient sleeping area suite. The exit access corridor in this unit was found obstructed a scale, a soiled material hamper, an IV stand and a stainless steel cart.

A) By direct observation the facility failed to provide:

1) Restraints for stored cylinders within the medical gas storage room. 02/02/10 - some tanks were not secured. Some tanks are located in too large of a space to be restrained by the chains provided.

A) (New 02/02/10): Duct penetrations through designated smoke barrier lacks smoke dampers in accordance with NFPA 101 and NFPA 90A: Typically duct penetrations through designated one hour smoke barriers have fire dampers and not smoke dampers.

By direct observation the facility failed to provide:

a. Corrected 02/02/10

b. Corrected 02/02/10

c. Distinctive identification, either by color or markings, receptacles supplied from the essential electrical system as required by NFPA 99, 1999, 3-4.2.2.4 (b) 2 & NFPA 70, 1999, 517-33 (c).

d. Panelboard and circuit identification at receptacles supplied from the emergency electrical system as required by NFPA 70, 1999, 517-19 (a).

e. Provide a circuit directory (panel directory) legibly identifying all circuits as to the purpose or use, NFPA 70-384-13 for each electrical panel.

f. Provide identification of electrical panels in order to determine normal and emergency power circuits, Life Safety, Critical, & Equipment.

A) (New 02/02/10): K130 Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction PoC and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

1) The facility does not comply with NFPA 101; identify any and all interim life safety measures that allow the building to remain occupied while corrections are being maintained.







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A) A726 482.41?(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.

1) Temperature, humidity and airflow in the operating rooms must be maintained within acceptable standards to inhibit bacterial growth and prevent infection, and promote patient comfort. Excessive humidity in the operating room is conducive to bacterial growth and compromises the integrity of wrapped sterile instruments and supplies. Each operating room should have separate temperature control.

By direct operation and staff interview the following conditions at the time of survey existed indicating the above standard is not being met

The air handling system for surgery located in the elevator penthouse, was out of service for maintenance as indicated by staff however the surveyor did not observe maintenance procedure being performed. The staff accompanying the surveyor returned the air handling unit to service. When question on the means for providing and maintaining acceptable humidity for the operation rooms staff indicated no automatic controls existed.

Survey of the surgical area on 4th floor, the surveyor noted surgical procedures were in progress during the time the air handling unit was off. Staff indicated at times the air handling system will be shut down for control of temperature when clinical staff complain they are cold.

The PoC does not identify that IDPH Project # that is part of the PoC for the above item.

2) This condition was also observed for the system on the 3rd floor nursing unit.

02/02/10: The above item was not corrected in accordance with the last submitted PoC. Also, no PoC was found for the citation at the 3rd Floor.

A) (New 02/02/10): Based on random observation, the surveyor finds that electrical installations and materials do not comply with NFPA 70/NFPA 99:

1) Electrical Panel 2/PP/3 in 2 North lacks circuit identification on all circuits, including spare circuits.

2) Elevator Machine Room for the East Elevator. The dumbwaiter space has an open panel box or junction box mount just above the floor. The cover was missing. There is a large cable running out of the box. The provider did not know what this cable served and did not know why the cable is not installed in conduit.

3) The 4th Floor Pre-op/Post-op patient room for outpatient surgery and the separate Surgical Recovery Room are both critical care areas. According to the provider, there are not electrical outlets in these two spaces that are backed up by emergency power. See also K106 f).

General
1. Through staff interview, the surveyors determined that elevators in the hospital are not equipped with automatic firemans recall.

The PoC does not identify the IDPH Project # that is part of the PoC for the above item.