HospitalInspections.org

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

The corridor door for patient room #4121 failed to positively latch into the door frame assembly.
Note: This item was corrected during the survey.

The corridor door deficiency item was discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A4, known as Porter Hospital ICU.

It was determined by observation during the survey on July 21, 2011, that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

The 70/30 double doors were not considered to be positive latching, on the "30 side" when in the closed position. Sixteen (16) of thirty-six (36) patient room corridor doors utilized slide locks on the "30 side" of the door for latching. The slide lock fail to automatically latch into the door frame assembly upon closure of the door, as required.

Note: NFPA 101, 18.3.6.3.2 requires that all corridor doors shall be provided with positive latching hardware. The "70 side" of these door assemblies, equipped with the latchset, were arranged to latch into the "30 side" door leaf that was equipped with the slide lock manual latching hardware. If the manual latching hardware was not engaged, neither leaf would be positively latched.

The corridor door deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A3, known as Porter Medical Plaza.

It was determined by observation during the survey, that the facility failed to maintain and protect the vertical openings in accordance with the Life Safety Code. This was evidenced by:

The South door of the West fire-rated door assembly at the fourth floor elevator lobby failed to positively latch into the door frame assembly when released from the fully open position. The elevators a customarily utilized by all patrons of the fourth floor, including those obtaining hospital services rendered on this floor.
Note: This item was corrected during the survey.

The vertical opening deficiency item was discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A2, known as the Cancer Center.

Through observation during the survey, July 20, 2011, it was determined that the facility failed to maintain the fire resistive rating of vertical openings.

During the walk through of the facility with staff, the atrium located in the Cancer Center was found not to be separated from adjacent spaces per NFPA 101, section 8.2.5.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to maintain the smoke barrier doors in accordance with the Life Safety Code. This was evidenced by:

The West smoke barrier door that separates Pre-Op from the main OR on the second floor (door #FD 2-039), failed to fully close and positively latch into the door frame assembly when released from the fully open position. Note: Due to a recent remodel of the Pre-Op area, this portion of the building was surveyed under the requirements of Chapter 18, New Health Care Occupancies, of the Life Safety Code.
Note: This item was corrected during the survey.

The smoke barrier door deficiency item was discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to maintain and protect sprinkler protected hazardous areas in accordance with the Life Safety Code. This was evidenced by:

1) The door to the linen storage room next to the staff lounge on 5 East, which housed a large amount of combustible material and is approximately 85 square feet in size, failed to have a corridor door and self-closure device separating the storage area from the corridor with a minimum of smoke resistive construction, as required.

2) The corridor door for the South end soiled utility room on 5 North failed to fully close and positively latch into the door frame assembly when released from the fully open position.
Note: This item was corrected during the survey.

3) The East corridor door for the North end soiled utility room on 4 North failed to fully close and positively latch into the door frame assembly when released from the fully open position.
Note: This item was corrected during the survey.

The hazardous area deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A6, known as the Anti-Coagulation Clinic.

Through observation during the survey, July 20, 2011, it was determined that the facility failed to maintain the doors to the hazardous locations.

During the walk through of the facility with staff, the door to the storage room, which housed a large amount of combustible material, did not latch into the frame.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

1) The exterior set of sliding ED entrance doors failed to have the required signage stating "In Emergency, Push to Open," as required by 7.2.1.9.1. Note: This item was corrected during the survey.

2) It took greater than the maximum allowable 30 pounds of force to set in motion from the closed position, as required by 7.2.1.4.5, the set of occupancy separation doors between the ICU and the Main Hospital, which are considered a means of egress from the Main Hospital side of the separation.

The means of egress deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A3, known as Porter Medical Plaza.

It was determined through observation during the survey, that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

The South stair exit enclosure failed to have a gate installed at the ground floor, which is the level of exit discharge, preventing egress through the parking garage.

Note: This exit enclosure is one of two means of egress from the building and is the only one of the two that discharges directly to the exterior of the building; however, discharging directly to the exterior of the building through this exit is only accomplished when occupants exit on the ground floor through the two-hour fire rated exit passageway.

The means of egress deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation, document review and staff interview during the survey, that the facility failed to conduct fire drills in accordance with the Life Safety Code and the facility's written procedures for response to fire emergencies. This was evidenced by:

1) Documentation was not provided at the time of the survey to show the following drills had been completed:
a. One (1) during the second shift in the first quarter of 2011.
b. One (1) during the first shift in the fourth quarter of 2010.
c. One (1) during the second shift in the fourth quarter of 2010.
(Note: The facility provided documentation at the time of the survey to reflect several drills had taken place over the course of the last year; however, many of these drills were documented during a false or actual alarm of the fire and smoke detection system. Fire drills must be pre-planned events and the facility may not utilize false alarms of the fire and smoke detection system or real events in lieu of these pre-planned events.)

2) A fire drill was held on July 27, 2011 at 13:12 during which responders failed to employ the written procedures of the facility's response to fire emergencies. This was evidenced by the following:
a. The facility's written procedures for response to fire emergencies state that all occupants are to evacuate from the compartment affected by the fire prior to the arrival of the fire department. During the drill, the staff serving the area affected by the mock fire stated and took action to maintain all patients in their rooms and stated they would wait for fire department direction prior to moving any patients.
b. The facility's written procedures for response to fire emergencies state that an announcement of "Code Red" is to be used upon discovery of a fire to alert other employees of the fire; the staff member responding to the mock fire:
i. Failed to announce the discovery of the mock fire until more than 2-minutes into the drill, and
ii. Announced the fire as "I have a fire," rather than the required "Code Red."
c. A manual pull station was not activated immediately upon discovery of the mock fire, as outlined in the facility's written procedures for response to fire emergencies.

The fire drill deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation and staff interview during the survey, that the facility failed to maintain the fire alarm system in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

1) During testing of the fire alarm system on July 27, 2011, the facility was unable to silence the audible alarms on the ground floor of the facility.
Note: This item was corrected during the survey.

2) During testing of the fire alarm system on July 27, 2011, it was observed that the audible alarm decibel level in the basement of facility was greater than 120. In accordance with NFPA 72, 4-3.1.2, at no point shall the alarm system exceed 120 decibels. Note: this item was corrected during the survey.

The fire alarm system deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A7, known as the South Denver Medical Building.

Through observation during the survey, July 20, 2011, it was determined that the facility failed to maintain the fire alarm system.

During the walk through of the facility with staff, a smoke detection device was installed above the fire alarm panel as required by NFPA 72.

This portion applies to Building AA, known as the Aurora X-Ray Building.

Through observation during the survey, July 20, 2011, it was determined that the facility failed to maintain the fire alarm system.

During the review of the fire alarm report with staff, the report noted the following deficiency:
1. Dialer battery failed load test.
2. Control valves are wired for supervisory signal yet no signal is transmitted to the panel.
3. No flow test of the fire sprinkler system was performed to test the functionality of the flow switch.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to install the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 13, Installation of Sprinkler Systems. This was evidenced by:

The facility, which utilizes several exceptions in the Life safety Code that require that the building have an Automatic Fire Sprinkler System throughout, failed to provide sprinkler protection in the following locations:
a. In the old pharmacy vestibule on the first floor, and
b. Two (2) radiology forms storage closets on the ground floor.

The automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to install and maintain the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection Testing, and Maintenance of Water-based Fire Protection Systems. This was evidenced by:

1) The following compartments contained Quick Response (QR) sprinkler heads and standard response (SR) sprinkler heads.
a. The basement corridor from the hospital to the Harvard Park X-Ray building, and
b. Patient room #2103 had two (2) standard response heads and one (1) quick response head.
Note: In accordance with NFPA 13, 5-4.5.3, in a compartment where residential quick response heads are installed, all sprinkler heads within that compartment must be of the quick response type.

2) There were two (2) sprinkler heads in the central plant office that were located four feet from one another.
Note: In accordance with NFPA 13, 5-6.3.4, sprinklers shall not be closer than six feet from one another.

3) The laundry room in the basement contained one (1) sprinkler head located one (1) inch off the wall.
Note: In accordance with NFPA 13, 5-6.3.3, sprinkler heads may not be located any closer than four inches to a wall.

4) The central storage room on the South wing on the third floor had an extended coverage sprinkler head that was located approximately six feet-two inches from another sprinkler head and within approximately seven feet of a third sprinkler head.
Note: In accordance with NFPA 13, 5-8.3.4, Extended coverage sprinklers may not be any closer than eight feet to other sprinkler heads.

The maintenance of the automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A3, known as Porter Medical Plaza.

It was determined through observation and record review, that the facility failed to maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, Installation of Sprinkler Systems, and NFPA 25, Inspection, Testing, and Maintenance of Water-based Fire Protection Systems. This was evidenced by:

1) The sprinkler head located in the back hall of the Transplant Center on the third floor was obstructed by the adjacent exit sign. Note: This item was corrected during the survey.

2) Documentation of the latest fire pump test shows that one (1) gauge on the fire pump needs to be replaced. The facility failed to provide documentation at the time of the survey to reflect that this item had been corrected.

The fire sprinkler system deficiency items were discussed during he survey and again during the exit conference on August 2, 2011.

This portion applies to Building A2, known as the Cancer Center.

Through observation during the survey, July 20, 2011, it was determined that the facility failed to maintain the automatic sprinkler system in a reliable operating condition.

During the walk through of the facility with staff, curtains were installed in rooms, which obstructed the fire sprinkler heads (Cancer Center).
a. 2nd floor, Dexa Room, Breast Center (corrected on-site)
b. 2nd floor, room #3, Breast Center (corrected on-site)

This portion applies to Building A5, known as the Harvard Park X-Ray.

Through observation during the survey, July 20, 2011, it was determined that the facility failed to maintain the automatic sprinkler system in a reliable operating condition.

During the walk through of the facility with staff, one (1) fire sprinkler head was obstructed by the ceiling mounted X-ray equipment located in the X-ray room.

This portion applies to Building A6, known as the Anti-Coagulation Clinic.

Through observation during the survey, July 20, 2011, it was determined that the facility failed to maintain the automatic sprinkler system in a reliable operating condition.

During the paperwork review portion of the survey, documentation was not available proving that the stand pipe system has been hydrostatically tested within the past five years.

This portion applies to Building AA, known as the Aurora X-Ray Building.

Through observation during the survey, July 20, 2011, it was determined that the facility failed to maintain the automatic sprinkler system in a reliable operating condition.

During the review of the fire sprinkler inspection report, the following deficiencies were noted:
1. Gauges on the fire sprinkler system are older then five years and must be replaced or recalibrated.
2. Two (2) fire department connections (FDC) caps are missing.

This portion applies to Building A3, known as Porter Medical Plaza.

It was determined through record review during the survey, that the facility failed to maintain an adequate and reliable water supply which provides continuous and automatic pressure in accordance with the Life Safety Code and NFPA 13, Installation of Sprinkler Systems. This was evidenced by:

Documentation of the latest fire pump inspection shows that the fire pump flow test failed. The facility failed to provide documentation at the time of survey to reflect that this item had been corrected.

The Fire sprinkler System Water Supply deficiency item was discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to continuously maintain the corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency in accordance with the Life Safety Code. This was evidenced by:

1) Located on the corridor wall at the door of each resident room on the East wing of the third floor is a nurse charting station that, when in the open position, protrudes into the corridor approximately two and a half feet. These charting stations failed to have self-closure devices that would ensure the stations do not obstruct the clear width of the corridor when not in use.
Note: This items was corrected during the survey.

2) Located on the corridor wall at the door of each of the resident rooms #2305-#2305, on the South wing of the second floor is a nurse charting station that, when in the open position, protrudes into the corridor approximately two and a half feet. These charting stations failed to have self-closure devices that would ensure the stations do not obstruct the clear width of the corridor when not in use.
Note: This item was corrected during the survey.

The corridor obstruction deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation and document review during the survey, that the facility failed to maintain loose hanging fabrics in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide documentation that the shower curtain for the gurney shower on 3 South, which is open to the corridor, met the requirements set forth in NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films, as required.
Note: This item was corrected during the survey.

The loose hanging fabric deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to maintain the bulk oxygen storage site in accordance with the Life Safety Code, NFPA 99, Healthcare Facilities, and NFPA 50, Bulk Oxygen Systems at Consumer Sites. This was evidenced by:

The uninsulated portions of the bulk oxygen storage site on the West side of the building failed to meet the distance requirements from combustibles, as set forth in NFPA 50. This was evidenced by:
a) The bulk storage location was within approximately 14 feet of one tree and 20 feet of another, both considered fuels that would burn slowly, and
b) The bulk storage location was within approximately 30 feet of a wood cedar fence to the South and 45 feet of a wood cedar fence to the North, both considered fuels that would burn rapidly.

The bulk oxygen storage site deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation, that the facility failed to maintain the existing fire-rated occupancy separation in accordance with the Life Safety Code and NFPA 221, Standard for Fire walls and Fire Barrier Walls. This was evidenced by:

The sequencer for the West occupancy separation door between the cancer center and the hospital failed to operate as designed, resulting in the doors not positively latching into the door frame assembly, as required.
Note: This item was corrected during the survey.

The maintenance of the fire-rated occupancy separation deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A3, known as Porter Medical Plaza.

It was determined through observation, that the facility failed to maintain the existing fire-rated occupancy separations in accordance with the Life Safety Code and NFPA 221, Standard for Fire walls and Fire Barrier Walls. This was evidenced by:

The existing one-hour fire rated occupancy separations between the following spaces licensed and certified under the Hospital and the adjacent spaces not licensed or certified under the Hospital failed to be complete, as required:

a) The separation for transplant services on the third floor failed to be fully sealed and had several unsealed penetrations. Note: This item was corrected during the survey.

b) The separation for GI lab on the third floor failed to be fully sealed and had several unsealed penetrations. Note: This item was corrected during the survey.

c) The separation for transplant center on the first floor failed to be fully sealed and had several unsealed penetrations.

d) The separation for the Center for Liver Transplant on the first floor failed to be fully sealed and had several unsealed penetrations.

The maintenance of the fire-rated occupancy separation deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building AA, known as the Aurora X-Ray Building.

Through observation during the survey, July 20, 2011, it was determined that the facility failed to maintain the one hour fire resistance rating of the common wall.

During the walk through of the facility with staff, the Aurora Radiology Center did not contain an one hour separation from the non-licensed non-certified adjacent spaces.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to maintain the oxygen transfer location in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

The facility was transferring oxygen in the storage closet in the Psychological Unit on the first floor, however:

a) The room was not separated from adjacent spaces by one-hour construction,
b) Mechanical ventilation to the exterior of the building was not provided,
c) The floor was not of ceramic tile or concrete, and
d) Items, combustible in nature, were stored in the same room.
Note: This item was corrected during the survey.

The oxygen transfer location deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to maintain the generator and related equipment in accordance with the Life Safety Code, NFPA 99, Healthcare Facilities, and NFPA 110, Standard for Emergency and Standby Power Equipment. This was evidenced by:

The facility failed to provide battery backed up lighting in the ATS room adjacent to receiving, as required.

The generator deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation, staff interview, and document review, that the facility failed to install and maintain the essential electrical system in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

1) Panel ERGA3 in the South wing on the third floor, found to be connected via the Critical Branch, supplied power to the Fire Alarm Control Panel. All portions of the fire alarm system shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

2) Panel EH3B in the North wing on the third floor, found to be connected via the Critical Branch, supplied power to the wing's emergency exit lights. All lights utilized for emergency egress lighting shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

3) Panel EH5A in the East wing on the fifth floor, found to be connected via the Critical Branch, supplied power to the wing's stair emergency lights. All lights utilized for emergency egress lighting shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

4) Panel EL5A in the East wing on the fifth floor, found to be connected via the Critical Branch, supplied power to the Fire Alarm Control Panel. All portions of the fire alarm system shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

5) Panel NW4LS in the North wing on the fourth floor, found to be connected via the Life Safety Branch, supplied power to the Pneumatic Tube for #2, #3, #4, and #3 North corridor outlets, neither of which may be on the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

6) Panel CLLECA in the Cathlab on the second floor, found to be connected via the Critical Branch, supplied power to the Med Gas Alarm. All portions of the med gas alarm system and all lighting used for emergency egress shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

7) Panel CLHECA in the Cathlab on the second floor, found to be connected via the Critical Branch, supplied power to the emergency lighting. All lighting used for emergency egress shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

8) Panel EL1A in the North wing on the first floor, found to be connected via the Critical Branch, supplied power to the Med Gas Alarm. All portions of the med gas alarm system shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

9) Panel ERGB in the South wing on the ground floor, found to be connected via the Critical Branch, supplied power to the Fire Alarm (Shunt Trip). All portions of the fire alarm system shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

10) Panel EDCBL3 in the ED on the ground floor, found to be connected via the Critical Branch, supplied power to the Fire Alarm Control Panel. All portions of the fire alarm system shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

The essential electrical system deficiency items were discussed during the survey and again during the exit conference on August 2, 2011.

This portion applies to Building A2, known as the Cancer Center.

Through observation during the survey, July 20, 2011, it was determined the facility failed to divide the essential electrical system onto the correct branches per NFPA 99.

During the walk through of the facility with staff, the following equipment was located on the life safety branch in the Cancer Center.
1. Block cutter
2. Three (3) linear accelerator
The equipment listed above may not be on the life safety branch.