HospitalInspections.org

Based on observation, interview, and document review, the facility failed to have exit and directional signs properly displayed, failed to have effective and functional written copies of a plan for the protection of all persons in the event of fire, failed to have an effective fire alarm system, failed to have a compliant heating, ventilation and cooling system, and has failed to fully implement all corrective actions that address the issues revealed in their analysis of the facility's response(s) to a fire that occurred in an air handler on 10/02/14. These issues include the distribution of radios and the installation of a repeater (device to enable enhanced communication) and the shutting off of medical gases. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census at the time of survey was 429 patients.

Findings:

See A701, A709.

Based on interview, observation, and record review, the facility failed to implement all steps to protect the occupants of its building from another fire.

Findings include:

1. Review of the facility's policy "Procedure for Job Site Risk Assessment and Monitoring Work in Progress", implemented on 10/09/14 and revised on 01/08/15 was completed on 01/08/15. The review revealed "After completion of the hot work permit, and prior to commencement of work, the fully completed top copy of the permit (all fields in Part A including signature fields) will be removed and retained by UCMC representative and the bottom copy will be posted on the job site. "

On 01/05/14 at 2:15 P.M. observation of the construction site on the second floor revealed a bottom copy of the Hot Work permit posted, but Part A had not been completely filled out. The section of where the person doing the hot work is to sign had been left unsigned.

The empty signature space was verified by two surveyors and Staff S.

2. Review of the facility's "Hot Wash" document dated 10/02/14 was completed on 01/08/15. The document describes issues related to the fire in the air handler on 10/02/14. Among them was that the third floor did not have a radio and was hard to keep track of where everyone was, that the fifth floor did not have a radio that worked and had to get one from a maintenance associate, that on the sixth floor people didn't know what was going on, and that on the seventh and eighth floors there were no radios.

Review of "areas for improvement" presented to the senior leadership council was completed on 01/08/15. The review revealed "There weren't enough radios".

Review of the facility's "working document" dated 12/23/14 regarding the fire of 10/02/14 and discussed at the senior leadership council revealed a corrective action for building a system wide radio plan with standard ordering across the system. A quote will be received 02/01/15 and radios distributed by 03/01/15 at the director/unit level, and education and expectations for those who need radios during a disaster set by 01/01/16 (sic).

3. Review of "areas for improvement" presented to the senior leadership council revealed "Fire department could not communicate with each other in the sub-basement. "

Review of the facility's "working document" dated on 12/23/14 regarding the fire of 10/02/14 and discussed at the senior leadership council revealed a corrective action revealed a repeater will be installed in the sub-basement for the fire department to have the ability to communicate with each other. The date of completion is 01/01/16 (sic).

4. Review of the facility's "working document" dated on 12/23/14 regarding the fire of 10/02/14 and discussed at the senior leadership council revealed a corrective action to have a liaison officer available to work with fire department with an implementation date of 05/01/15.

On 01/08/15 at 10:20 A.M. in an interview, Staff M stated the liaison officer would also help coordinate between security and the fire department.

5. Review of the facility's "Hot Wash" revealed that on the fifth floor the medical gases were not shut off. Review of the fire drill on 12/8/14 on the 6th floor revealed staff did not know medical gas shut off procedure. Review of failed fire drill completed on 12/19/14 on the eighth floor revealed staff did not know of medical gas procedure.

Review of the facility's safety training review was completed on 01/08/15. The review revealed medical gas valves may be turned off by a supervisor or designee.

On 01/07/15 at 11:10 A.M. in an interview, Staff A stated "anybody" can turn off medical gases in an emergency.

On 01/07/15 at 11:53 A.M. in an interview, Staff B stated the charge nurse could turn off the gases in an emergency after nursing supervisor approval.

On 01/07/15 at 12:25 P.M. in an interview, Staff C stated "anyone" can turn off medical gases in an emergency.

Review of the facility's "working document" dated on 12/23/14 regarding the fire of 10/02/14 and discussed at the senior leadership council revealed a corrective action revealed a corrective action of educating staff on shutting off medical gases with a completion date of 07/01/15.

6. Review of the facility's "Hot Wash" working document dated on 12/23/14 regarding the fire of 10/02/14 and discussed at the senior leadership council, and review of "areas for improvement" presented to the senior leadership council did not reveal any discussion of how the smoke traveled up to the second floor, or into the radiology area of the first floor, or its smell into the fourth floor causing people to vomit, or its smell traveling throughout the rest of the floors above. The review also did not reveal any discussion of what role (if any) inaccessible dampers played in the dissemination of smoke. (See A709).

On 01/07/14 at 3:15 P.M. in an interview with Staff S, Q, and R, Staff S said he/she believed smoke traveled up through stairways from people coming in and out of them and from them being held partially open by water hoses brought in by the fire department to run to the basement.

Staff Q stated he/she believed smoke traveled from the basement via the affected air handler (2B) because most smoke was in the corridors, not patient rooms. He/she said patient rooms were supplied by a different, unaffected handler.

Staff R stated he/she believed the higher floors may have smelled smoke because the air handler on the roof may have taken in smoke that escaped to the outside from the fire in air handler 2B.

There was no evidence this information or any analysis of the migration of smoke throughout the building, and what role inaccessible dampers may have played, triggering the evacuation of 187 patients has been presented to the senior leadership council. Consequently, there is no evidence of corrective action and therefore no date for completion.

However, on 01/07/14 at 3:00 P.M. in an interview Staff M stated if construction occurs in an area where there is an inaccessible damper, the damper will be made accessible.

Based on interview, observation, and record review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The facility's main building at 230 Goodman Street, Cincinnati, OH, was determined to have been constructed prior to 2003 and therefore Chapter 19 of the Life Safety Code 101, 2000 edition applies. This has the potential to affect all patients, visitors, and staff to the facility.

Findings include:

K47 failed to have exit and directional signs displayed in accordance with 7.1.
K48 failed to have effective and functional written copies of a plan for the protection of all persons in the event of fire, especially for their evacuation to areas of refuge
K51 failed to have an alarm system that provides an effective warning of fire
K67 failed to have an heating, ventilation and cooling system in compliance with National Fire Protection Association 90A.

Based on interview and record review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The facility's main building at 230 Goodman Street, Cincinnati, OH, was determined to have been constructed prior to 2003 and therefore Chapter 19 of the Life Safety Code 101, 2000 edition applies. The facility is not in compliance with 19.5.2.1 and therefore Section 9.2 and therefore section 9.2.1 that states the heating, ventilation and cooling and related equipment shall be in accordance with National Fire Protection Association 90A, which states at 2-1.1 equipment shall be arranged to afford access for inspection, maintenance, and repair. On the second floor the facility was not in compliance with 19.2.10.1 and therefore 7.10. This has the potential to affect all patients, visitors, and staff to the facility. The facility's census was 429 patients.

Findings include:

1. Review of the facility's damper inspection report completed from 07/05/12 to 01/11/13 revealed 16 percent of their dampers (smoke and fire inclusive) were inaccessible including three (GSD011, GSD012, and GSD028) in or near the smoke barrier on the west side of radiology. (The radiology department had sustained char damage from smoke during the fire on 10/02/14).

Review of the damper inspection report revealed an inaccessible smoke damper near endoscopy. (The endoscopy suite required evacuation due to the fire.)

On 01/07/15 at 2:50 P.M. in an interview, Staff Q confirmed the dampers in question are inaccessible and of the entire number of dampers hospital wide, 16 percent are inaccessible. He/she stated there isn't any way of knowing when they were tested prior to the testing of the accessible dampers on 07/05/12 to 01/11/13.

On 01/08/05 at 8:45 A.M. in an interview Staff R said he/she could not be certain if the dampers are working.

On 01/08/15 at 8:45 A.M. in an interview, Staff Q and R stated they were unable to determine if the inaccessible dampers on the west side of the radiology department were in the H-VAC system controlling the air flow from air handler 2B-the handler in which a fire occurred on 10/02/14 and which caused smoke damage to the radiology department or if they were located in another air handler unit of the H-VAC system.

Staff R said, "It's like a spider web" of duct work.

2. On 01/07/15 at 11:50 A.M. a tour was conducted of the endoscopy area with Staff S and P. Observation of recovery area 2132 revealed four recovery beds facing three doors in the opposite wall. The path of egress was observed to be through double doors out of sight and perpendicular to the beds. No exit sign was observed directing patients to that path of egress.

On 01/07/15 at 11:50 A.M. in an interview Staff S confirmed the path of egress and the lack of an exit sign on the path of egress.