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Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency had the potential to affect all patients, staff and visitors within 1 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/22/2013 at 2:10 pm, observation revealed on the 1st Floor at the Production Kitchen to the Loading Dock, that the corridor door would not positively self-latch. The fire-rated door was equipped with a closer, but it would not hold the door in the latched position. Wood wedges were observed under the doors to prevent them from closing. The building was 'not sprinkled', creating a hazard to life in the event of a fire emergency. This deficiency has been previously approved for correction by September 13th, 2013.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide corridor separation doors without deadbolts. This deficiency had the potential to affect all patients, staff and visitors within 3 of the 22 smoke compartments.

FINDINGS INCLUDE:
2. On 04/24/2013 at 3:25 pm, observation revealed on the Wing area 4/ Level 3-A floor in the Conference Room/Activites Space 3203-13, that the corridor double fire doors were observed to have a latching mechanism 'deadbolt' that was located greater than 50 inches above-finished-floor (AFF). Door latching mechanisms are required to be located between 34 inches and 48 inches AFF and deadbolts are not permitted in a hospital for patient egress purposes per NFPA 101 section 7.2.1.5.4. Five patients were observed in the room at time of the verification visit. This observed situation was not compliant with NFPA 101 section 19.3.6.3.2. These doors have been previously approved for correction on August 2, 2013.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer), staff Y (Maintenance Supervisor) and staff X (Assistant Hospital Administrator).
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Based on observation, interview, and record review the facility did not ensure the path of egress was clearly identified by appropriate exit signage. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:
1. On 04/22/2013 at 11:05 am, observation revealed on the Wing area 5/ Level 2-B floor at the Door 2303, that signage was installed in the egress path that made the exact exit route confusing. The Exit Sign is blocked or miss-placed. This observation was from the Inspection 9/25/2012 completed by Daniel Schumacher of the Wauwatosa Fire Department. The deficiency has not been found to be corrected as yet. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 sections 19.2.10 and 7.10.1.2. These exit signs have been previously approved for correction on July 5, 2013.

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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies held-open with the required safe guards. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:
2. On 04/25/2013 at 11:00 am, observation revealed on the Wing area 5/ Level 2-A floor in the Laundry Room 2336A, that the hazardous room door located within a smoke barrier wall was prevented from self-closing by a wood pie-shaped door-stop placed under the door. The room was over 100 square feet and had a large amount of combustibles within the room, considering it hazardous. These doors have been previously approved for correction on July 19, 2013.


These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). These observed situations were not compliant with NFPA 101 section 7.2.1.8.
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Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, and a smoke-tight room enclosure (in a sprinkled smoke zone). This deficiency had the potential to affect all patients, staff and visitors in 4 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/23/2013 at 8:33 am, observation revealed on the Wing area 3/ Level 1-A floor in the Human Resources File Room, that the door would not self-close because the door was blocked-open to prevent the door closer from working. The door had a door closer due to the significant amount of combustibles within the room and to keep the door closed. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). The room was considered hazardous because it exceeded 50 sq. ft. and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 sections 19.3.2.1 and 8.4.1. This deficiency has been previously approved for correction by July 19, 2013.

5a. On 02/25/2013 at 11:34 am, observation revealed on the Wing area 5/Level 2 floor in the Loading Dock, the non-fire-rated Oxygen Storage Room was venting into the Loading Dock. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). The room was considered hazardous because it exceeded 50 sq. ft. and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 sections 19.3.2.1. This deficiency has been previously approved for correction by August 1, 2013.

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Based on observation, interview, and record review, the facility did not maintain all exit stair treads. This deficiency had the potential to affect all patients, staff and visitors in 3 of the 22 smoke compartments.

FINDINGS INCLUDE: On 04/22/2013 at 10:35 am, observation revealed on the Wing area 4/ Level 2 floor at the lowest level in Stairwell 4-11, that the stairwell was not compliant. During the last Annual Fire Department Inspection report dated 9/25/2012, the stair tread was found to be in need of repair. The deficiency has not been found to be corrected as of the time of this survey. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer). This observed situation was not compliant with NFPA 101 sections 19.2.2.3 and 7.2.2. This deficiency has been previously approved for correction by July 1, 2013.

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Based on observation and interview, the facility did not provide egress paths at all times with no obstructions in the path of egress, doors that opened with the necessary force, travel interruption at stairs that go below the level of exit discharge, and door hardware that operated with a single release motion. This deficiency had the potential to affect all patients, staff and visitors in 6 of the 22 smoke compartments.

FINDINGS INCLUDE:
1. On 04/23/2013 at 5:35 pm, observation revealed on the Wing area 5/ Level 3-B floor in the Conference Room 13, that the exit path was not readily accessible because the door had a deadbolt on the door. Deadbolts are prohibited. This observed situation was not compliant with NFPA 101 section 7.5.1.1. This deficiency has been previously approved for correction by August 9, 2013.


2. On 04/24/2013 at 8:44 am, observation at the exterior of the building at the Wing area 1/ Level 1, that the exit path was not readily accessible because there was a drop-off of at least 4 inches to the ground from the concrete stoop and the egress pathway was not a 'hard surface' capable of supporting a wheelchair in all weather conditions. This observed situation was not compliant with NFPA 101 section 7.5.1.1. This deficiency has been previously approved for correction by March 1, 2014.

4. On 04/25/2013 at 9:24 am, observation revealed on the Wing area 4/ Level 3-C floor in the Inpatient Sleeping & Toilet/Shower Rooms 26 & 29, that the exit path was not readily accessible because the room doors had deadbolts. Deadbolts are prohibited. This observed situation was not compliant with NFPA 101 section 7.5.1.1. This deficiency has been previously approved for correction by August 23, 2013.

6. On 04/22/2013 at 2:25 pm, observation revealed on the 1st Floor floor in the Two Stairwells, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. This observed situation was not compliant with NFPA 101 section 7.7.3. This deficiency has been previously approved for correction by August 1, 2013.

7. On 04/24/2013 at 11:08 am, observation at the exterior of the building at the Wing area 5/ Level 3-A & B, that the door release hardware required more than a single motion to release the door for exiting. The hardware included chain-link devices with keyed locks. I was told all staff have keys to these locks. The fenced-in outside courtyards, used by inpatients, were locked by chains around the entire campus. The lock and chain assemblies required several hand motions to open. These conditions do not meet provide a reliable means to egress. This observed situation was not compliant with NFPA 101 section 7.2.1.5.4. This deficiency has been previously approved for correction by August 2, 2013.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide and maintain means of egress ilumination, including the minimum 2-bulbs from the exit discharge to a public way. This deficiency had the potential to affect all patients, staff and visitors in 2 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/24/2013 at 8:45 am, observation at the exterior of the Building #3, Wing area 1/ Level 1, that the path of egress was illuminated by a single light fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 section 7.8.1.4. This deficiency has been previously approved for correction by July 1, 2013.


This condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).

Based on observation, interview and record review, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings or ceilings sealed above the sprinklers to collect heat. This deficiency had the potential to affect all patients, staff and visitors in all of the 22 smoke compartments.

FINDINGS INCLUDE:
21. On 04/24/2013 at 11:11 am, observation revealed on the Wing area 5/ Level 3-C floor in the Main Corridor 3308, that there was one or more unsealed holes near the ceiling. The hole(s) included a ceiling light fixture cap between the ceiling tiles and fixture. One of the openings was a missing cap about 3 inches x 6 inches in area and the other location was farther down the same corridor next to the wall valence at ceiling light fixture. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1. This deficiency has been previously approved for correction by July 1, 2013.

31. On 04/23/2013 at 9:30 am, observation revealed that during a review of documents the facility could not verify that all elements of the fire pump system's annual test were performed. The Annual Fire Pump Test was performed by Grunau Company, Milwaukee, WI. During review of the report is was observed the record motor 'amps' were missing. This is a required field that must be filled out annually. Also missing was the 30 minute churn. No start time or stop time was recorded. Documentation of the 'lubing of the coupling' was missing in the Report. This observed situation was not compliant with NFPA 25 (1998 ed.), sectionn 5-3. This deficiency has been previously approved for correction by October 31, 2013.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide semi-annually cleaning of the range hood, and ducts constructed per the NFPA 96 Fire Protection of Commercial Cooking Operations. This deficiency had the potential to affect all patients, staff and visitors within 1 of the 3 smoke compartments.

FINDINGS INCLUDE:

On 04/23/2013 at 11:50 am, observation revealed that during a review of facility maintenance documents it was discovered that the semi-annual Range Hood and Exhaust Duct inspection and cleaning documents were incomplete. The documents failed to identify if the exhaust hood fans were working properly, if the pilot was cleaned, was the floor cleaned, was the exit access route to safety reviewed. This observed situation was not compliant with NFPA 101 sections 19.3.2.6 and 9.2.3; and NFPA 96, section 8-3.1. This deficiency has been previously approved for correction by August 31, 2013.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation, interview, and record review, the facility did not provide a kitchen extinguishing system as required by NFPA 96. Missing information in the range hood semi-annual cleaning, and hoods and ducts constructed per the NFPA 96 Fire Protection of Commercial Cooking Operations. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

1. On 04/23/2013 at 11:50 am, observation revealed that during a review of facility maintenance documents it was discovered that the semi-annual Range Hood and Exhaust Duct inspected and cleaning documentation was incomplete. The documents failed to identify if the exhaust hood fans were working properly, if the pilot was cleaned, was the floor cleaned, would the oven doors lock upon alarm activation, was the exit access route to safety reviewed. This observed situation was not compliant with NFPA 101 sections 19.3.2.6 and 9.2.3; and NFPA 96, section 8-3.1. This deficiency has been previously approved for correction by August 31, 2013.


This condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with sealed wall penetrations. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:
On 04/25/2013 at 11:29 am, observation revealed on the Wing area 5/ Level 2 floor in the Oxygen Storage Room located on Loading Dock, that penetration(s) were not sealed according to an approved method. The deficiency also included a mechanical duct exhausting from the Oxygen Storage Room into the Loading Dock. There were 34 e-cylinders that were off-gassing, potentially creating a hazardous situation with the Loading Dock area, that was considered hazardous. Did not see a direct exhaust to the outside of the building from the oxygen storage room. This room was used to store greater than 3,000 cubic feet of compressed gas and was required to be enclosed with 1-hour fire-rated construction. This observed situation was not compliant with NFPA 101 section 19.3.2.4 and NFPA 99 (1999 ed.) section 8-3.1.11. This deficiency has been previously approved for correction by July 1, 2013.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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Based on observation, staff interviews and record review, the facility did not provide limited combustible partitions. This deficiency had the potential to affect all patients, staff and visitors in 1 of the 22 smoke compartments.

FINDINGS INCLUDE:

On 04/25/2013 at 12:40 pm, observation revealed on the Wing area 4/ Level 2-B & C floor in the Maintenance, Plumbers, Carpenters, Painters, HVAC, and Electrical Shops 2220 & 2221, that during a review of facility documents the Hospital Building is a Type I (332) fire resistive construction. All wood partitions used in a Building Type I (332) facility shall be of limited-combustibility or enclosed in a fire-rated assembly. The hospital could not provide documentation that the exposed wood studs meet a limited-combustibility requirement per NFPA 259. This deficiency has been previously approved for correction by a April 1, 2014.

The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).

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Based on observation, interview, and record review, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords, closed electrical raceways, electrical panels with complete directories, and proper working clearances. This deficiency had the potential to affect all patients, staff and visitors in 12 of the 22 smoke compartments.

FINDINGS INCLUDE:
18. On 04/25/2013 at 10:30 am, observation revealed on the Wing area 5/ Level 2 floor, that the Level of service was incorrect. It was observed that the single-line electrical drawings incorrectly show the Level for the electrical panels. Example: The 2nd Level is shown as Level 1. This observed situation was not compliant with NFPA 70 (1999 ed.) section 110-22. This deficiency has been previously approved for correction by August 31, 2013.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor).
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