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Based on observations, review of floor plans, and staff interviews, the facility failed to ensure the 2 hour fire rated barrier between buildings maintained the two hour fire resistance rating. This involved 3 floors of the building (floors 7, 4, and ground) and could affect all patients, staff, and visitors in the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:



21521


a) Tour of the seventh floor was begun on 11/04/13 with Staff AA, BB, CC, and DD from 11:40 A.M. to 3:01 P.M. with Staff AA, BB, CC, and DD. At 2:25 P.M. observation of the two hour fire wall in the nurse practitioner's office in four east revealed above the drop down ceiling an annular space around a pipe. Directly above the penetration and pipe the words " fire barrier " is stenciled. Review of the floor plan as provided by the facility also confirmed the presence of a two hour fire wall.
b) During the tour of the seventh floor that was begun on 11/04/13 with Staff AA, BB, CC, and DD and went from 11:40 A.M. to 3:01 P.M., in an interview Staff BB and EE confirmed the observation.
c) On 11/05/13 at 3:04 P.M. observation of the fire doors in the 2 hour fire rated wall that separated four west from four east revealed one fire door to be unrated.
On 11/05/13 at 3:04 P.M. in an interview, Staff BB and DD confirmed the observation.
d) Tour of three west was begun on 11/07/13 at 9:40 A.M. with Staff AA, BB, CC, and DD from 9:40 A.M. to 10:16 A.M. At 10:10 A.M. at the two hour fire barrier separating three west from three east and above the drop down ceiling above the double doors revealed an open conduit box and an open conduit box near stair N.
During the tour on 11/07/13 from 9:40 A.M. to 10:16 A.M. in an interview Staff BB and EE confirmed the observation.
e) On 11/08/13 at 10:46 P.M. observation of the doors in the two hour fire wall that separated the north building from the west building near stair P, revealed they were not rated two hours.
On 11/08/13 at 10:46 P.M. in an interview, Staff BB and EE confirmed the observation.
f) On 11/08/13 at 11:46 A.M. observation of the fire barrier between Administration and the West building, and near Stair D, a two inch conduit lumen was observed above the drop down ceiling and open to air.
On 11/08/13 at 11:46 A.M. in an interview BB and EE confirmed the observation.

g) During tour on 11/12/13 at 3:00 P.M. with Staff BB, CC, DD, and PP, the 1 and 1/2 hour fire rated door to the dry food storage area in the corridor between Stairwell O and H was tested. The fire door failed to latch into the frame during the testing. According to the facility floor plan, this door was located in a 2 hour fire rated barrier. Staff BB, CC, and DD verified the fire door failed to latch when tested at 3:00 P.M.

h) During tour on 11/13/13 at 9:15 A.M. with Staff BB, CC, and DD the fire doors located between the East and West Building leading into the dialysis unit failed to latch when tested. These doors were observed with a 1 and 1/2 hour fire rated label. The aforementioned staff at 9:15 A.M. verified the doors should have latched but failed to do so when tested.

Based on observation, staff interview, and review of the facility's floor plans, the facility failed to ensure access to three exits were marked by an approved, readily visible sign in one area of the building. This could affect all patients, staff, and visitors in the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

During tour with Staff CC, DD, FF, and HH, the following areas were observed without exit signs when the exit pathway was not readily apparent, or failed to lead to an acceptable exit as follows:

Tour of the fourth floor was conducted on 11/06/13 at 9:13 A.M.

a) Tour of the third floor was conducted on 11/06/13 between 9:29 A.M. and 10:19 A.M.
The SC 3-5/FC 3-3 compartment for the Behavior Outpatient department revealed a group of rooms consisting of private meeting rooms, waiting room, and offices. The floor plan revealed this compartment contained 9695 square feet. An exit sign was observed posted above a doorway which led to a group of rooms. Observation of the rooms revealed only one door used for group therapy opened into the exit corridor. During tour the door was verified by Staff CC to be locked to prevent exiting into the hallway. This was verified with Staff CC at 9:50 A.M. on 11/06/13.

b) Tour of the second floor on 11/06/13 at 11:15 A.M. revealed a suite of rooms used by a home care agency. This compartment lacked a 2 hour fire separation between this agency and the facility. Tour inside the home care agency office revealed a mixture of offices, cubicles, and storage areas. Review of the floor plan revealed this office space was a total of 9753 square feet. This area lacked exit signs indicated the exit access doors from the suite.

c) Tour of the basement on 11/07/13 between 9:45 A.M. and 10:36 A.M. revealed an exit discharge door lacked a visible exit sign. Located in this same area was another room which could be entered in the event of a fire or smoke. However, this room lacked a visible means to exit.

The lack of these aforementioned exits and signs was verified with Staff DD at the time of the observations.

Based on observations, review of facility floor plans, and staff interviews, the facility failed to ensure 4 smoke barriers on one floor of the facility maintained at least a one hour fire resistance rating. This could affect all staff, patients, and visitors. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

Tour was conducted with Staff BB, CC, and DD on 11/07/13 between 2:22 P.M. and 4:00 P.M., and on 11/12/13 between 1:00 P.M. and 1:20 P.M.

During this tour of the ground floor on 11/07/13 penetrations were observed in the one hour fire rated barrier as follows:
a) The corridor across from room 402 revealed a curved conduit (approximately 3/4 inch diameter) which was open around wiring.

b) Room 71 was observed with a one inch high by 2 feet long opening at the top of the smoke barrier at the corrugated decking. The bathroom in this room was observed with a three inch wide by ten inch long opening around a steel beam that passed into the barrier.

On 11/12/13 the following penetrations were observed
c) Outside Stairwell #1 a curved conduit (approximately 3/4 inch diameter) was observed open inside the conduit.

d) The one hour fire rated barrier located between SCG-12 (Smoke compartment) and SCG-13, near Stairwell T, was observed with three sets of smoke barrier doors. The corrugated decking at the top of the barrier was observed with a 1-2 inch high by 21 feet long opening along the top portion of the smoke barrier. One square metal conduit over one set of the fire doors was observed with a cloth rag stuffed into the conduit. When the cloth rag was removed by Staff CC, the conduit was observed open.

These penetrations were verified with Staff CC during the aforementioned tour at the time of the observations.

Based on observations, staff interview, and review of the facility floor plans, the facility failed to ensure eight hazardous areas located in 3 areas of the facility maintained a one hour fire rated construction. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

a) On 11/04/13 at 2:29 P.M., tour with Staff BB and DD, on seven east in room 15, above the drop ceiling, a blue tip conduit with an unsealed lumen was observed. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/04/13 at 2:29 P.M. in an interview, Staff BB and DD confirmed the observation.
b) On 11/04/13 at 2:54 P.M. on seven east in room 0023, a soiled utility room, and above the drop down ceiling, three two inch holes were observed in the one hour rated construction. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/04/13 at 2:54 P.M. an interview, Staff BB and DD confirmed the observation.
c) On 11/05/13 at 2:09 P.M. in the clean utility room across from room 439 on four west, and above the drop down ceiling, a one inch conduit's lumen was observed open to air. Review of the drawing revealed the room was wrapped in one hour fire construction.
On 11/05/13 at 2:09 P.M. in an interview, BB and EE confirmed the observation.
d) On 11/05/13 at 2:15 P.M. in the clean utility room on four west, observation above the drop down ceiling on the eastern most wall, two white pipes and a metal conduit had annular spaces. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/05/13 at 2:15 P.M. in an interview, Staff BB and DD confirmed the observation.
e) On 11/07/13 at 2:37 P.M. observation of the door to the clean linen room on two east revealed it was not on a self closer. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/07/13 at 2:37 P.M. in an interview, Staff BB and DD confirmed the observation.
f) On 11/07/13 at 2:43 P.M. the door to the soiled utility room across from room 208 on two east was observed to have two half inch openings in it. Review of the drawing revealed the room to be surrounded in one hour fire construction.
On 11/07/13 at 2:43 P.M. in an interview, Staff BB and DD confirmed the observation.
g) On 11/07/13 at 4:35 P.M. observation of the doors from equipment room B to the corridor in the surgery building revealed the doors did not have a means suitable for keeping the door closed.
h) On 11/07/13 at 5:00 P.M. observation in the surgery building of the door on the soiled utility room to the corridor with certificates hanging on the wall revealed the doors did not have a means suitable for keeping the door closed and a sign was posted to remind staff to keep the door closed.
On 11/07/13 at 4:35 P.M. and at 5:00 P.M. in interviews, Staff BB and EE confirmed the observations.

Based on observations and staff interviews, the facility failed to ensure stairway doors contained a fire resistance rating of at lease one hour due to missing or illegible fire rated labels. This affected 4 stairways and three floors of the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted with Staff BB and EE on 11/05/13 at 10:52 A.M., on 11/05/13 at 11:12 A.M., on 11/05/13 at 11:49 A.M., on 11/05/13 at 12:08 P.M., and on 11/08/13 at 11:38 A.M. During this tour the following stairway doors were observed:

a) On 11/05/13 at 10:52 A.M. the fire door to exit stairway P on the fifth floor revealed a rating label painted over. Staff removed the label, and underneath the words " void " was written several times.
b) On 11/05/13 at 11:12 A.M. observation of the fire door to exit stairway O on the fifth floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
c) On 11/05/13 at 11:49 A.M. observation of the fire door to exit stairway N on the fifth floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
d) On 11/05/13 at 12:08 P.M. observation of the fire door to exit stairway R on the fourth floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
e) On 11/08/13 at 11:38 A.M. observation of the fire door to exit stairway O on the first floor revealed the rating label to be painted over, and the surveyor was unable to read the label.
In interview with Staff BB and EE on 11/05/13 at 10:52 A.M., on 11/05/13 at 11:12 A.M., on 11/05/13 at 11:49 A.M., on 11/05/13 at 12:08 P.M., and on 11/08/13 at 11:38 A.M. in interviews Staff BB and EE confirmed the observations.

Based on observation, review of the floor plan, and staff interviews, the facility failed to ensure one exit access was arranged to ensure a continuous surface between the exit discharge and the public way. This could affect all patients, staff, and visitors in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted on 11/13/13 at 10:20 A.M. with Staff BB, CC, and DD. Observations of the exit discharge from Stairwell CC revealed a concrete pad outside the exit door. The pad was approximately 4 feet by 4 feet in diameter. The area beyond the concrete pad was observed leading up a steep hillside approximately 50 feet to the public way. The hillside was observed with smaller rocks and minimal grass. The exit to the public way lacked a continuous hard surface to the public way.

The floor evacuation plans revealed this exit discharge was used by patients, staff, and visitors in the Same Day Surgery building, the Emergency Department building, and the lower level of the main hospital building.

This was verified with Staff BB and CC at 10:20 A.M. on 11/13/13. Staff BB stated this exit discharge was present before the addition of the Emergency Department (ED) building, and the hillside was made steeper with the addition of the ED building.

Based on observations and staff interview, the facility failed to ensure smoke detectors were located greater than 36 inches from air diffusers. This could affect all staff, patients, and visitors in the building. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted on 11/12/13 between 2:19 P.M. and 3:22 P.M. with Staff BB, CC, and DD.

During this tour, the following smoke detectors were observed located less than 36 inches from air diffusers:

a) In the hallway outside the cafeteria on the ground level by Stairwell H, and

b) Two smoke detectors on the ground level in the storage room labeled FC0-3 on the facility floor plan.


Interview with Staff CC during tour at 10:20 A.M. on 11/13/13 revealed the smoke detectors should be greater than 36 inches from air supply and air return diffusers. During tour Staff BB, CC, and DD verified the location of the aforementioned smoke detectors.

Based on observations and staff interviews, the facility failed to maintain the sprinkler system as required by the code in regards to missing escutcheon covers and dirty sprinkler heads. This involved 3 floors of the facility and could affect all patients, staff, and visitors in those areas of the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:





21521


Tour of the seventh floor was begun on 11/04/13 with Staff AA, BB, CC, and DD at from 11:40 A.M. to 3:01 P.M. with Staff AA, BB, CC, and DD.
a) At 11:58 A.M. a missing sprinkler escutcheon was observed in the medication room on seven west.
b) At 2:05 P.M. a missing sprinkler escutcheon was observed in room 726A and the sprinkler head over the nursing desk on seven west was observed to be dirty.
c) At 2:09 P.M. a dirty sprinkler head was observed in room 126.
d) At 2:13 P.M. on seven west in room 103 a dirty sprinkler head was observed.
During the tour of the seventh floor on 11/04/13 from 11:40 A.M. to 3:01 P.M. Staff BB and CC confirmed the observations in an interview.
On 11/08/13 at 9:00 A.M. the finding was again presented to Staff BB and CC.
e) On 11/05/13 from 8:20 A.M. to 9:54 A.M. a tour of the seventh floor was resumed with Staff AA, BB, CC, and EE. At 8:39 A.M. a women's bathroom between stairwell N and O was observed to have a missing sprinkler escutcheon.
f) At 9:29 A.M. shower rooms 005 and 006 on were observed to have missing sprinkler escutcheons.
Sixth Floor:
g) On 11/04/13 from 3:02 P.M. to 3:50 P.M. a tour was conducted of the sixth floor with Staff AA, BB, CC, and DD. At 3:50 P.M. a missing sprinkler escutcheon was observed in the housekeeping closet near Stair O.
In interviews during the tour on 11/04/13 from 3:02 P.M. to 3:50 P.M. of the sixth floor with Staff AA, BB, CC, and DD, they confirmed the observation.
On 11/08/13 at 9:00 A.M. the finding was again presented to Staff BB and CC.
Sixth Floor:
h) At 9:32 A.M. a staff only room on six east, near the smoke barrier, was observed to have a missing sprinkler escutcheon.
In interviews on 11/05/13 from 8:20 A.M. to 9:54 A.M. when a tour of the seventh floor was resumed with Staff AA, BB, CC, and EE, Staff BB and EE confirmed the observations.
On 11/08/13 at 9:00 A.M. the finding was again presented to Staff BB and CC.
Ground floor:
i) During tour on 11/12/13 2:18 P.M., at tour was conducted in the radiology read room suite with Staff BB, CC, and DD. This suite of rooms was observed with 4 missing escutcheon sprinkler head covers. These missing covers were verified with Staff BB and CC at the time of the observation.

Based on observations and staff interviews, the facility failed to ensure one medical gas storage room door self-closed when tested. This could affect all patients, staff, and visitors in the facility. The total capacity was 1061 beds and a census on the first day of survey of 401 patients.

Findings include:

A tour was conducted on 11/12/13 at 2:37 P.M. with Staff BB, CC, and DD on the ground level floor. The main egress corridor located outside FCO-3 compartment (on floor plan) and the ultrasound suite was observed with a room which opened into this corridor. The room was observed with multiple H-tanks of nitrous oxide gases (greater than 300 cubit feet). The door to the hallway was observed with a 1 and 1/2 hour fire rated label; however, failed to self close and latch into the frame when tested. This was verified with Staff BB, CC, and DD at the time of the tour. Staff CC stated the door should have closed and latched.

NFPA 101

Chapter 20

20.2.9.1

Emergency illumination is provided in accordance with section 7.9.

*Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regards to monthly and annual testing. The facility had 12 treatment rooms with a census of nine patients at the time of the survey completed on 11/13/13. Potentially all patients, visitors and staff could be affected.

Findings included;

On 11/13/13 between 3:10 P.M. and 5:45 P.M. tour of the building was conducted with Staff II, FF and KK. The free standing emergency department was location on the ground floor of the building. Emergency services were available 24 hours per day, seven days per week.

Tour of the emergency department, radiology and cancer care center was conducted with Staff II, FF and KK, revealed the presence of battery backup lighting in the patient care areas. Review of testing documentation on 11/13/13 at 4:45 P.M. with Staff KK revealed that testing dates were noted but there was no indication of the length of time for the testing. Further review of the documentation revealed there was no documented evidence of a 90 minute test completed in the past 12 months.

Staff KK and II verified the facility testing documentation lacked the length of time tested each month as well when the 90 minute annual test was conducted.