HospitalInspections.org

Building A1: Main Hospital, 400 W. 16th St.

Through observation, during the survey January 11 through 19, 2011, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through of the facility, with the Construction Manager and the Facilities Director:

1) The 70/30 double doors were not considered to be positive latching, on the "30 side", when in the closed position. The following doors contained slide locks on the "30 side" of the door for locking;
a) Room eight (8) south
b) Third floor (3rd) mechanical room door to corridor
c) Third (3rd) floor south equipment room

2) Corridor doors contained a gap larger than one half inch (1/2 " )
a) 2 south room #6
b) Third (3rd) floor south room #6
c) Third (3rd) floor southwest room #22
d) Room 28 4S
e) Room 31 5S

NOTE: All above items were corrected during the survey with the exception of the door #23 to 4S, item 2d.

3) Seven (7) ICU rooms contained glass sliding doors that did not positively latch into the frame.
a) Room #1
b) Room #2
c) Room #9
d) Room #10
e) Room #11
f) Room #12
g) Room #13

Note: All above items were corrected during the survey.

4) Four South (4S), contained five (5) resident rooms, bathroom doors that when in the fully open position, obstruct the corridor doors for the respective rooms from closing and latching into the doorframe assembly.
a) Room #27
b) Room #28
c) Room #29
d) Room #30
e) Room #31

Note: All items above were corrected during the survey

Building AF: Pueblo West Emergency Department, 899 E. Industrial Blvd.

Through observation, during the survey January 11 through 19, 2011, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through of the facility, with the Plant Operations Director, the facility contained thirteen (13) emergency rooms located off of the corridor. These rooms contained glass sliding doors that did not positively latch into the frame.

Per 2000 Edition of NFPA 101, Chapter 18, Section 18.2.2.2.9 "Horizontal sliding doors, as permitted by 7.2.1.14, that are not automatic-closing shall be limited to a single leaf and shall have a latch or other mechanism that ensures that doors will not rebound into a partially open position if forcefully closed in an emergency."

This portion applies to Building A-2, known as the North Annex.

Through observation, during the survey January 11 through 19, 2011, it was determined that the facility failed to maintain the doors to the corridor. This was evidenced by:

The corridor doors in the following locations failed to be smoke resistive, as required. The corridor doors serving resident rooms N205 and N215, had a gap on the latch-side of the door at the top that were in excess of a half of an inch.

The corridor door deficiency items were discussed during the survey and again during the exit conference.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to maintain the fire resistive rating of the vertical openings.

During the walk through of the facility with the Plant Operation Director:

1) Elevator 3 fire wall contained one (1) unsealed wire penetration
2) Second floor (2nd) middle stairwell contains two (2) unsealed pipe penetration
3) Second floor (2nd) middle stairwell contains one (1) unsealed ventilation duct
4) Third floor (3rd) middle stairwell contained one (1) unsealed pipe penetration
5) The five southwest (5 SW) Telephone closet (5-3) was found to have an approximately three inch (3") wire chase sealed with a "KBS Sealbag," an unapproved method for sealing this vertical penetration.

Note: Items 1, 2, 3, and 4 were corrected during the survey.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to maintain the smoke barrier walls.

During the walk through of the facility, with the Plant Operations Director, one (1) smoke wall, located adjacent to room #20 on the fifth floor, contained one (1) unsealed electrical conduit penetration without fire caulking or other approved method of maintaining the smoke rating of the wall per 19.3.7.3 and 8.3.2.

Note: This item was corrected during the survey.

Building A1: Main Hospital, 400 W. 16th St.

Through observation, during the survey January 11 through 19, 2011, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility, with the Plant Operations Director, three (3) fire barrier doors would not latch into the frame when closed;

1) One (1) of the smoke barrier doors outside the Trauma office
2) One (1) of the smoke barrier doors located at Same Day Surgery
3) One (1) of the smoke barrier doors located at 2 South

Note: All cross corridor deficiencies were corrected during the survey.

Building AF: Pueblo West Emergency Department, 899 E. Industrial Blvd.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to maintain the smoke barrier doors.
During the walk through of the facility with the Plant Operations Director, one (1) side of the smoke barrier doors located in the basement did not latch into the frame when operated.

This portion applies to Building AC, known as the Chemical Dependency Unit.

It was determined by observation, during the course of the survey on January 13, 2011, that hazardous areas were not protected in compliance with NFPA 101. This was evidenced by the following:

Self-closing corridor door for environmental service room not closing and latching on own.

Note: This item was corrected during the survey.

The hazardous area deficiency item was discussed during the survey and again during the exit conference.

Building A1: Main Hospital, 400 W. 16th St.

Through observation, during the survey January 11 through 19, 2011, it was determined that the facility failed to have two (2) remote exits.

During the walk through of the facility, with the Plant Operations Director, the facility failed to contain exits;

1) NICU (Neuro Intensive Care Unit) contained locked doors in the egress corridor. The doors contained a keypad and keycard swipe and dropped on fire alarm. (No delayed and no access control.) Per Chapter 19, section 19.2.2.2.4.
2) The fifth floor Nursery Unit contained locked doors in the egress corridor. The doors contained a keypad and keycard swipe and dropped on fire alarm. (No delayed and no access control.) Per Chapter 19, section 19.2.2.2.4
3) The facility did not contain exits directly to the exterior of the building or through exit passageways on several floors;
a) Second floor (2nd) contained six (6) stairwells and only one (1) discharged top to the exterior
b) Third floor (3rd) contained six (6) stairwells and only one (1) discharged to the exterior
c) Fourth floor (4th) contained six (6) stairwells and two (2) discharged to the exterior
d) Fifth floor (5th) contained six (6) stairwells and two (2) discharged to the exterior
e) Sixth floor (6th) contained three (3) stairwells and zero (0) discharged to the exterior

Per 2000 NFPA 101, Chapter 7, Section 7.7.2
" Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall be permitted to discharge through areas on the level of exit discharge, provided that the criteria of 7.7.2(1) through (3) are met:

(1) Such discharge shall lead to a free and unobstructed way to the exterior of the building, and such way is readily visible and identifiable from the point of discharge from the exit."

This portion applies to Building AC, known as the Chemical Dependency Unit.

It was determined by observation, during the survey on January 13, 2011, the facility failed to provide and maintain a means of egress, so arranged that exits are readily accessible at all times in accordance with the Life Safety Code. This was evidenced by the following:

1) Rear exit at dock has two doors, both with a deadbolt and the inner door has access controlled egress, but does not have motion sensor, as required.

2) The following labeled exits do not have a maintainable surface to the public way, as required:
a) Door to south patio on the back of the building, and
b) Exit door to the exterior serving rooms 3-12.

3) Cross-corridor door by the kitchen has access controlled egress, but does not have the motion sensor, as required.

4) Cross-corridor door by the Coordinator's Office has access controlled egress, but does not have the motion sensor, as required.

5) The main entry has both a deadbolt and access controlled egress, but does not have the motion sensor, as required.

The Means of Egress deficiency items were discussed during the exit conference.

Building 10: Satellite Imaging Center, 1619 N. Greenwood Ave.

Through observation during the survey, conducted January 11 through 19, 2011, it was determined that the facility failed to install a fire alarm system with approved components, devices or equipment.

During the walk through of the facility, with the Facilities Maintenance Director, the facility did not contain smoke detection per NFPA 101, Chapter 39, Section 39.3.4.1.
"A fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants."

Building A1: Main Hospital, 400 W. 16th St.

Through a review of the records and discussions during the survey, conducted on January 11 through 19, 2011, it was determined that the facility failed to inspect and test the fire alarm system.

During the review of the facility records, with the Plant Operations Director, documentation was not available to verify the sensitivity testing of the smoke detectors was conducted in the past two (2) years. Per NFPA 101, (Section 9.6, Paragraph 9.6.1.4), and NFPA 72, (Chapter 7, Paragraph 7-1.2.2).

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to install a full NFPA automatic sprinkler system, per the 1999 Edition of NFPA 13.

During the walk through of the facility, with the Plant Operations Director, automatic sprinkler system components were not installed or installed incorrectly in the following areas;

1) Housekeeping storage in the 1926 building contained duct work that extended eighteen inches (18") below the ceiling. The area on one (1) side of the duct work did not contain adequate sprinkler coverage. Per NFPA 13 1999 Edition, section 5-6.5.2.1.

2) The Housekeeping storage room in the 1926 building contained a sidewall sprinkler located adjacent to a fenced in storage area.
a) The top of the fence contained angle iron, which obstructed the sprinkler. Per NFPA 13 1999 Edition, section 5-7.5.1.3
b) The sidewall sprinkler was positioned in a way that the sprinkler was not horizontal to the ceiling.

NFPA 13, 1999 Edition, section 5-7.4.2.2 "Deflectors of sprinklers shall be aligned parallel to ceilings or roofs."

3) Dirty Utensil room on the first floor contained one (1) pendant sprinkler head located one inch (1") from the wall. The sprinkler head was located above the washer area. Per 1999 Edition, NFPA 13, section 5-6.3.3
"Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall."

4) Third (3rd) floor south corridor, outside clean utility room and elevator 7& 8, contained a sprinkler head installed one inch (1") to the wall. This head was also located closer than six feet (6') to the next sprinkler head and could cause a cold solder effect.

5) The fifth floor Labor and Delivery rooms all contained closets that failed to be sprinkler protected.
Note: This item was corrected during the survey.

6) The men's restroom on the sixth floor, had a party wall adjacent to the corridor door that terminates approximately one-foot from the ceiling and fails to allow the sprinkler within the restroom to cover the area immediately inside the corridor door. Per NFPA 13, 1999 ed., 5-8.5.2.3.

7) The women's restroom on the sixth floor (6th), had a party wall adjacent to the corridor door that terminates approximately one-foot (1') from the ceiling and fails to allow the sprinkler within the restroom to cover the area immediately inside the corridor door. Per NFPA 13, 1999 ed., 5-8.5.2.3.

8) The Cath Lab West Equipment room, failed to be covered by the automatic fire suppression system.

9) Fifth (5rd) floor south OB waiting area, contained three (3) sprinkler heads closer than six feet (6') to the next sprinkler head and could cause a cold solder effect.

10) Room #57 in labor and Delivery, has a ceiling pocket for the draperies that extends three-feet from the room ceiling and is approximately sixty three cubic feet (63 cf) in volume. This ceiling pocket failed to be protected by the automatic fire suppression system.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to maintain the automatic fire sprinkler system.

During the walk through of the facility, with the Plant Operations Director;

1) Escutcheon plates Missing
a) One (1) missing escutcheon in hallway outside ground floor satellite lab
b) One (1) missing escutcheon in closet of Laboratory classroom
c) One (1) missing escutcheon in Anesthesia Work Room
d) One (1) missing escutcheon plate in Dirty Utensil room on first floor
e) One (1) missing escutcheon plate at 2 South nurses station
f) One (1) missing escutcheon plate of room #4 bathroom

NOTE: The above escutcheon plates were corrected during the survey.

2) Compartments that contained Quick Response (QR) sprinkler heads and standard response (SR) sprinkler heads
a) Outside ground floor Trauma office contained one (1) QR head all others were SR heads
b) Environmental Services office (1926 Building) contained one (1) SR and two (2) QR sprinkler heads
c) Laboratory area adjacent to Microbiology Lab contains two (2) QR heads mixed in a compartment with SR heads
d) Anesthesia office contains two (2) QR heads and one (1) SR head
e) Surgery suite corridor outside Anesthesia office contains five (5) QR heads mixed with SR heads
f) Same Day surgery contains four (4) QR heads with all others being SR heads
g) Corridor outside the sleep lab contained one (1) QR head with all other being SR heads
h) Fifth Floor labor and Delivery - all heads north of Lead Clinical Nurse's Office are Quick Response
i) AHU 15 Mechanical room contained one (1) QR head with all other being SR heads
j) Sixth floor elevator lobby contained one (1) QR head with all other being SR heads
k) Five southeast (5 SE) end storage contained one (1) QR head and one (1) SR head
l) Fourth floor ICU waiting room contained one (1) QR head and one (1) SR head

Per NFPA 13 1999 Edition, section 5-4.5.3 "Where residential sprinklers are installed in a compartment as defined in 1-4.2, all sprinklers within the compartment shall be of the fast-response type that meets the criteria of 1-4.5.1(a)1."

3) Sprinkler heads contained corrosion or paint around the working parts of the sprinkler head
a) One (1) sprinkler head above the dishwasher in the main kitchen
b) One (1) sprinkler at entry vestibule at 17th street entrance to building 1926
c) One (1) painted sprinkler head in the corridor outside Cat Scan room #2
d) One (1) painted sprinkler head in the CEO office
e) One (1) painted sprinkler head outside third floor (3rd) south equipment room

Per 1999 Edition of NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

4) Documentation was not available to verify that sprinkler gauges were calibrated or replaced every five (5) years per 1999 Edition of NFPA 25, section 2-3.2
a) Five (5) gauges at the MRI/ER/Radiology riser contained 2000 and 2001 manufacturer dates
b) Three (3) gauges on first floor (1st) riser in shipping and receiving did not contain manufacture dates
c) Two (2) gauges on third floor (3rd) riser contained 2005 manufacture dates
d) AHU 15 Mechanical room had a manufacture date of 1999

Per 1999 Edition NFPA 25, Chapter 5, section 5.3.2. "Gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge. Gauges not accurate to within three percent of the full scale shall be recalibrated or replaced."

NOTE: The above sprinkler gauges were corrected during the survey.

This portion applies to Building AB, known as the Adolescent Psychiatric Unit.

Through observation, during the survey January 13, 2011, it was determined that the facility failed to maintain the automatic fire sprinkler system. This was evidenced by:

Documentation was not available to verify that sprinkler gauges were calibrated or replaced every five (5) years per 1999 Edition of NFPA 25, section 2-3.2. The gauge on the facility's riser was not dated.

NOTE: The above sprinkler gauge was corrected during the survey.

The sprinkler gauge deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Chemical Dependency Unit.

Through observation, during the survey January 13, 2011, it was determined that the facility failed to maintain the automatic fire sprinkler system. This was evidenced by:

Documentation was not available to verify that sprinkler gauges were calibrated or replaced every five (5) years per 1999 Edition of NFPA 25, section 2-3.2. The gauge on the facility's riser was not dated.

NOTE: The above sprinkler gauge was corrected during the survey.

The sprinkler gauge deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Chemical Dependency Unit.

Based on observation and interview, the facility was found to have not met heating, ventilation, and service equipment requirements.

Findings on 1/13/2011 include:

The fireplace in the main gathering area is not separated from the resident room in the hallway servicing rooms 3-12 or the hallway servicing rooms 13-16 by one-hour rated construction, as required. The doors in the one-hour fire barriers serving these locations are 20-minute doors, rather than the required minimum of three-quarter hour doors.

Ref: 2000 NFPA 101 19.5.2.2.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, conducted January 11 through 19, 2011, the fire suppression failed to provide complete protection for the cooking facilities per NFPA 96.

During the walk through of the facility, with the Plant Operations Director, the deep fat fryer did not provide coverage from open flames.

Per NFPA 96, Section 9-1.2.3 "All deep fat fryers shall be installed with at least a 16-in. (406.4-mm) space between the fryer and surface flames from adjacent cooking equipment.

Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 in. (203 mm) in height between the fryer and surface flames of the adjacent appliance."

NOTE: The splash protection was corrected during the survey.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walk through of the facility, with the Plant Operations Director;

1) One (1) Hoyer lift was observed stored and unattended in the corridor of the Imaging department at 11:10 a.m., and again at 11:45 a.m., on January 12, 2011.

2) Corridor outside Payroll business office contained one (1) mailbox that extended eight inches (8") into the corridor

3) Corridor outside Payroll business office contained one (1) shelf that extended twelve inches (12") into the corridor

NOTE: All items above were corrected during the survey.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to install electrical outlets in accordance with NFPA 99 in the Nitrous Oxide storage room.

During the walk through of the facility, with the Plant Operations Director, the nitrous oxide storage room contained an electrical outlet installed at thirty two inches (32") off of the floor.

Per NFPA 99, 1999 Edition, section 4-3.1.1.2(4) "The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage."

NOTE: This item was corrected during the survey.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to provide a separation between service valves as required by NFPA 99.
During the walk through of the facility, with the Plant Operations Director, the surgery pre-op area contained a piped medical gas system shut off valve without separation between the beds that it controls and the shut off valve.

Per NFPA 99 section 4-3.1.2.3(d) "Zone Valve. Station outlets shall not be supplied directly from a riser unless a manual shut off valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet."

Building AF: Pueblo West Emergency Department, 899 E. Industrial Blvd.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to provide a separation between service valves as required by NFPA 99.
During the walk through of the facility, with the Plant Operations Director, the triage area contained a piped medical gas system shut off valve without separation between the three (3) beds that it controls and the shut off valve.

Per NFPA 99 section 4-3.1.2.3(d) "Zone Valve. Station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet."

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility and staff interviews, with the Plant Operations Director;

1) The facility failed to maintain a minimum of 35% humidity in all anesthetizing locations. The documented humidity levels maintained in the Cesarean Section OR in July of 2010 were between 24 and 31%.

Per NFPA 99, 1999 Edition 5-4.1.1* "The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater."

2) The facility failed to provide electrical shock protection in the Cesarean Section OR.
Per the 1999 Edition of NFPA 99, Section 3-3.2.1.2 " Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA."

3) Operating rooms #2 through #8 and the "C Section OR" did not contain exhaust capabilities in case of a fire in the operating room.

4) OR #1 and #9 did contain exhaust function on the HVAC unit; however was not setup for exhaust during the day of the survey.

5) OR's #1 through #9 did not contain smoke detection in the OR or a duct detector located at the OR ductwork to detect the products of combustion to activate the exhaust sequence or damper activation.

Per NFPA 99, 1999 Edition 5-4.1.3 "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

Building AE: YMCA Outpatient Rehab, 3204 Spaulding Ave.

Through observation, during the survey January 11 through 19, 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 the Plant Operations Director, the one-hour separation fire-rated wall, located between the Rehabilitation Unit and the YMCA gym did not continue to the metal roof deck. The wall was constructed to the bottom edge of the metal corrugated roof deck and contained insulation between the gaps of the corrugated metal deck and the drywall. Documentation could not be located indicating the gaps contained a fire rated material or a spray on type material. The drywall portion of the wall was confirmed to be two (2) sheets of 5/8 inch Type X drywall on metal studs.

This portion applies to Building A-8, known as the Medical Office Building.

Through observation during the survey, January 13, 2011, it was determined that the facility failed to maintain the one hour fire resistance rating of the common wall. This was evidenced by the following:

The facility failed to provide a 1-hour fire rated wall separation between the licensed space and unlicensed space on the east side. (Between Radiology and Quest Diagnostics.)

The separation wall deficiency item was discussed during the course of the survey and again during the exit conference.

This portion applies to Building AA, known as the Coumadin Clinic and Adult Psych Rehab.

Through observation, during the survey January 13, 2011, it was determined that the facility failed to maintain the one hour fire resistance rating of the common wall. This was evidenced by the following:

The facility did not contain a fully protected 1-hour wall separation between the licensed space and unlicensed space. The door between the Clinic and Homecare must be a minimum of a three-quarter hour, fire rated door; the current door is unrated and has louvers.

The separation wall deficiency item was discussed during the course of the survey and again during the exit conference.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined the facility failed to divide the essential electrical system onto the correct branches per NFPA 99.

During the document review and observation, with the Plant Operations Director;

1) The second floor (2nd) Life Safety Branch contained the nurse call circuits. The Nurse Call system shall be connected to the Critical Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

2) The second floor (2nd) Life Safety Branch contained the fire dampers circuits. The fire dampers shall be connected to the equipment branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

3) The Equipment Branch panel in the AHU15 Mechanical room (PEQL2) contained fire alarm panel circuits and emergency lighting circuits for the pharmacy. The fire alarm panel and emergency lighting circuits shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

Building A7: East Addition, 400 W. 17th St.

Through observation, during the survey January 11 through 19, 2011, it was determined the facility failed to divide the essential electrical system onto the correct branches per NFPA 99.

During the document review and observation, with the Plant Operations Director;

1) The sixth floor Equipment Branch (6EQLET) contained fire dampers circuits. The fire damper circuits shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

2) The fifth floor Equipment Branch (5EQLET) contained fire dampers circuits. The fire damper circuits shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

3) The 5T fifth floor Equipment Branch (5EQLT) contained fire dampers circuits. The fire damper circuits shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility, with the Plant Operations Director, extension cords or surge protectors' were found to be in use in the following areas;

1) The sixth floor pharmacy had a surge protected electrical power strip plugged into a second surge protected electrical power strip.

2) The sixth floor pharmacy had a surge protected electrical power strip plugged into a UPS device.

3) The sixth floor Chaplain's Office has an extension cord being used in place of permanent electrical wiring.

Per NFPA 70 1999 Edition, Chapter 4, Article 400, Paragraph 400.8, (" ... flexible cords and cables shall not be used for the following: (1) as a substitute for the fixed wiring of a structure ... ")

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, conducted January 11 through 19, 2011, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walk through of the facility, with the Plant Operations Director, hand sanitizers were installed directly above an electrical switch in the following areas;

1) Room #S121
2) Room #S122
3) Room #S123
4) Room #S125
5) Rehab kitchen on first floor
6) Room 5T R5
7) Room 4T R4
8) ICU Staff Lounge

Note: All ABHR dispensers were relocated or removed during the survey.

Building A1: Main Hospital, 400 W. 16th St.

Through observation, during the survey January 11 through 19, 2011, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through of the facility, with the Construction Manager and the Facilities Director:

1) The 70/30 double doors were not considered to be positive latching, on the "30 side", when in the closed position. The following doors contained slide locks on the "30 side" of the door for locking;
a) Room eight (8) south
b) Third floor (3rd) mechanical room door to corridor
c) Third (3rd) floor south equipment room

2) Corridor doors contained a gap larger than one half inch (1/2 " )
a) 2 south room #6
b) Third (3rd) floor south room #6
c) Third (3rd) floor southwest room #22
d) Room 28 4S
e) Room 31 5S

NOTE: All above items were corrected during the survey with the exception of the door #23 to 4S, item 2d.

3) Seven (7) ICU rooms contained glass sliding doors that did not positively latch into the frame.
a) Room #1
b) Room #2
c) Room #9
d) Room #10
e) Room #11
f) Room #12
g) Room #13

Note: All above items were corrected during the survey.

4) Four South (4S), contained five (5) resident rooms, bathroom doors that when in the fully open position, obstruct the corridor doors for the respective rooms from closing and latching into the doorframe assembly.
a) Room #27
b) Room #28
c) Room #29
d) Room #30
e) Room #31

Note: All items above were corrected during the survey

Building AF: Pueblo West Emergency Department, 899 E. Industrial Blvd.

Through observation, during the survey January 11 through 19, 2011, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through of the facility, with the Plant Operations Director, the facility contained thirteen (13) emergency rooms located off of the corridor. These rooms contained glass sliding doors that did not positively latch into the frame.

Per 2000 Edition of NFPA 101, Chapter 18, Section 18.2.2.2.9 "Horizontal sliding doors, as permitted by 7.2.1.14, that are not automatic-closing shall be limited to a single leaf and shall have a latch or other mechanism that ensures that doors will not rebound into a partially open position if forcefully closed in an emergency."

This portion applies to Building A-2, known as the North Annex.

Through observation, during the survey January 11 through 19, 2011, it was determined that the facility failed to maintain the doors to the corridor. This was evidenced by:

The corridor doors in the following locations failed to be smoke resistive, as required. The corridor doors serving resident rooms N205 and N215, had a gap on the latch-side of the door at the top that were in excess of a half of an inch.

The corridor door deficiency items were discussed during the survey and again during the exit conference.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to maintain the fire resistive rating of the vertical openings.

During the walk through of the facility with the Plant Operation Director:

1) Elevator 3 fire wall contained one (1) unsealed wire penetration
2) Second floor (2nd) middle stairwell contains two (2) unsealed pipe penetration
3) Second floor (2nd) middle stairwell contains one (1) unsealed ventilation duct
4) Third floor (3rd) middle stairwell contained one (1) unsealed pipe penetration
5) The five southwest (5 SW) Telephone closet (5-3) was found to have an approximately three inch (3") wire chase sealed with a "KBS Sealbag," an unapproved method for sealing this vertical penetration.

Note: Items 1, 2, 3, and 4 were corrected during the survey.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to maintain the smoke barrier walls.

During the walk through of the facility, with the Plant Operations Director, one (1) smoke wall, located adjacent to room #20 on the fifth floor, contained one (1) unsealed electrical conduit penetration without fire caulking or other approved method of maintaining the smoke rating of the wall per 19.3.7.3 and 8.3.2.

Note: This item was corrected during the survey.

Building A1: Main Hospital, 400 W. 16th St.

Through observation, during the survey January 11 through 19, 2011, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility, with the Plant Operations Director, three (3) fire barrier doors would not latch into the frame when closed;

1) One (1) of the smoke barrier doors outside the Trauma office
2) One (1) of the smoke barrier doors located at Same Day Surgery
3) One (1) of the smoke barrier doors located at 2 South

Note: All cross corridor deficiencies were corrected during the survey.

Building AF: Pueblo West Emergency Department, 899 E. Industrial Blvd.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to maintain the smoke barrier doors.
During the walk through of the facility with the Plant Operations Director, one (1) side of the smoke barrier doors located in the basement did not latch into the frame when operated.

This portion applies to Building AC, known as the Chemical Dependency Unit.

It was determined by observation, during the course of the survey on January 13, 2011, that hazardous areas were not protected in compliance with NFPA 101. This was evidenced by the following:

Self-closing corridor door for environmental service room not closing and latching on own.

Note: This item was corrected during the survey.

The hazardous area deficiency item was discussed during the survey and again during the exit conference.

Building A1: Main Hospital, 400 W. 16th St.

Through observation, during the survey January 11 through 19, 2011, it was determined that the facility failed to have two (2) remote exits.

During the walk through of the facility, with the Plant Operations Director, the facility failed to contain exits;

1) NICU (Neuro Intensive Care Unit) contained locked doors in the egress corridor. The doors contained a keypad and keycard swipe and dropped on fire alarm. (No delayed and no access control.) Per Chapter 19, section 19.2.2.2.4.
2) The fifth floor Nursery Unit contained locked doors in the egress corridor. The doors contained a keypad and keycard swipe and dropped on fire alarm. (No delayed and no access control.) Per Chapter 19, section 19.2.2.2.4
3) The facility did not contain exits directly to the exterior of the building or through exit passageways on several floors;
a) Second floor (2nd) contained six (6) stairwells and only one (1) discharged top to the exterior
b) Third floor (3rd) contained six (6) stairwells and only one (1) discharged to the exterior
c) Fourth floor (4th) contained six (6) stairwells and two (2) discharged to the exterior
d) Fifth floor (5th) contained six (6) stairwells and two (2) discharged to the exterior
e) Sixth floor (6th) contained three (3) stairwells and zero (0) discharged to the exterior

Per 2000 NFPA 101, Chapter 7, Section 7.7.2
" Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall be permitted to discharge through areas on the level of exit discharge, provided that the criteria of 7.7.2(1) through (3) are met:

(1) Such discharge shall lead to a free and unobstructed way to the exterior of the building, and such way is readily visible and identifiable from the point of discharge from the exit."

This portion applies to Building AC, known as the Chemical Dependency Unit.

It was determined by observation, during the survey on January 13, 2011, the facility failed to provide and maintain a means of egress, so arranged that exits are readily accessible at all times in accordance with the Life Safety Code. This was evidenced by the following:

1) Rear exit at dock has two doors, both with a deadbolt and the inner door has access controlled egress, but does not have motion sensor, as required.

2) The following labeled exits do not have a maintainable surface to the public way, as required:
a) Door to south patio on the back of the building, and
b) Exit door to the exterior serving rooms 3-12.

3) Cross-corridor door by the kitchen has access controlled egress, but does not have the motion sensor, as required.

4) Cross-corridor door by the Coordinator's Office has access controlled egress, but does not have the motion sensor, as required.

5) The main entry has both a deadbolt and access controlled egress, but does not have the motion sensor, as required.

The Means of Egress deficiency items were discussed during the exit conference.

Building 10: Satellite Imaging Center, 1619 N. Greenwood Ave.

Through observation during the survey, conducted January 11 through 19, 2011, it was determined that the facility failed to install a fire alarm system with approved components, devices or equipment.

During the walk through of the facility, with the Facilities Maintenance Director, the facility did not contain smoke detection per NFPA 101, Chapter 39, Section 39.3.4.1.
"A fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants."

Building A1: Main Hospital, 400 W. 16th St.

Through a review of the records and discussions during the survey, conducted on January 11 through 19, 2011, it was determined that the facility failed to inspect and test the fire alarm system.

During the review of the facility records, with the Plant Operations Director, documentation was not available to verify the sensitivity testing of the smoke detectors was conducted in the past two (2) years. Per NFPA 101, (Section 9.6, Paragraph 9.6.1.4), and NFPA 72, (Chapter 7, Paragraph 7-1.2.2).

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to install a full NFPA automatic sprinkler system, per the 1999 Edition of NFPA 13.

During the walk through of the facility, with the Plant Operations Director, automatic sprinkler system components were not installed or installed incorrectly in the following areas;

1) Housekeeping storage in the 1926 building contained duct work that extended eighteen inches (18") below the ceiling. The area on one (1) side of the duct work did not contain adequate sprinkler coverage. Per NFPA 13 1999 Edition, section 5-6.5.2.1.

2) The Housekeeping storage room in the 1926 building contained a sidewall sprinkler located adjacent to a fenced in storage area.
a) The top of the fence contained angle iron, which obstructed the sprinkler. Per NFPA 13 1999 Edition, section 5-7.5.1.3
b) The sidewall sprinkler was positioned in a way that the sprinkler was not horizontal to the ceiling.

NFPA 13, 1999 Edition, section 5-7.4.2.2 "Deflectors of sprinklers shall be aligned parallel to ceilings or roofs."

3) Dirty Utensil room on the first floor contained one (1) pendant sprinkler head located one inch (1") from the wall. The sprinkler head was located above the washer area. Per 1999 Edition, NFPA 13, section 5-6.3.3
"Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall."

4) Third (3rd) floor south corridor, outside clean utility room and elevator 7& 8, contained a sprinkler head installed one inch (1") to the wall. This head was also located closer than six feet (6') to the next sprinkler head and could cause a cold solder effect.

5) The fifth floor Labor and Delivery rooms all contained closets that failed to be sprinkler protected.
Note: This item was corrected during the survey.

6) The men's restroom on the sixth floor, had a party wall adjacent to the corridor door that terminates approximately one-foot from the ceiling and fails to allow the sprinkler within the restroom to cover the area immediately inside the corridor door. Per NFPA 13, 1999 ed., 5-8.5.2.3.

7) The women's restroom on the sixth floor (6th), had a party wall adjacent to the corridor door that terminates approximately one-foot (1') from the ceiling and fails to allow the sprinkler within the restroom to cover the area immediately inside the corridor door. Per NFPA 13, 1999 ed., 5-8.5.2.3.

8) The Cath Lab West Equipment room, failed to be covered by the automatic fire suppression system.

9) Fifth (5rd) floor south OB waiting area, contained three (3) sprinkler heads closer than six feet (6') to the next sprinkler head and could cause a cold solder effect.

10) Room #57 in labor and Delivery, has a ceiling pocket for the draperies that extends three-feet from the room ceiling and is approximately sixty three cubic feet (63 cf) in volume. This ceiling pocket failed to be protected by the automatic fire suppression system.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to maintain the automatic fire sprinkler system.

During the walk through of the facility, with the Plant Operations Director;

1) Escutcheon plates Missing
a) One (1) missing escutcheon in hallway outside ground floor satellite lab
b) One (1) missing escutcheon in closet of Laboratory classroom
c) One (1) missing escutcheon in Anesthesia Work Room
d) One (1) missing escutcheon plate in Dirty Utensil room on first floor
e) One (1) missing escutcheon plate at 2 South nurses station
f) One (1) missing escutcheon plate of room #4 bathroom

NOTE: The above escutcheon plates were corrected during the survey.

2) Compartments that contained Quick Response (QR) sprinkler heads and standard response (SR) sprinkler heads
a) Outside ground floor Trauma office contained one (1) QR head all others were SR heads
b) Environmental Services office (1926 Building) contained one (1) SR and two (2) QR sprinkler heads
c) Laboratory area adjacent to Microbiology Lab contains two (2) QR heads mixed in a compartment with SR heads
d) Anesthesia office contains two (2) QR heads and one (1) SR head
e) Surgery suite corridor outside Anesthesia office contains five (5) QR heads mixed with SR heads
f) Same Day surgery contains four (4) QR heads with all others being SR heads
g) Corridor outside the sleep lab contained one (1) QR head with all other being SR heads
h) Fifth Floor labor and Delivery - all heads north of Lead Clinical Nurse's Office are Quick Response
i) AHU 15 Mechanical room contained one (1) QR head with all other being SR heads
j) Sixth floor elevator lobby contained one (1) QR head with all other being SR heads
k) Five southeast (5 SE) end storage contained one (1) QR head and one (1) SR head
l) Fourth floor ICU waiting room contained one (1) QR head and one (1) SR head

Per NFPA 13 1999 Edition, section 5-4.5.3 "Where residential sprinklers are installed in a compartment as defined in 1-4.2, all sprinklers within the compartment shall be of the fast-response type that meets the criteria of 1-4.5.1(a)1."

3) Sprinkler heads contained corrosion or paint around the working parts of the sprinkler head
a) One (1) sprinkler head above the dishwasher in the main kitchen
b) One (1) sprinkler at entry vestibule at 17th street entrance to building 1926
c) One (1) painted sprinkler head in the corridor outside Cat Scan room #2
d) One (1) painted sprinkler head in the CEO office
e) One (1) painted sprinkler head outside third floor (3rd) south equipment room

Per 1999 Edition of NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."

4) Documentation was not available to verify that sprinkler gauges were calibrated or replaced every five (5) years per 1999 Edition of NFPA 25, section 2-3.2
a) Five (5) gauges at the MRI/ER/Radiology riser contained 2000 and 2001 manufacturer dates
b) Three (3) gauges on first floor (1st) riser in shipping and receiving did not contain manufacture dates
c) Two (2) gauges on third floor (3rd) riser contained 2005 manufacture dates
d) AHU 15 Mechanical room had a manufacture date of 1999

Per 1999 Edition NFPA 25, Chapter 5, section 5.3.2. "Gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge. Gauges not accurate to within three percent of the full scale shall be recalibrated or replaced."

NOTE: The above sprinkler gauges were corrected during the survey.

This portion applies to Building AB, known as the Adolescent Psychiatric Unit.

Through observation, during the survey January 13, 2011, it was determined that the facility failed to maintain the automatic fire sprinkler system. This was evidenced by:

Documentation was not available to verify that sprinkler gauges were calibrated or replaced every five (5) years per 1999 Edition of NFPA 25, section 2-3.2. The gauge on the facility's riser was not dated.

NOTE: The above sprinkler gauge was corrected during the survey.

The sprinkler gauge deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Chemical Dependency Unit.

Through observation, during the survey January 13, 2011, it was determined that the facility failed to maintain the automatic fire sprinkler system. This was evidenced by:

Documentation was not available to verify that sprinkler gauges were calibrated or replaced every five (5) years per 1999 Edition of NFPA 25, section 2-3.2. The gauge on the facility's riser was not dated.

NOTE: The above sprinkler gauge was corrected during the survey.

The sprinkler gauge deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Chemical Dependency Unit.

Based on observation and interview, the facility was found to have not met heating, ventilation, and service equipment requirements.

Findings on 1/13/2011 include:

The fireplace in the main gathering area is not separated from the resident room in the hallway servicing rooms 3-12 or the hallway servicing rooms 13-16 by one-hour rated construction, as required. The doors in the one-hour fire barriers serving these locations are 20-minute doors, rather than the required minimum of three-quarter hour doors.

Ref: 2000 NFPA 101 19.5.2.2.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, conducted January 11 through 19, 2011, the fire suppression failed to provide complete protection for the cooking facilities per NFPA 96.

During the walk through of the facility, with the Plant Operations Director, the deep fat fryer did not provide coverage from open flames.

Per NFPA 96, Section 9-1.2.3 "All deep fat fryers shall be installed with at least a 16-in. (406.4-mm) space between the fryer and surface flames from adjacent cooking equipment.

Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 in. (203 mm) in height between the fryer and surface flames of the adjacent appliance."

NOTE: The splash protection was corrected during the survey.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walk through of the facility, with the Plant Operations Director;

1) One (1) Hoyer lift was observed stored and unattended in the corridor of the Imaging department at 11:10 a.m., and again at 11:45 a.m., on January 12, 2011.

2) Corridor outside Payroll business office contained one (1) mailbox that extended eight inches (8") into the corridor

3) Corridor outside Payroll business office contained one (1) shelf that extended twelve inches (12") into the corridor

NOTE: All items above were corrected during the survey.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to install electrical outlets in accordance with NFPA 99 in the Nitrous Oxide storage room.

During the walk through of the facility, with the Plant Operations Director, the nitrous oxide storage room contained an electrical outlet installed at thirty two inches (32") off of the floor.

Per NFPA 99, 1999 Edition, section 4-3.1.1.2(4) "The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage."

NOTE: This item was corrected during the survey.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to provide a separation between service valves as required by NFPA 99.
During the walk through of the facility, with the Plant Operations Director, the surgery pre-op area contained a piped medical gas system shut off valve without separation between the beds that it controls and the shut off valve.

Per NFPA 99 section 4-3.1.2.3(d) "Zone Valve. Station outlets shall not be supplied directly from a riser unless a manual shut off valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet."

Building AF: Pueblo West Emergency Department, 899 E. Industrial Blvd.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to provide a separation between service valves as required by NFPA 99.
During the walk through of the facility, with the Plant Operations Director, the triage area contained a piped medical gas system shut off valve without separation between the three (3) beds that it controls and the shut off valve.

Per NFPA 99 section 4-3.1.2.3(d) "Zone Valve. Station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet."

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility and staff interviews, with the Plant Operations Director;

1) The facility failed to maintain a minimum of 35% humidity in all anesthetizing locations. The documented humidity levels maintained in the Cesarean Section OR in July of 2010 were between 24 and 31%.

Per NFPA 99, 1999 Edition 5-4.1.1* "The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater."

2) The facility failed to provide electrical shock protection in the Cesarean Section OR.
Per the 1999 Edition of NFPA 99, Section 3-3.2.1.2 " Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA."

3) Operating rooms #2 through #8 and the "C Section OR" did not contain exhaust capabilities in case of a fire in the operating room.

4) OR #1 and #9 did contain exhaust function on the HVAC unit; however was not setup for exhaust during the day of the survey.

5) OR's #1 through #9 did not contain smoke detection in the OR or a duct detector located at the OR ductwork to detect the products of combustion to activate the exhaust sequence or damper activation.

Per NFPA 99, 1999 Edition 5-4.1.3 "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

Building AE: YMCA Outpatient Rehab, 3204 Spaulding Ave.

Through observation, during the survey January 11 through 19, 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 the Plant Operations Director, the one-hour separation fire-rated wall, located between the Rehabilitation Unit and the YMCA gym did not continue to the metal roof deck. The wall was constructed to the bottom edge of the metal corrugated roof deck and contained insulation between the gaps of the corrugated metal deck and the drywall. Documentation could not be located indicating the gaps contained a fire rated material or a spray on type material. The drywall portion of the wall was confirmed to be two (2) sheets of 5/8 inch Type X drywall on metal studs.

This portion applies to Building A-8, known as the Medical Office Building.

Through observation during the survey, January 13, 2011, it was determined that the facility failed to maintain the one hour fire resistance rating of the common wall. This was evidenced by the following:

The facility failed to provide a 1-hour fire rated wall separation between the licensed space and unlicensed space on the east side. (Between Radiology and Quest Diagnostics.)

The separation wall deficiency item was discussed during the course of the survey and again during the exit conference.

This portion applies to Building AA, known as the Coumadin Clinic and Adult Psych Rehab.

Through observation, during the survey January 13, 2011, it was determined that the facility failed to maintain the one hour fire resistance rating of the common wall. This was evidenced by the following:

The facility did not contain a fully protected 1-hour wall separation between the licensed space and unlicensed space. The door between the Clinic and Homecare must be a minimum of a three-quarter hour, fire rated door; the current door is unrated and has louvers.

The separation wall deficiency item was discussed during the course of the survey and again during the exit conference.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined the facility failed to divide the essential electrical system onto the correct branches per NFPA 99.

During the document review and observation, with the Plant Operations Director;

1) The second floor (2nd) Life Safety Branch contained the nurse call circuits. The Nurse Call system shall be connected to the Critical Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

2) The second floor (2nd) Life Safety Branch contained the fire dampers circuits. The fire dampers shall be connected to the equipment branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

3) The Equipment Branch panel in the AHU15 Mechanical room (PEQL2) contained fire alarm panel circuits and emergency lighting circuits for the pharmacy. The fire alarm panel and emergency lighting circuits shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

Building A7: East Addition, 400 W. 17th St.

Through observation, during the survey January 11 through 19, 2011, it was determined the facility failed to divide the essential electrical system onto the correct branches per NFPA 99.

During the document review and observation, with the Plant Operations Director;

1) The sixth floor Equipment Branch (6EQLET) contained fire dampers circuits. The fire damper circuits shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

2) The fifth floor Equipment Branch (5EQLET) contained fire dampers circuits. The fire damper circuits shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

3) The 5T fifth floor Equipment Branch (5EQLT) contained fire dampers circuits. The fire damper circuits shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

Building A1: Main Hospital, 400 W. 16th St.

Through observation during the survey, January 11 through 19, 2011, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility, with the Plant Operations Director, extension cords or surge protectors' were found to be in use in the following areas;

1) The sixth floor pharmacy had a surge protected electrical power strip plugged into a second surge protected electrical power strip.

2) The sixth floor pharmacy had a surge protected electrical power strip plugged into a UPS device.

3) The sixth floor Chaplain's Office has an extension cord being used in place of permanent electrical wiring.

Per NFPA 70 1999 Edition, Chapter 4, Article 400, Paragraph 400.8, (" ... flexible cords and cables shall not be used for the following: (1) as a substitute for the fixed wiring of a structure ... ")