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Based on observations and staff interviews, the hospital failed to ensure stairway enclosure doors and smoke barrier compartment doors closed into the frame when tested. This involved one set of smoke barrier compartment doors and two stairway doors. This affected all staff, visitors, and patients on the first floor, fourth floor, and seventh floor.

Findings include:

A tour was conducted between 03/01/11 and 04/04/11 with Staff WW and YY. Vertical opening doors and fire doors were tested and failed to close into the frame as follows:

a) Stair door 7-7 on the seventh floor did not latch when tested on 03/01/11 at 2:05 PM.

b) Stair door 6-4 on the 4 North unit did not latch on 03/02/11 at 2:03 PM.

c) A set of fire doors outside the cafeteria and elevators, on the 1st floor, did not latch when released from the hold open device on 03/03/11 at 10:51 PM.

The failure of these doors to latch properly was verified with Staff WW and YY during the tour. Each of these doors were equipped with positive latching hardware.

Based on observations and staff interviews, the hospital failed to ensure smoke
compartment barriers were free of penetrations in order to provide at least a one half hour fire resistance rating in accordance with 8.3. This affected 4 smoke compartment barriers in the hospital.

Findings include:

During tour on 03/01/11 and 03/04/11, with Staff WW, XX, YY, and ZZ, the following four smoke compartment barriers were observed with penetrations:

a) The smoke compartment barrier on the 6th floor, leading into the cardiac telemetry unit, had penetrations in the barrier (approximately 1 and 1/2 inches ) around a water sprinkler pipe, a 6-8 inch high by 1/2 inch penetration along a beam in the corner of the barrier by room 6204.

b) The smoke compartment barrier leading into the medical progressive unit, by room 7218, contained eight penetrations around pipes. These penetrations were 1/2 to 2 inches each in size.

c) The smoke compartment barrier on the 5th floor trauma unit (leading into the Burns Special Care Unit) was observed with a penetration around a rigid conduit.

d) The smoke barrier on the 2nd floor by room 2110 was observed with two penetrations around a conduit. These penetrations measured approximately 1 inch each in size.

These penetrations in the smoke compartment barriers were verified with the aforementioned staff during the tour.

Based on observations and staff interviews, the hospital failed to ensure smoke compartment barriers were free of penetrations in order to maintain a one half hour fire resistance rating in accordance with 8.3. This affected one smoke barrier on the third floor.

Findings include:

On 03/04/11, at 9:45 AM, a tour was conducted with staff WW, XX, and YY. The smoke compartment barrier located near room 3039 was observed with penetrations around a three inch black pipe and a one inch copper pipe that penetrated the barrier. Another portion of this barrier, located across from the water fountain, was observed with a 2 inch wide by 3 inch high opening around an electrical wire, a 1 inch wide by 2 inch high opening around 2 conduits, and an approximately 1 inch opening around another conduit. These penetrations were approximated in size and were verified with Staff WW and YY.

Based on observations and staff interviews, the hospital failed to ensure hazardous areas (soiled utility rooms) contained doors that were self closing and resisted the passage of smoke. There were four doors involved on three floors of the hospital.

Findings include:

During tour on 03/01/11 and 03/04/11, with Staff WW, XX, YY, and ZZ, the following soiled utility doors (equipped with positive latching hardware) were observed:

a) On 03/02/11 at 10:39 AM, Room 5522 was observed with a 1/4 inch or greater opening at the top right side of the door when in the closed position.


b) On 03/02/11 at 1:50 PM, Room 4421 was observed with a gap exceeding 1/8 inch at the top of the right side of the door.

c) On 03/03/11 at 9:40 AM, the door to Room 2418 (on the endoscopy unit) failed to latch into the frame when tested.

d) On 03/03/11 at 10:10 AM, the door to Room 2240 was not equipped with an automatic self-closing device and had to be manually closed into the frame. Two biohazard containers were observed in this room at the time of tour.

At the time of tour, the aforementioned staff verified these doors did not resist the passage of smoke.

Based on observations and staff interviews, the hospital failed to ensure four exit access doors were not blocked or locked and were readily accessible at all times in accordance with section 7.1. This involved four doors on the first floor of the hospital.

Findings include:

During tour of the first floor on 03/03/11, between 11:10 AM and 11:50 AM, with Staff WW, XX, and YY, three sets of sliding glass exit access doors were observed in the Admitting area (west end of the building). These inner access doors were equipped with deadbolt locks that could be locked against egress and required a key to unlock the doors. Each of these sets of doors led to an acceptable exit discharge door.

Observation in the Wall Street Deli revealed an exit door in the food prep area which opened into the main corridor. These doors were blocked with cardboard boxes and a tray with breads.

During tour, Staff WW, XX, and YY verified these doors were not readily accessible.

Based on observations and staff interviews, the hospital failed to ensure two exit discharges were equipped with more than a single lighting fixture to prevent the failure of any single lighting fixture leaving the area in darkness in accordance with section 7.8.

Findings include:

During tour of the facility on 03/03/11, the exit discharge lighting fixture, located between the gift shop storage room and the chapel, was observed with one single light bulb. A sidewalk, approximately 30 feet in length, led to the public way that contained additional lighting.

A second exit on the ground floor north side of the building (used by several hospital buildings) was equipped with a single light fixture at the exit discharge. At least 100 feet of sidewalk was observed outside this exit discharge was noted without adequate lighting. This was verified with Staff WW at that time.

Based on observations and staff interviews, the hospital failed to provide one food prep area with a K type extinguisher in accordance with the code at 9.7.4.1 and NFPA 10, 3-7.1.

Findings include:

During tour on 03/03/11 at 10:50 AM, a Chinese food restaurant was observed in the main cafeteria seating area. There was no fire barrier construction between this restaurant and the cafeteria. A tour of the restaurant revealed an ansul extinguishing system and use of oil to prepare the food. There was no K fire extinguisher in this area. The closest K extinguisher was in the main hospital kitchen and was located greater than 30 feet away from this restaurant.

This was verified with Staff WW, XX, and YY on tour.

Based on observations and staff interview, the hospital failed to ensure portable space heating devices were not used in patient sleeping areas and failed to ensure portable space heaters used in non sleeping areas used by staff did not exceed 212 degrees Fahrenheit (F.). This affected 2 patient sleeping areas and one office area.

Findings include:

Tour was conducted in the facility between 03/01/11 and 03/03/11 with Staff WW and YY.

Portable space heaters were observed in patient sleeping areas as follows:

a) On the fourth floor in room 4434 (neuroscience nurse practitioners' office), three space heaters were observed in use during tour. This office is located in a patient sleeping area. This was observed on 03/02/11 at 1:55 PM.

b) A portable ceramic space heater was observed on the fourth floor in the nursing station immediately outside patient sleeping room 4132. This occurred at 3:00 PM on 03/02/11.

c) In non-patient sleeping areas, a space heater was observed on the second floor in radiology office (G269) on 03/03/11 at 2:05 PM.

On tour, an interview with Staff WW verified the use of these heaters. This employee could not provide documentation or evidence these heaters do not exceed 212 degrees Fahrenheit.

Based on observations and staff interviews, the hospitalfailed to ensure the trash chute door in the discharge room was not blocked so the chute door would close properly in the event of a fire. This could affect all patient care areas in this building (floors 3-8).

Findings include:

A tour was conducted on 03/03/11 at 2:25 PM with Staff WW, XX, and YY. The trash chute discharge room B132 was observed with trash backed up into the chute, blocking the trash chute door in the event of a fire. This door was observed with a chain and fusible link.
This was verified with all three staff on tour.

Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Ch. 7 and 21.2.1.

This requirement is NOT MET as evidenced by:

Based on observations made during tour and staff interview, it was determined that the hospital failed to ensure that two of five exits from the hospital had a hard or paved surface from the exit discharge to the common way and the path of egress travel from one of five exits did not require a change from downward travel to upward travel.

Findings include:

Tour was conducted on 03/02/11 from 10:00 AM until 12:00 PM with Staff CC, Staff EE, Staff HH, Staff II, and Staff JJ. During the tour stairwell SW4 was followed from the second floor, where the same day surgery unit was located, to the exit discharge onto ground level from the exterior staircase. The staircase ended at a mulched area and travel to the common way involved approximately five feet across the mulch and grass. This was confirmed by Staff EE and Staff HH during the tour.

Stairwell SW5 was followed from the second floor to the level of exit discharge near the loading dock. The path of egress travel led to the ground floor; then a change in the direction of travel was required from the ground floor upward one floor in order to reach the exterior door. This was confirmed by Staff HH during the tour.

Based on observations and staff interviews, the hospital failed to ensure stairway enclosure doors and smoke barrier compartment doors closed into the frame when tested. This involved one set of smoke barrier compartment doors and two stairway doors. This affected all staff, visitors, and patients on the first floor, fourth floor, and seventh floor.

Findings include:

A tour was conducted between 03/01/11 and 04/04/11 with Staff WW and YY. Vertical opening doors and fire doors were tested and failed to close into the frame as follows:

a) Stair door 7-7 on the seventh floor did not latch when tested on 03/01/11 at 2:05 PM.

b) Stair door 6-4 on the 4 North unit did not latch on 03/02/11 at 2:03 PM.

c) A set of fire doors outside the cafeteria and elevators, on the 1st floor, did not latch when released from the hold open device on 03/03/11 at 10:51 PM.

The failure of these doors to latch properly was verified with Staff WW and YY during the tour. Each of these doors were equipped with positive latching hardware.

Based on observations and staff interviews, the hospital failed to ensure smoke
compartment barriers were free of penetrations in order to provide at least a one half hour fire resistance rating in accordance with 8.3. This affected 4 smoke compartment barriers in the hospital.

Findings include:

During tour on 03/01/11 and 03/04/11, with Staff WW, XX, YY, and ZZ, the following four smoke compartment barriers were observed with penetrations:

a) The smoke compartment barrier on the 6th floor, leading into the cardiac telemetry unit, had penetrations in the barrier (approximately 1 and 1/2 inches ) around a water sprinkler pipe, a 6-8 inch high by 1/2 inch penetration along a beam in the corner of the barrier by room 6204.

b) The smoke compartment barrier leading into the medical progressive unit, by room 7218, contained eight penetrations around pipes. These penetrations were 1/2 to 2 inches each in size.

c) The smoke compartment barrier on the 5th floor trauma unit (leading into the Burns Special Care Unit) was observed with a penetration around a rigid conduit.

d) The smoke barrier on the 2nd floor by room 2110 was observed with two penetrations around a conduit. These penetrations measured approximately 1 inch each in size.

These penetrations in the smoke compartment barriers were verified with the aforementioned staff during the tour.

Based on observations and staff interviews, the hospital failed to ensure smoke compartment barriers were free of penetrations in order to maintain a one half hour fire resistance rating in accordance with 8.3. This affected one smoke barrier on the third floor.

Findings include:

On 03/04/11, at 9:45 AM, a tour was conducted with staff WW, XX, and YY. The smoke compartment barrier located near room 3039 was observed with penetrations around a three inch black pipe and a one inch copper pipe that penetrated the barrier. Another portion of this barrier, located across from the water fountain, was observed with a 2 inch wide by 3 inch high opening around an electrical wire, a 1 inch wide by 2 inch high opening around 2 conduits, and an approximately 1 inch opening around another conduit. These penetrations were approximated in size and were verified with Staff WW and YY.

Based on observations and staff interviews, the hospital failed to ensure hazardous areas (soiled utility rooms) contained doors that were self closing and resisted the passage of smoke. There were four doors involved on three floors of the hospital.

Findings include:

During tour on 03/01/11 and 03/04/11, with Staff WW, XX, YY, and ZZ, the following soiled utility doors (equipped with positive latching hardware) were observed:

a) On 03/02/11 at 10:39 AM, Room 5522 was observed with a 1/4 inch or greater opening at the top right side of the door when in the closed position.


b) On 03/02/11 at 1:50 PM, Room 4421 was observed with a gap exceeding 1/8 inch at the top of the right side of the door.

c) On 03/03/11 at 9:40 AM, the door to Room 2418 (on the endoscopy unit) failed to latch into the frame when tested.

d) On 03/03/11 at 10:10 AM, the door to Room 2240 was not equipped with an automatic self-closing device and had to be manually closed into the frame. Two biohazard containers were observed in this room at the time of tour.

At the time of tour, the aforementioned staff verified these doors did not resist the passage of smoke.

Based on observations and staff interviews, the hospital failed to ensure four exit access doors were not blocked or locked and were readily accessible at all times in accordance with section 7.1. This involved four doors on the first floor of the hospital.

Findings include:

During tour of the first floor on 03/03/11, between 11:10 AM and 11:50 AM, with Staff WW, XX, and YY, three sets of sliding glass exit access doors were observed in the Admitting area (west end of the building). These inner access doors were equipped with deadbolt locks that could be locked against egress and required a key to unlock the doors. Each of these sets of doors led to an acceptable exit discharge door.

Observation in the Wall Street Deli revealed an exit door in the food prep area which opened into the main corridor. These doors were blocked with cardboard boxes and a tray with breads.

During tour, Staff WW, XX, and YY verified these doors were not readily accessible.

Based on observations and staff interviews, the hospital failed to ensure two exit discharges were equipped with more than a single lighting fixture to prevent the failure of any single lighting fixture leaving the area in darkness in accordance with section 7.8.

Findings include:

During tour of the facility on 03/03/11, the exit discharge lighting fixture, located between the gift shop storage room and the chapel, was observed with one single light bulb. A sidewalk, approximately 30 feet in length, led to the public way that contained additional lighting.

A second exit on the ground floor north side of the building (used by several hospital buildings) was equipped with a single light fixture at the exit discharge. At least 100 feet of sidewalk was observed outside this exit discharge was noted without adequate lighting. This was verified with Staff WW at that time.

Based on observations and staff interviews, the hospital failed to provide one food prep area with a K type extinguisher in accordance with the code at 9.7.4.1 and NFPA 10, 3-7.1.

Findings include:

During tour on 03/03/11 at 10:50 AM, a Chinese food restaurant was observed in the main cafeteria seating area. There was no fire barrier construction between this restaurant and the cafeteria. A tour of the restaurant revealed an ansul extinguishing system and use of oil to prepare the food. There was no K fire extinguisher in this area. The closest K extinguisher was in the main hospital kitchen and was located greater than 30 feet away from this restaurant.

This was verified with Staff WW, XX, and YY on tour.

Based on observations and staff interview, the hospital failed to ensure portable space heating devices were not used in patient sleeping areas and failed to ensure portable space heaters used in non sleeping areas used by staff did not exceed 212 degrees Fahrenheit (F.). This affected 2 patient sleeping areas and one office area.

Findings include:

Tour was conducted in the facility between 03/01/11 and 03/03/11 with Staff WW and YY.

Portable space heaters were observed in patient sleeping areas as follows:

a) On the fourth floor in room 4434 (neuroscience nurse practitioners' office), three space heaters were observed in use during tour. This office is located in a patient sleeping area. This was observed on 03/02/11 at 1:55 PM.

b) A portable ceramic space heater was observed on the fourth floor in the nursing station immediately outside patient sleeping room 4132. This occurred at 3:00 PM on 03/02/11.

c) In non-patient sleeping areas, a space heater was observed on the second floor in radiology office (G269) on 03/03/11 at 2:05 PM.

On tour, an interview with Staff WW verified the use of these heaters. This employee could not provide documentation or evidence these heaters do not exceed 212 degrees Fahrenheit.

Based on observations and staff interviews, the hospitalfailed to ensure the trash chute door in the discharge room was not blocked so the chute door would close properly in the event of a fire. This could affect all patient care areas in this building (floors 3-8).

Findings include:

A tour was conducted on 03/03/11 at 2:25 PM with Staff WW, XX, and YY. The trash chute discharge room B132 was observed with trash backed up into the chute, blocking the trash chute door in the event of a fire. This door was observed with a chain and fusible link.
This was verified with all three staff on tour.

Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Ch. 7 and 21.2.1.

This requirement is NOT MET as evidenced by:

Based on observations made during tour and staff interview, it was determined that the hospital failed to ensure that two of five exits from the hospital had a hard or paved surface from the exit discharge to the common way and the path of egress travel from one of five exits did not require a change from downward travel to upward travel.

Findings include:

Tour was conducted on 03/02/11 from 10:00 AM until 12:00 PM with Staff CC, Staff EE, Staff HH, Staff II, and Staff JJ. During the tour stairwell SW4 was followed from the second floor, where the same day surgery unit was located, to the exit discharge onto ground level from the exterior staircase. The staircase ended at a mulched area and travel to the common way involved approximately five feet across the mulch and grass. This was confirmed by Staff EE and Staff HH during the tour.

Stairwell SW5 was followed from the second floor to the level of exit discharge near the loading dock. The path of egress travel led to the ground floor; then a change in the direction of travel was required from the ground floor upward one floor in order to reach the exterior door. This was confirmed by Staff HH during the tour.