HospitalInspections.org

Building A3 - Penrose St. Francis Health Center
Through observation during the survey, March 2 through March 18, 2010, it was determined 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:
A) Three (3) resident room doors, located in the wound clinic, contained roller latches.
B) Resident room #5 contained a sliding glass door, which would not latch into the frame when closed.

Building A5 - Penrose St. Francis Medical Center
Through observation during the survey March 2 through March 18, 2010, 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:
A) Patient room door #2414 contained excessive gaps in excess of 1/2-inch between the door and the frame or the door and the stop and would not resist the passage of smoke per section 19.3.6.1. All gaps on doors were corrected during the survey
B) Thirteen corridor doors would not positively latch into the frame when closed. 19.3.6.3.2
1) Nine (9) patient room doors would not latch into the frame;
a) Rooms #3136, 3332, 3336, 3406, 3410, 3416, 3428, 3438, 3440, and 5410...These items were corrected during the survey.
2) Four (4) 70/30 double doors were not considered to be positive latching (due to a thumb bolt lock), 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) Bio Medical door to the corridor, Clean linen room (outside dietary entrance), #4412, and #4301B

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined 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;
A) Seven (7) patient room doors contained gaps larger than 1/2" between the door and the doorstop, which would not maintain a positive smoke seal.
1) E-2008
2) E-2010
3) E-2013
4) E-2018
5) E-2022
6) E-2028
7) E-2032
Note: All door gaps corrected during the survey
B) Three (3) patient room doors would not latch into the frame when closed.
1) BT-10000
2) BT-10020
3) E-3007
Note: All three (3) doors corrected during the survey
C) Two (2) patient room doors would not close due to chairs blocking the doors from closing and latching.
1) Room #W-422
2) Room #BT-5012
Note: Both chairs moved during survey
D) Forty-seven (47) 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;
1) Thirty-six (36) doors located on the second floor (2nd) ICU area
2) Ten (10) doors located in the second floor operating room area. Note: The operating room square footage exceeds a non-sleeping suite area.
3) One door located in the Radiology Department (door #OC1016A). This door was located in the egress corridor.

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to construct smoke barriers to provide at least a smoke resistance rating.

During the walk through of the facility with the Construction Manager and the Facilities Director, five (5) smoke barrier walls had wire penetrations or pipe penetrations without fire caulking or other approved method of maintaining the fire rating of the wall.
1) Eighth floor (8th) smoke wall #BT8000GG contained a two inch by two inch (2"x2") square hole.
2) Third floor (3rd) smoke wall #EBT-3037 contained one (1) unsealed wire penetration.
3) Second floor (2nd) smoke wall #MR-2006 contained three (3) unsealed wire penetrations.
4) Second floor (2nd) smoke wall #BT-2032 contained a duct work flange that was missing and caused an unsealed penetration.
5) Basement smoke wall #BT-0063 contained one (1) unsealed wire penetration.
Note: All smoke wall deficiencies were corrected during the survey.

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility with the Construction Manager and the Facilities Director, two (2) fire barrier doors would not latch into the frame when closed;
1) Second floor (2nd) smoke wall doors #BT-2023 would not latch into the frame.
2) Basement fire door #CC0001 would not latch into the frame.
Note: All fire barrier door deficiencies were corrected during the survey.

Building A4 - Langston-Brown
Through observation and testing during the survey conducted March 2 through March 18, 2010, it was determined that the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 72.

During the walk through of the facility with the Construction Manager and the Facilities Director;
A) A smoke detector, located at the nurses' station, installed within one inch (1") from the wall. NFPA 72, section 2-2.2.1 "fire detectors shall be located on the ceiling not less than 4 in. (100 mm) from the sidewall."
B) A manual pull station, located in the patient waiting area, was located approximately twenty-nine feet (29') from the exit doorway. Per NFPA 72 section 2-8.2.2 "Manual fire alarm boxes shall be located within 5 ft (1.5 m) of the exit doorway opening at each exit on each floor."

Building A-1 - Penrose Main Hospital
Through observation during the survey conducted March 2 through March 18, 2010, it was determined that the facility failed to provide a complete automatic sprinkler system in accordance with NFPA 13.

During the walk through of the facility with the Construction Manager and the Facilities Director, the automatic sprinkler system did not provide coverage in the following areas;
1) Fourteenth (14th) floor elevator control room
2) Thirteenth (13th) floor telecom room
3) Second floor (2nd) Cryogenics Lab missing coverage in a ceiling pocket
4) Basement elevator control room (#EBT-0006)

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain the automatic sprinkler system in a reliable operating condition.

During the walk through of the facility with the Construction Manager and the Facilities Director:
A) Room #BT-11013A sprinkler head missing the required escutcheon plate per NFPA 13 section 3-2.7.2. Corrected during survey.
B) Separation curtains contained quarter-inch (1/4") mesh at the top eighteen inches (18") of the curtain which created a sprinkler obstruction per NFPA 13 5-6.5.2.3. The curtains were removed during the survey.
1) One (1) separation curtain in room #BT-9012
2) Two (2) separation curtains in room #W-921
C) IT closet located on the third (3rd) floor, room #BT-3067, was missing the lay in ceiling tiles. This created a distance greater than allowed per NFPA 13 2000 Edition, section 5-6.4.1.1. Corrected during survey by replacing the ceiling tiles.
D) Mail room, located in the basement, contained two (2) standard sprinkler heads and two (2) quick response sprinkler heads. Per NFPA 13 5-3.1.5.2 "When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed." The area contained a lintel between the two (2) areas that was measured at five inches (5"). Per NFPA 1, the definition of a compartment is "A space completely enclosed by walls and a ceiling. The compartment enclosure is permitted to have openings to an adjoining space if the openings have a minimum lintel depth of 8 in. (203 mm) from the ceiling."

Building A5 -Penrose St. Francis Medical Center
Through record review during the survey March 2 through March 18, 2010, it was determined that the facility failed to test the fire sprinkler pump per NFPA 25.

During the review of the facility records with the Construction Manager and the Facilities Director, documentation was not available to indicate the fire pump was tested weekly per NFPA 25, section 5-3.2.1. Documentation was missing between August 27, 2009 through September 23, 2009, October 30, 2009 through November 25, 2009, December 4, 2009 through January 22, 2010, February 5, 2010 and February 19, 2010 through March 4, 2010 for a total of six (6) weeks of no testing documentation.

Building A5 -Penrose St. Francis Medical Center
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain access to the fire extinguishers.

During the walkthrough of the facility with the Construction Manager and the Facilities Director, the portable "K" type fire extinguisher in the kitchen was located in an area that was approximately forty feet (40') from the stove area. The kitchen contained two (2) "K" type extinguishers and both were farther than thirty feet (30') from the stove area. Per Chapter 18, section 18.3.5.6, section 9.7.4.1 and NFPA 10 section 3-7.2 states "Maximum travel distance shall not exceed 30 ft (9.15 m) from the hazard to the extinguishers."

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, the kitchen stove and deep fat fryer failed to be protected per NFPA 96, section 9-1-2-3.

During the walk through of the facility with the Construction Manager and the Facilities Director, the deep fryer was sitting next to the range (with approximately a one inch (1") gap between the two appliances) and did not contain splash protection between the stove and the deep fat fryer. 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."

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain the rubbish chute doors.

During the walk through of the facility with the Construction Manager and the Facilities Director, laundry chute doors, located on the fourth floor (4th), fifth floor (5th), and seventh floor (7th) corridors, contained an electronic latching device. The device would unlock the door however the door would not positively latch for thirty seconds (30) after the door was shut. The doors did not contain a thumb lock or latch on the door.

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, 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 Construction Manager and the Facilities Director;
A) The operating room egress corridor contained a wheelchair and two (2) beds stored in the corridor. These items were moved during the survey.
B) The facility contained "chart keepers" mounted onto the wall of the corridor. The "chart keepers" are mounted on the corridor wall outside each patient room at forty-four inches (44") off of the floor and protrude into the corridor by three and a half inches (3 1/2"). When the doors to the "chart keepers" are opened, the door protrudes into the corridor eighteen inches (18"). Per 7.1.10 "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use." The following areas contained the "chart keepers"
1) Tenth floor (10th) contained twenty-four (24)
2) Ninth floor (9th) contained twenty-four (24)
3) Fifth floor (5th) contained twenty-six (26)
4) Fourth floor (4th) contained twenty-four (24)
Note: all "chart keepers" were corrected during the survey by installing a screw so that the door could not be opened.

Building A-1 - Penrose Main Hospital
Through observation and record review during the survey March 2 through March 18, 2010, 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 Construction Manager and the Facilities Director, five (5) areas contained emergency shut off valves without separation between the area it controls and the shut off valve per NFPA 99 4-3.1.2.3:
1) The "ACC" prep and recovery area, located on the third (3rd) floor, contained fourteen (14) rooms without separation.
2) The "PACU" recovery area for the operating rooms, located on the second floor (2nd). There appeared to be a door at one time due to a door frame located next to the valve, however the door was missing from the frame.
3) "Outpatient Rehab" area
4) Emergency Department, located on the first floor, contained two (2) areas where the valves were not separated from the area it served.
a) Gas valve controlling rooms twelve through sixteen (12 through 16). There appeared to be a door at one time due to a door frame located next to the valve, however the door was missing from the frame. The rooms are separated by curtains as well.
b) Gas valve controlling nineteen and twenty (19 and 20). The rooms contained a curtain separation between the valve and the rooms. The valve is located directly across from the rooms.

Through observation and record review during the survey, March 2 through March 18, 2010, it was determined that the facility utilized a corridor as a use area.

During the walk through of the facility, with the Construction Manager and Facilities Director, piped oxygen medical gas was found to be in the corridor of the Radiation Department. Per interviews with the Radiation Department Manager, this oxygen valve is utilized on a daily basis for patient waiting to utilize the radiation department rooms. Chapter 18.3.6.1 exception 1 (a).

Building A4 - Langston-Brown
Through observation during the survey, March 2 through March 18, 2010, 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 Construction Manager and the Facilities Director, the prep area contained a piped medical gas system to rooms "B" and "C". The emergency shut off valve that controlled the two rooms was 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 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 A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility with the Construction Manager and the Facilities Director;
A) Eighteen (18) anesthetizing operating rooms (fourteen (14) operating rooms and four (4) cath-lab procedure rooms, which use inhaled anesthesia) did not contain ground fault or line isolation electrical protection. Per the 2000 Edition of NFPA 99, Section 3-3.2.1.2 these locations are considered "wet" locations and must be protected by either GFCI (ground fault circuit interruption) or LIM (line isolation monitors).
B) The facility failed to provide a means by which to exhaust the eighteen (18) windowless anesthetizing operating rooms in the event that smoke or the products of combustion are detected, as required by NFPA 99, 5-4.1.2. Per discussions with Maintenance staff, it appears that the exhaust function shuts down on smoke detector activation, but does not exhaust products of combustion or prevent the recirculation of smoke per NFPA 99 5-4.1.2 and 5-4.1.3.

Building A5 -Penrose St. Francis Medical Center
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility with the Construction Manager and the Facilities Director, six (6) anesthetizing operating rooms (four (4) operating rooms and two (2) c-section operating rooms) did not contain ground fault or line isolation electrical protection. Per the 2000 Edition of NFPA 99, Section 3-3.2.1.2 these locations are considered "wet" locations and must be protected by either GFCI (ground fault circuit interruption) or LIM (line isolation monitors).

Building A3 - Penrose St. Francis Health Center
Through observation during the survey, conducted March 2 through March 18, 2010, it was determined that the facility failed to maintain the dead end corridors.

During the walk through of the facility, with the Construction Manager and the Facilities Director, a dead end corridor measuring sixty feet (60') was observed in the wound care clinic area. The wall, which created the dead end corridor, was installed within the past three (3) years. Per chapter 19, section 19.2.5.10, existing dead end corridors shall be permitted to be used. Since this wall was installed within the last 3 years, chapter 19, section 19.2.5.10 states that no dead end corridor shall exceed 30 feet.
Note: The city code indicates that this area is classified as Business occupancy. Chapter 38, section 38.2.5.2 exception 1 states that if an approved automatic sprinkler system is installed, dead end corridors shall not exceed 50 feet.

Building A5 -Penrose St. Francis Medical Center
Through observation during the survey conducted March 2 through March 18, 2010, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walkthrough of the facility with the Construction Manager and the Facilities Director, the alcohol based hand rub dispensers (ABHR) were installed above or adjacent (between on-half inch (1/2") and six inches (6")) to an electrical source in numerous patient rooms (see below for a list). Per Chapter 18, section 18.3.2.7(6) "The dispensers shall not be installed over or directly adjacent to an ignition source."
A) Patient room numbers noted 5112, 5118, 5122, 5128, 5212, 5228, 5330, 5404, 5426, 3136, 3402, 3436, 3440, 3452, 3454.

Building A4 - Langston-Brown
Through observation during the survey conducted March 2 through March 18, 2009, it was determined that the facility failed to maintain the oxygen storage/transfer room.

During the walk through of the facility with the Construction Manager and the Facilities Director, the exhaust system for the oxygen-transfer-room did not function. Per NFPA 99, Chapter 8, section 8-6.2.5.2(b) "The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring;"

Building A3 - Penrose St. Francis Health Center
Through observation during the survey, March 2 through March 18, 2010, it was determined 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:
A) Three (3) resident room doors, located in the wound clinic, contained roller latches.
B) Resident room #5 contained a sliding glass door, which would not latch into the frame when closed.

Building A5 - Penrose St. Francis Medical Center
Through observation during the survey March 2 through March 18, 2010, 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:
A) Patient room door #2414 contained excessive gaps in excess of 1/2-inch between the door and the frame or the door and the stop and would not resist the passage of smoke per section 19.3.6.1. All gaps on doors were corrected during the survey
B) Thirteen corridor doors would not positively latch into the frame when closed. 19.3.6.3.2
1) Nine (9) patient room doors would not latch into the frame;
a) Rooms #3136, 3332, 3336, 3406, 3410, 3416, 3428, 3438, 3440, and 5410...These items were corrected during the survey.
2) Four (4) 70/30 double doors were not considered to be positive latching (due to a thumb bolt lock), 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) Bio Medical door to the corridor, Clean linen room (outside dietary entrance), #4412, and #4301B

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined 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;
A) Seven (7) patient room doors contained gaps larger than 1/2" between the door and the doorstop, which would not maintain a positive smoke seal.
1) E-2008
2) E-2010
3) E-2013
4) E-2018
5) E-2022
6) E-2028
7) E-2032
Note: All door gaps corrected during the survey
B) Three (3) patient room doors would not latch into the frame when closed.
1) BT-10000
2) BT-10020
3) E-3007
Note: All three (3) doors corrected during the survey
C) Two (2) patient room doors would not close due to chairs blocking the doors from closing and latching.
1) Room #W-422
2) Room #BT-5012
Note: Both chairs moved during survey
D) Forty-seven (47) 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;
1) Thirty-six (36) doors located on the second floor (2nd) ICU area
2) Ten (10) doors located in the second floor operating room area. Note: The operating room square footage exceeds a non-sleeping suite area.
3) One door located in the Radiology Department (door #OC1016A). This door was located in the egress corridor.

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to construct smoke barriers to provide at least a smoke resistance rating.

During the walk through of the facility with the Construction Manager and the Facilities Director, five (5) smoke barrier walls had wire penetrations or pipe penetrations without fire caulking or other approved method of maintaining the fire rating of the wall.
1) Eighth floor (8th) smoke wall #BT8000GG contained a two inch by two inch (2"x2") square hole.
2) Third floor (3rd) smoke wall #EBT-3037 contained one (1) unsealed wire penetration.
3) Second floor (2nd) smoke wall #MR-2006 contained three (3) unsealed wire penetrations.
4) Second floor (2nd) smoke wall #BT-2032 contained a duct work flange that was missing and caused an unsealed penetration.
5) Basement smoke wall #BT-0063 contained one (1) unsealed wire penetration.
Note: All smoke wall deficiencies were corrected during the survey.

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility with the Construction Manager and the Facilities Director, two (2) fire barrier doors would not latch into the frame when closed;
1) Second floor (2nd) smoke wall doors #BT-2023 would not latch into the frame.
2) Basement fire door #CC0001 would not latch into the frame.
Note: All fire barrier door deficiencies were corrected during the survey.

Building A4 - Langston-Brown
Through observation and testing during the survey conducted March 2 through March 18, 2010, it was determined that the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 72.

During the walk through of the facility with the Construction Manager and the Facilities Director;
A) A smoke detector, located at the nurses' station, installed within one inch (1") from the wall. NFPA 72, section 2-2.2.1 "fire detectors shall be located on the ceiling not less than 4 in. (100 mm) from the sidewall."
B) A manual pull station, located in the patient waiting area, was located approximately twenty-nine feet (29') from the exit doorway. Per NFPA 72 section 2-8.2.2 "Manual fire alarm boxes shall be located within 5 ft (1.5 m) of the exit doorway opening at each exit on each floor."

Building A-1 - Penrose Main Hospital
Through observation during the survey conducted March 2 through March 18, 2010, it was determined that the facility failed to provide a complete automatic sprinkler system in accordance with NFPA 13.

During the walk through of the facility with the Construction Manager and the Facilities Director, the automatic sprinkler system did not provide coverage in the following areas;
1) Fourteenth (14th) floor elevator control room
2) Thirteenth (13th) floor telecom room
3) Second floor (2nd) Cryogenics Lab missing coverage in a ceiling pocket
4) Basement elevator control room (#EBT-0006)

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain the automatic sprinkler system in a reliable operating condition.

During the walk through of the facility with the Construction Manager and the Facilities Director:
A) Room #BT-11013A sprinkler head missing the required escutcheon plate per NFPA 13 section 3-2.7.2. Corrected during survey.
B) Separation curtains contained quarter-inch (1/4") mesh at the top eighteen inches (18") of the curtain which created a sprinkler obstruction per NFPA 13 5-6.5.2.3. The curtains were removed during the survey.
1) One (1) separation curtain in room #BT-9012
2) Two (2) separation curtains in room #W-921
C) IT closet located on the third (3rd) floor, room #BT-3067, was missing the lay in ceiling tiles. This created a distance greater than allowed per NFPA 13 2000 Edition, section 5-6.4.1.1. Corrected during survey by replacing the ceiling tiles.
D) Mail room, located in the basement, contained two (2) standard sprinkler heads and two (2) quick response sprinkler heads. Per NFPA 13 5-3.1.5.2 "When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed." The area contained a lintel between the two (2) areas that was measured at five inches (5"). Per NFPA 1, the definition of a compartment is "A space completely enclosed by walls and a ceiling. The compartment enclosure is permitted to have openings to an adjoining space if the openings have a minimum lintel depth of 8 in. (203 mm) from the ceiling."

Building A5 -Penrose St. Francis Medical Center
Through record review during the survey March 2 through March 18, 2010, it was determined that the facility failed to test the fire sprinkler pump per NFPA 25.

During the review of the facility records with the Construction Manager and the Facilities Director, documentation was not available to indicate the fire pump was tested weekly per NFPA 25, section 5-3.2.1. Documentation was missing between August 27, 2009 through September 23, 2009, October 30, 2009 through November 25, 2009, December 4, 2009 through January 22, 2010, February 5, 2010 and February 19, 2010 through March 4, 2010 for a total of six (6) weeks of no testing documentation.

Building A5 -Penrose St. Francis Medical Center
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain access to the fire extinguishers.

During the walkthrough of the facility with the Construction Manager and the Facilities Director, the portable "K" type fire extinguisher in the kitchen was located in an area that was approximately forty feet (40') from the stove area. The kitchen contained two (2) "K" type extinguishers and both were farther than thirty feet (30') from the stove area. Per Chapter 18, section 18.3.5.6, section 9.7.4.1 and NFPA 10 section 3-7.2 states "Maximum travel distance shall not exceed 30 ft (9.15 m) from the hazard to the extinguishers."

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, the kitchen stove and deep fat fryer failed to be protected per NFPA 96, section 9-1-2-3.

During the walk through of the facility with the Construction Manager and the Facilities Director, the deep fryer was sitting next to the range (with approximately a one inch (1") gap between the two appliances) and did not contain splash protection between the stove and the deep fat fryer. 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."

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain the rubbish chute doors.

During the walk through of the facility with the Construction Manager and the Facilities Director, laundry chute doors, located on the fourth floor (4th), fifth floor (5th), and seventh floor (7th) corridors, contained an electronic latching device. The device would unlock the door however the door would not positively latch for thirty seconds (30) after the door was shut. The doors did not contain a thumb lock or latch on the door.

Building A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, 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 Construction Manager and the Facilities Director;
A) The operating room egress corridor contained a wheelchair and two (2) beds stored in the corridor. These items were moved during the survey.
B) The facility contained "chart keepers" mounted onto the wall of the corridor. The "chart keepers" are mounted on the corridor wall outside each patient room at forty-four inches (44") off of the floor and protrude into the corridor by three and a half inches (3 1/2"). When the doors to the "chart keepers" are opened, the door protrudes into the corridor eighteen inches (18"). Per 7.1.10 "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use." The following areas contained the "chart keepers"
1) Tenth floor (10th) contained twenty-four (24)
2) Ninth floor (9th) contained twenty-four (24)
3) Fifth floor (5th) contained twenty-six (26)
4) Fourth floor (4th) contained twenty-four (24)
Note: all "chart keepers" were corrected during the survey by installing a screw so that the door could not be opened.

Building A-1 - Penrose Main Hospital
Through observation and record review during the survey March 2 through March 18, 2010, 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 Construction Manager and the Facilities Director, five (5) areas contained emergency shut off valves without separation between the area it controls and the shut off valve per NFPA 99 4-3.1.2.3:
1) The "ACC" prep and recovery area, located on the third (3rd) floor, contained fourteen (14) rooms without separation.
2) The "PACU" recovery area for the operating rooms, located on the second floor (2nd). There appeared to be a door at one time due to a door frame located next to the valve, however the door was missing from the frame.
3) "Outpatient Rehab" area
4) Emergency Department, located on the first floor, contained two (2) areas where the valves were not separated from the area it served.
a) Gas valve controlling rooms twelve through sixteen (12 through 16). There appeared to be a door at one time due to a door frame located next to the valve, however the door was missing from the frame. The rooms are separated by curtains as well.
b) Gas valve controlling nineteen and twenty (19 and 20). The rooms contained a curtain separation between the valve and the rooms. The valve is located directly across from the rooms.

Through observation and record review during the survey, March 2 through March 18, 2010, it was determined that the facility utilized a corridor as a use area.

During the walk through of the facility, with the Construction Manager and Facilities Director, piped oxygen medical gas was found to be in the corridor of the Radiation Department. Per interviews with the Radiation Department Manager, this oxygen valve is utilized on a daily basis for patient waiting to utilize the radiation department rooms. Chapter 18.3.6.1 exception 1 (a).

Building A4 - Langston-Brown
Through observation during the survey, March 2 through March 18, 2010, 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 Construction Manager and the Facilities Director, the prep area contained a piped medical gas system to rooms "B" and "C". The emergency shut off valve that controlled the two rooms was 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 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 A-1 - Penrose Main Hospital
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility with the Construction Manager and the Facilities Director;
A) Eighteen (18) anesthetizing operating rooms (fourteen (14) operating rooms and four (4) cath-lab procedure rooms, which use inhaled anesthesia) did not contain ground fault or line isolation electrical protection. Per the 2000 Edition of NFPA 99, Section 3-3.2.1.2 these locations are considered "wet" locations and must be protected by either GFCI (ground fault circuit interruption) or LIM (line isolation monitors).
B) The facility failed to provide a means by which to exhaust the eighteen (18) windowless anesthetizing operating rooms in the event that smoke or the products of combustion are detected, as required by NFPA 99, 5-4.1.2. Per discussions with Maintenance staff, it appears that the exhaust function shuts down on smoke detector activation, but does not exhaust products of combustion or prevent the recirculation of smoke per NFPA 99 5-4.1.2 and 5-4.1.3.

Building A5 -Penrose St. Francis Medical Center
Through observation during the survey March 2 through March 18, 2010, it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility with the Construction Manager and the Facilities Director, six (6) anesthetizing operating rooms (four (4) operating rooms and two (2) c-section operating rooms) did not contain ground fault or line isolation electrical protection. Per the 2000 Edition of NFPA 99, Section 3-3.2.1.2 these locations are considered "wet" locations and must be protected by either GFCI (ground fault circuit interruption) or LIM (line isolation monitors).

Building A3 - Penrose St. Francis Health Center
Through observation during the survey, conducted March 2 through March 18, 2010, it was determined that the facility failed to maintain the dead end corridors.

During the walk through of the facility, with the Construction Manager and the Facilities Director, a dead end corridor measuring sixty feet (60') was observed in the wound care clinic area. The wall, which created the dead end corridor, was installed within the past three (3) years. Per chapter 19, section 19.2.5.10, existing dead end corridors shall be permitted to be used. Since this wall was installed within the last 3 years, chapter 19, section 19.2.5.10 states that no dead end corridor shall exceed 30 feet.
Note: The city code indicates that this area is classified as Business occupancy. Chapter 38, section 38.2.5.2 exception 1 states that if an approved automatic sprinkler system is installed, dead end corridors shall not exceed 50 feet.

Building A5 -Penrose St. Francis Medical Center
Through observation during the survey conducted March 2 through March 18, 2010, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walkthrough of the facility with the Construction Manager and the Facilities Director, the alcohol based hand rub dispensers (ABHR) were installed above or adjacent (between on-half inch (1/2") and six inches (6")) to an electrical source in numerous patient rooms (see below for a list). Per Chapter 18, section 18.3.2.7(6) "The dispensers shall not be installed over or directly adjacent to an ignition source."
A) Patient room numbers noted 5112, 5118, 5122, 5128, 5212, 5228, 5330, 5404, 5426, 3136, 3402, 3436, 3440, 3452, 3454.

Building A4 - Langston-Brown
Through observation during the survey conducted March 2 through March 18, 2009, it was determined that the facility failed to maintain the oxygen storage/transfer room.

During the walk through of the facility with the Construction Manager and the Facilities Director, the exhaust system for the oxygen-transfer-room did not function. Per NFPA 99, Chapter 8, section 8-6.2.5.2(b) "The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring;"