HospitalInspections.org

Based on observation, the facility did not ensure the fire barrier having 4-hour resistance rating was properly maintained between the two nonconforming building/occupancy types.

1. The fire barrier separating the old hospital from the clinic/CAH addition of 1994 was required to be maintained with a 4- hour construction. The 3-hour fire rated door with a self closure device found in this separation was exercised at 2:34 p.m. on 5/22/12. The door failed to self close when exercised three consecutive times. The maintenance staff A and B verified this finding who were accompanying the surveyor at the time of the observation.

2. On 5/23/12 at 3:16 p.m., four open ended conduits, measuring approximately 3-inches in diameter, carrying communication cables, penetrated fire rated wall between the new "2-3 HVAC room" and the 60's building.

Based on observations, the facility did not ensure the fire resistive construction of all corridor walls to be resistant to the passage of smoke.

Findings include:

In accordance with Section 19.3.6.2.1 of NFPA 101, corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

1. On 5/22/12 at 1:41 p.m. an open ended conduit, measuring approximately 2 inches in diameter, housing several communication cables, penetrated the corridor wall from the "Main Electrical" into the service hall to Radiology.

2. On 5/23/12 at 9:00 a.m., an unsealed open conduit penetrated the exit corridor wall (north side) on "Med/Surge". Staff member B sealed the penetration with fire rated material after he was notified of the concern.

3. On 5/23/12 at 10:35 a.m., an unsealed open ended conduit measuring approximately 3 inches in diameter, housing several communication cables, penetrated the 1- hour rated exit corridor wall above the north entrance door of the "Lab".

4. On 5/23/12 at 10:39 a.m. an unsealed open ended conduit penetrated the 1-hour rated exit corridor wall above the entrance door to the Surgery.

Based on observation, the facility did not ensure vertical openings between floors were sealed and/or enclosed by fire resistive construction of 1-hour rating.

Findings included:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition, pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

On 5/23/12 at 3:11 p.m., several unsealed floor/vertical penetrations around conduits carrying communication cables were observed in an electrical/phone room on the second floor where the main fire alarm control panel was located on the "Med/Surge" wing.

Based on observations, the facility did not maintain or establish the fire rated protection for areas with potential hazards.

Findings include:

In accordance with section 39.3.2.1 of NFPA 101, LSC, 2000 Edition; Existing Business Occupancies, hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with 8.4.

In accordance with Section 8.4.1.1 of NFPA 101, LSC, 2000 Edition; protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by the following: Enclose the area with a fire barrier that has a 1-hour fire resistance rating, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 8.4.1.3 of NFPA 101 LSC.

Hazardous areas must be separated from non-hazardous areas with 1-hour rated wall and ceiling assemblies.

1. On 5/23/12 at 7:20 a.m., two medical records storage rooms were observed on the third floor of the 60's building. None of the rooms' corridor doors had self closure devices. The doors had 90 minute fire ratings.

2. On 5/23/12 at 1:59 p.m., an unsealed wall penetration (that appeared to be previously repaired) was observed in the boiler room of the 60's building. Orange colored pipes as well as communication cables and the fire alarm panel cables (red) entered this penetration in the boiler room's north wall. The penetration was not sealed with proper fire rated material from the other side (crawl space) as well.

Based on observations, the facility did not maintain the fire alarm system in accordance with the standards of NFPA 72, 1999 edition.

Findings include:

The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit per section 1-5.2.5.2 of NFPA 72, 1999 edition.

A Notifier model NFS-2 3030 Fire Alarm Control Panel (FACP) located in the communication room on the "Med/Surg" wing was observed at 3:11 p.m. on 5/23/12. The disconnect means for the normal power serving this FACP was not identified in a red colored marking at the panel identified as 2LSB.

Based on observations, the facility did not ensure the automatic sprinkler system and/or its components in accordance with NFPA 13.

Findings include:

On 5/22/12 at 1:53 p.m. no wrench was observed in the supply cabinet holding sprinkler parts which supplied the sprinkler system at the location of the main sprinkler risers in the boiler room of the new building.

Based on observation, the facility did not maintain portable fire extinguishers in accordance with the standards of NFPA 10, 1998 Edition.

Findings include:

1. In accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 Edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

At 3:17 p.m. on 5/22/12, the fire extinguisher #40 found in the exit hallway near the Director of Medical Practice Operation office was hanging at 64.5 inches (from the top of the unit).

Based on observation, the facility did not maintain portable fire extinguishers in accordance with the standards of NFPA 10, 1998 Edition.

Findings include:

In accordance with 39.3.5 of NFPA 101 LSC 2000 Edition, portable fire extinguishers shall be provided in every business occupancy in accordance with NFPA 10.

In accordance with 1-6.6 and 4-3.2 of NFPA 10 fire extinguishers shall not be obstructed or obscured from view and no obstruction to access or visibility will impair the periodic inspection of fire extinguishers.

On 5/23/12 at 8:04 a.m., a fire extinguisher was found behind the entrance door to the Cardiac Rehabilitation on the third floor of the 60's building. The door had a magnetic hold device and was held open. If the door was not exercised for proper latching and closure, the fire extinguisher could not be discovered behind it. If this door was kept open, as observed on 5/22/12 and 5/23/12, during the building operating hours, no one could have a proper visual on the fire extinguisher.

Based on observation the facility failed to meet the standards of either NFPA 70 or NFPA 99 in regards to electrical service in the building.

Findings include:

1. On 5/23/12 at 9:28 a.m., circuit breakers 9, 11, and 13 were in off positions in electrical panel 2MA located in the mechanical room at the south OB entrance. These circuit breakers were not marked as spares in the panel directory. Additionally, the circuit breakers 6-24 in the electrical panel 2EQC, located in the same area, were not marked as spares in the panel directory although they were in the off position.

2. On 5/23/12 at 10:50 a.m., circuit breaker #21 was in the on position in the electrical panel 2CPA in the surgical suite; however, the panel directory did not identify what breaker #21 serviced.

Based on observation the facility failed to meet the standards of either NFPA 70 or NFPA 99 in regards to electrical service in the building.

Findings include:

In accordance with 39.5.1 of NFPA 101 LSC 2000 Edition, utilities shall comply with the provisions of NFPA 70 and 99.

In accordance with 240-4 of the NFPA 70 (1999 edition), 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 edition) and previous interpretations from CMS (transmittal notice dated 3-30-99) extension cords or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing surge strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings. The listed ampere rating of these strips or adaptors are based upon the use of one strip only, not several strips or adaptors in a series.

1. On 5/22/12 at 3:00 p.m., a small refrigerator was plugged into a surge protector in the PT reception office. Staff member B confiscated the unit.

2. On 5/22/12 at 3:05 p.m., a three receptacle/single plug in adaptor was found in the PT room. Staff member B confiscated the unit.

Based on review of the fire watch policy and interview, the facility did not have a fire watch policy which included contacting the authority having jurisdiction (State Agency/Certification Bureau at 406-444-4170) whenever a fire watch was instituted when the sprinkler system was out of service.

In accordance with the 2000 Edition of NFPA 101 Section 9.7.6.1, where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the automatic sprinkler system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the Interim Life Safety Policy was reviewed on 5/22/12 with staff member A and it included fire watch procedures. However, the procedures lacked information/instructions on contacting the State Agency/Certification Bureau when a fire watch was conducted or required.

An interview with the maintenance staff during review revealed that a fire watch was conducted on 3/5/12, but the State Agency was not notified. Staff member A confirmed that their policy did not include contacting the State Agency when the sprinkler system was out of service for 4 hours within 24 hour period.

Based on review of the fire watch policy and interview, the facility did not have a fire watch policy which included contacting the authority having jurisdiction (State Agency Certification Bureau at 406-444-4170) whenever a fire watch was instituted when the fire alarm control panel was out of service.

In accordance with the 2000 Edition of NFPA 101 Section 9.7.6.1, where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction (State Agency) also be notified.

Findings include:

A copy of the Interim Life Safety Policy was reviewed on 5/22/12 with staff member A and it included fire watch procedures. However, the procedures lacked information/instructions on contacting the State Agency/Certification Bureau when a fire watch was conducted or required.

An interview with the maintenance staff during review revealed that a fire watch was conducted on 3/5/12, but the State Agency was not notified. Staff member A confirmed that their policy did not include contacting the State Agency when the fire alarm system was out of service for 4 hours within 24 hour period.

Based on observation, the facility did not prevent the installation of an Alcohol Based Hand Rub (ABHR) dispenser directly over or near an ignition source.

Findings include:

In accordance with CMS interpretations (Ref: S&C-05-33) issued on June 9, 2005 Alcohol Based Hand Rub (ABHR) dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. The State Agency (SA) enforces that ABHR dispensers be offset by at least one inch and not mounted above any electrical source.

On 5/23/12 at 10:25 a.m., the ABHR dispenser was observed above and next to the light switch in the Lab. Alcohol sanitizer solution found in the dispenser was in liquid gel form.

Based on observation, the facility did not ensure the fire barrier having 4-hour resistance rating was properly maintained between the two nonconforming building/occupancy types.

1. The fire barrier separating the old hospital from the clinic/CAH addition of 1994 was required to be maintained with a 4- hour construction. The 3-hour fire rated door with a self closure device found in this separation was exercised at 2:34 p.m. on 5/22/12. The door failed to self close when exercised three consecutive times. The maintenance staff A and B verified this finding who were accompanying the surveyor at the time of the observation.

2. On 5/23/12 at 3:16 p.m., four open ended conduits, measuring approximately 3-inches in diameter, carrying communication cables, penetrated fire rated wall between the new "2-3 HVAC room" and the 60's building.

Based on observations, the facility did not ensure the fire resistive construction of all corridor walls to be resistant to the passage of smoke.

Findings include:

In accordance with Section 19.3.6.2.1 of NFPA 101, corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

1. On 5/22/12 at 1:41 p.m. an open ended conduit, measuring approximately 2 inches in diameter, housing several communication cables, penetrated the corridor wall from the "Main Electrical" into the service hall to Radiology.

2. On 5/23/12 at 9:00 a.m., an unsealed open conduit penetrated the exit corridor wall (north side) on "Med/Surge". Staff member B sealed the penetration with fire rated material after he was notified of the concern.

3. On 5/23/12 at 10:35 a.m., an unsealed open ended conduit measuring approximately 3 inches in diameter, housing several communication cables, penetrated the 1- hour rated exit corridor wall above the north entrance door of the "Lab".

4. On 5/23/12 at 10:39 a.m. an unsealed open ended conduit penetrated the 1-hour rated exit corridor wall above the entrance door to the Surgery.

Based on observation, the facility did not ensure vertical openings between floors were sealed and/or enclosed by fire resistive construction of 1-hour rating.

Findings included:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition, pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

On 5/23/12 at 3:11 p.m., several unsealed floor/vertical penetrations around conduits carrying communication cables were observed in an electrical/phone room on the second floor where the main fire alarm control panel was located on the "Med/Surge" wing.

Based on observations, the facility did not maintain or establish the fire rated protection for areas with potential hazards.

Findings include:

In accordance with section 39.3.2.1 of NFPA 101, LSC, 2000 Edition; Existing Business Occupancies, hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with 8.4.

In accordance with Section 8.4.1.1 of NFPA 101, LSC, 2000 Edition; protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by the following: Enclose the area with a fire barrier that has a 1-hour fire resistance rating, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 8.4.1.3 of NFPA 101 LSC.

Hazardous areas must be separated from non-hazardous areas with 1-hour rated wall and ceiling assemblies.

1. On 5/23/12 at 7:20 a.m., two medical records storage rooms were observed on the third floor of the 60's building. None of the rooms' corridor doors had self closure devices. The doors had 90 minute fire ratings.

2. On 5/23/12 at 1:59 p.m., an unsealed wall penetration (that appeared to be previously repaired) was observed in the boiler room of the 60's building. Orange colored pipes as well as communication cables and the fire alarm panel cables (red) entered this penetration in the boiler room's north wall. The penetration was not sealed with proper fire rated material from the other side (crawl space) as well.

Based on observations, the facility did not maintain the fire alarm system in accordance with the standards of NFPA 72, 1999 edition.

Findings include:

The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit per section 1-5.2.5.2 of NFPA 72, 1999 edition.

A Notifier model NFS-2 3030 Fire Alarm Control Panel (FACP) located in the communication room on the "Med/Surg" wing was observed at 3:11 p.m. on 5/23/12. The disconnect means for the normal power serving this FACP was not identified in a red colored marking at the panel identified as 2LSB.

Based on observations, the facility did not ensure the automatic sprinkler system and/or its components in accordance with NFPA 13.

Findings include:

On 5/22/12 at 1:53 p.m. no wrench was observed in the supply cabinet holding sprinkler parts which supplied the sprinkler system at the location of the main sprinkler risers in the boiler room of the new building.

Based on observation, the facility did not maintain portable fire extinguishers in accordance with the standards of NFPA 10, 1998 Edition.

Findings include:

1. In accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 Edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

At 3:17 p.m. on 5/22/12, the fire extinguisher #40 found in the exit hallway near the Director of Medical Practice Operation office was hanging at 64.5 inches (from the top of the unit).

Based on observation, the facility did not maintain portable fire extinguishers in accordance with the standards of NFPA 10, 1998 Edition.

Findings include:

In accordance with 39.3.5 of NFPA 101 LSC 2000 Edition, portable fire extinguishers shall be provided in every business occupancy in accordance with NFPA 10.

In accordance with 1-6.6 and 4-3.2 of NFPA 10 fire extinguishers shall not be obstructed or obscured from view and no obstruction to access or visibility will impair the periodic inspection of fire extinguishers.

On 5/23/12 at 8:04 a.m., a fire extinguisher was found behind the entrance door to the Cardiac Rehabilitation on the third floor of the 60's building. The door had a magnetic hold device and was held open. If the door was not exercised for proper latching and closure, the fire extinguisher could not be discovered behind it. If this door was kept open, as observed on 5/22/12 and 5/23/12, during the building operating hours, no one could have a proper visual on the fire extinguisher.

Based on observation the facility failed to meet the standards of either NFPA 70 or NFPA 99 in regards to electrical service in the building.

Findings include:

1. On 5/23/12 at 9:28 a.m., circuit breakers 9, 11, and 13 were in off positions in electrical panel 2MA located in the mechanical room at the south OB entrance. These circuit breakers were not marked as spares in the panel directory. Additionally, the circuit breakers 6-24 in the electrical panel 2EQC, located in the same area, were not marked as spares in the panel directory although they were in the off position.

2. On 5/23/12 at 10:50 a.m., circuit breaker #21 was in the on position in the electrical panel 2CPA in the surgical suite; however, the panel directory did not identify what breaker #21 serviced.

Based on observation the facility failed to meet the standards of either NFPA 70 or NFPA 99 in regards to electrical service in the building.

Findings include:

In accordance with 39.5.1 of NFPA 101 LSC 2000 Edition, utilities shall comply with the provisions of NFPA 70 and 99.

In accordance with 240-4 of the NFPA 70 (1999 edition), 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 edition) and previous interpretations from CMS (transmittal notice dated 3-30-99) extension cords or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing surge strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings. The listed ampere rating of these strips or adaptors are based upon the use of one strip only, not several strips or adaptors in a series.

1. On 5/22/12 at 3:00 p.m., a small refrigerator was plugged into a surge protector in the PT reception office. Staff member B confiscated the unit.

2. On 5/22/12 at 3:05 p.m., a three receptacle/single plug in adaptor was found in the PT room. Staff member B confiscated the unit.

Based on review of the fire watch policy and interview, the facility did not have a fire watch policy which included contacting the authority having jurisdiction (State Agency/Certification Bureau at 406-444-4170) whenever a fire watch was instituted when the sprinkler system was out of service.

In accordance with the 2000 Edition of NFPA 101 Section 9.7.6.1, where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the automatic sprinkler system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the Interim Life Safety Policy was reviewed on 5/22/12 with staff member A and it included fire watch procedures. However, the procedures lacked information/instructions on contacting the State Agency/Certification Bureau when a fire watch was conducted or required.

An interview with the maintenance staff during review revealed that a fire watch was conducted on 3/5/12, but the State Agency was not notified. Staff member A confirmed that their policy did not include contacting the State Agency when the sprinkler system was out of service for 4 hours within 24 hour period.

Based on review of the fire watch policy and interview, the facility did not have a fire watch policy which included contacting the authority having jurisdiction (State Agency Certification Bureau at 406-444-4170) whenever a fire watch was instituted when the fire alarm control panel was out of service.

In accordance with the 2000 Edition of NFPA 101 Section 9.7.6.1, where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction (State Agency) also be notified.

Findings include:

A copy of the Interim Life Safety Policy was reviewed on 5/22/12 with staff member A and it included fire watch procedures. However, the procedures lacked information/instructions on contacting the State Agency/Certification Bureau when a fire watch was conducted or required.

An interview with the maintenance staff during review revealed that a fire watch was conducted on 3/5/12, but the State Agency was not notified. Staff member A confirmed that their policy did not include contacting the State Agency when the fire alarm system was out of service for 4 hours within 24 hour period.