HospitalInspections.org

A. From random observation, the surveyors finds that fire separations between the hospital and other occupancies are incomplete, Findings include:

1. Ground Floor. Receiving Department is open to a non compliant pre-engineered building addition containing unprotected steel members and insulated infill panels which appear to be Construction Type II, 000. A continous 2-hour fire rated separation is not present between the Hospital's Construction Type I (332) in order to comply with NFPA 220 and NFPA 101 19.1.6.3.

2. First Floor, Temporary Main Entry connection between the Hospital and the Medical Office Building (MOB). This is a one story connection with a construction type of unprotected steel and infill glass panels addition that appears to be Type II (000). The surveyor was informed that this area is a Business Occupancy, however, there is no continuous 2-hour separation between the Hospital construction type (I, 332) and this area to comply with 19.1.2.1. Refer to K-Tag 044 item A.2.

A. Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. Portions of the steel structure were observed that are not covered by fire proofing materials in accordance with the designated UL Design. Location observed, 7th floor at the 2 hour separation from the Psychiatric Unit, above the cross corridor doors.

A. Based on random observation during the survey walk-through and staff interview, not all wall finishes in the corridors and exitways could be verified as carrying a flame spread rating of Class A or B in accordance with 19.3.3.1. Findings include:

1. 5th floor, East and West wings were unoccupied at the time of this inspection. The West wing is being remodeled with finish upgrades. Documentation as to what finishes have been installed, or the flame spread ratings of the current upgrades were not available for review.

2. 1st floor, Exit Access Corridors contain wood paneling, which do not appear to meet a Class A or B flame spread rating.

A. Based on random observation during the survey walk-through not all finishes in the corridors and exitways could not be verified as carrying a flame spread rating of Class A or B in accordance with 10.3. The finding is:

The fabric at the covered exitway which appears to be connected to the building (side entry) could not be verified as to is flame spread rating. (39.3.3.2.)

A. Based on random observation during the survey walk-through, not all means of egress are separated from patient use areas to comply with 7.2.1.5.4. Locations observed:

The treatment area doors were not equipped with positive latching door hardware. (39.2.2.2)

A. From random observation, the surveyor finds that spaces open to corridors do not comply with the exceptions under 19.3.6.1:

Second Floor Endoscopy (Inpatient/Outpatient) has patient recovery/holding bays that are open to the adjacent corridor. This condition does not comply with 19.3.6.1. Based upon this, the surveyor finds that this space is very likely intended to be a health care suite (treatment suite). No information is provided that identifies this space as a suite (see K048). The size and boundaries of the suite are not clearly identified.

A. Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. Findings include:

1. 7th floor, Kitchen / Dumbwaiter room, the 1 1/2 hour fire rated corridor door was observed to be damaged / defaced around the handle. The fire resistance integrity of this door can not be verified.

2. 2nd floor, Recovery contains cross corridor horizontal sliding doors, the first door is activated by a floor mat, the second door is activated from a wall plate. During the fire alarm test the 2nd door did not reset and remained open, which does not comply with 7.2.1.9.



20224


B. Based on random observation the surveyor finds that corridor doors through out the facility lack positive latching hardware to comply with 19.3.6.3.2. Example locations and conditions observed include the following:

1. 2nd Floor O. R. area, (facility life safety plans do not indicate this area to be a suite) the following corridor doors lack latching hardware to comply with 19.3.6.3.2

a. The door leading to O.R. # 3 room 266 (contains multiple combustible materials-being used as "equipment storage") lacks latching hardware and is not self closing to comply with 19.3.2.1 for a hazardous area.
b. The door leading to Suture Storage (contains multiple combustible materials) lacks latching hardware and is not self closing to comply with 19.3.2.1 for a hazardous area.
c. The door leading to Clean Storage (contains multiple combustible materials) lacks latching hardware and is not self closing to comply with 19.3.2.1 for a hazardous area.

2. 2nd Floor ICU rooms, the doors leading from each room(horizontal sliding doors) to the adjacent corridor (facility life safety plans do not indicate this area to be a suite) lacks latching hardware.

3. First Floor Emergency Dept. Fracture room, the door leading from the corridor (facility life safety plans do not indicate this area to be a suite) lacks latching hardware.

4. First Floor Lab - Multiple room doors leading from the corridor (facility life safety plans do not indicate this area to be a suite) lack latching hardware.


C. Based on random observation during the survey walk through corridor doors were observed being held open by unapproved devices which does not comply with 19.3.6.3.2. Example locations observed:

1. First floor Lab room # 1012
2. First floor Waiting # 176A
3. First floor Nuclear Med. Locker room

A. Based on random observation during the survey walk-through, not all ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. Location observed:

7th floor, Unisex bathroom by nursing station, contains a 1 1/2 hour rated access hatch. The door frame was installed on open cut block, which does not appear to be an approved UL design installation. The hatch door was not self closing (spring has been removed).(8.2.3.2.3.1)



20224


B. Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. Location observed:

2nd Floor Mechanical room 237A, 8th Floor Penthouse - approximately 20inch diameter blue colored duct extends vertically through Mechanical room 237A. Surveyor was informed that the duct "might be Exhaust #13" associated with Pharmacy Chemotherapy Hood. This duct appears to terminate in the penthouse at the 8th floor, however, it is open to various mechanical rooms on each floor. This duct does not appear to be enclosed within a continuous 2-hour fire rated shaft to comply with 8.2.5.4 (1).

A. Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. Location and condition as follows:

7th floor, Communication closet by the bank of 4 elevators. The LSC drawing indicates the closet containing one hour rated corridor walls. A large unsealed penetration was observed on the North wall of the closet.

A. Based on random observation during the survey walk through, not all areas having a degree of hazard greater than that normal to the general occupancy, are separated from the remainder of the building to comply with 19.3.2.1. Findings as follows:

1. Blanket warmers which are considered to be potentially fire / smoke-producing pieces of equipment, were observed that are in areas open to an exit access corridor which does not comply with 19.3.2.1.

a. 4th floor by Mechanical Room (437A) a blanket warmer is located in the exit acces corridor of a non-sprinkler protected area.

b. 2nd floor, there is a blanket warmer located through the exit corridor wall by Room 383.

2. 3rd floor, Soiled Utility (385) is a hazardous area enclosed by one hour rated construction. The fire rating labels located on the top of both doors, have been painted. The door ratings could not be verified as meeting NFPA 101, 8.2.3.2.3.1.

3. 5th floor, Pulmonary Clinic, appears to be a business use within a hospital occupancy. The clinic contains a large fire load due to the number of files being stored in this area. The clinic is not separated by 2 hour rated construction as required by 19.1.2.3 or 1 hour required for a hazardous area (19.3.2.1) the space is not provided with sprinkler protection

B. 5th floor, Pulmonary Clinic, is a business use within a hospital occupancy. The clinic "suite" contains a large fire load due to the number of files being stored in this area. The clinic is not separated by 2 hour rated construction as required by 19.1.2.3 or 1 hour required for a hazardous area (19.3.2.1) the space is not provided with sprinkler protection.



20224


C. Based on random observation during the survey walk through, not all areas having a degree of hazard greater than that normal to the general occupancy, are separated from the remainder of the building to comply with 19.3.2.1.

1. Basement Level: Storage room adjacent to Room B-9 Maintenance Repair, the corridor wall contains an approximate 10"x12" through wall transfer grill. This installation does not comply with 19.3.6.4. "Regardless of whether they are protected by fusible link - operated dampers", transfer grills are not allowed within corridor walls.

2. Basement Level: (The compartment containing the "Old Laundry and the exit access corridor is not fully sprinkler protected). "Old Laundry" area currently under construction, lacks separation from the exit access corridor due to two openings in the North wall (3'x7' and 3'x3') which contain plastic fabric tarps to separate the construction from the corridor. The construction area is a hazardous location and lacks a fire rated separation to comply with 8.4.1.1 (1).

3. Basement Level: "Incinerator Room" located adjacent to the Boiler room, contains multiple holes in the fire rated perimeter wall. The holes are located above the entry door from the exit access corridor.

D. Based on random observation during the survey walk through, not all areas having a degree of hazard greater than that normal to the general occupancy, are separated from the remainder of the building to comply with 19.3.2.1. Due to the lack of complying corridor entry doors the following hazardous areas are not compliant:

1. Basement Level: Storage room adjacent to Room B-9 Maintenance Repair lacks a self closing door.

2. Basement Level: Fire Pump room lacks a fire rated U.L. labeled door.

3. Basement Level: Boiler room upper level adjacent to the incinerator chimney, contains a storage room with a door containing a noncompliant hold open device (a string tied to the door handle and attached to the wall) and is not self closing due to the lack of a door closer.

E. Based on random observation during the survey walk through, not all hazardous areas are separated from the exit access route. The Facility Life Safety Plans designate the Basement Level as a Business Occupancy (the Basement is not fully sprinkler protected). The Life Safety plans do not distinguish between walls and fences for the separation of hazardous areas. The surveyor observed spaces greater than 100 square feet with a fence used for separation from the exit access route. The amount of stored combustible items open to the designated exit route does not comply with 39.3.2 and 8.4 for a means of fire rated separation.

A. Based on random observation during the survey walk-through, not all hazardous area were separated as required by NFPA 101, 39.3.2.1 and 8.4. Observations include;

Front mechanical room contains unsealed wall penetrations on the East and West walls. The corrugated metal ceiling to wall connection could not be verified as being sealed to maintain the fire/smoke separation.

A. Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. Locations observed:

1. Stair referred to as Unit A, North Stair contains direct entry to mechanical rooms at two separate levels (3rd and 4th) which does not comply with 7.1.3.2.1.

2. The facility does not comply with 7.7.1 or 7.7.2 for the required number of exits permitted to discharge through areas on the level of exit discharge. Of the five stairs observed, three contain non compliant exit components. Stairs serving upper floor levels discharge as follows:
A. Unit B Central stair discharges to the interior of the building on the first floor.
B. Unit B East Stair discharges to an exit passageway.
C. Unit B West Stair discharges on the first floor to the MOB with a deficient discharge.
D. Unit A Center stair discharges interior to a non compliant exit passageway.
E. Unit A North Stair discharges interior to a non compliant exterior discharge.

B. Based on random observation during the survey walk through it was noted that not all exit components are provided with elements which maintain the fire resistant rating of the enclosure. Surveyor observed in numerous locations exit door hardware components which contained a brass knob.
Example locations observed:

1. First floor level "Forum" Stair entry door.

C. Based on random observation during the survey walk through not all exit components are protected from exposure to wall openings in other parts of the building. Location observed:

Basement floor level and all levels above - Exiting Stair from Basement "Laurndry" contains windows within the stairway which are not fire resistant to maintain the stair enclosure. These windows do not comply with 8.2.5.4 and 7.2.2.5.2 for exposure to building window openings that are within 10 feet of the stair and at an angle of less than 180 degrees.

D. Based upon random observation ,the surveyor finds that vertical opening and protection of vertical openings are not installed and maintained in accordance with Section 8.2.3.2 and 8.2.5: Location observed: Basement Floor, Stair adjacent to Paint shop, contains ductwork passing through the Stair that do not serve the stair. Due to the location of the duct penetration within the Paint Shop wall the surveyor was unable to determine the presence of a damper installation.

A. Based on random observation during the survey walk-through, the stair identification signs in stairs serving five or more stories were not installed in the proper location or provided with the information required by NFPA 101, 7.2.2.5.4. Findings include:

1. Stair identification signs throughout the facility were observed to be improperly placed because they are not readily visible whether the door is in the open or closed position. They are also required to be located 5'-0" above the finished floor.

2. Stair identification signs throughout the facility were observed to not include all required information. The signs must include, Stair Identification, indicate the floor level of the landing, where the stairwell terminates at the top and bottom, identify and show the direction to the exit discharge.

A. Based upon random observation during the survey walk through, travel distances to exits do not appear to comply with 19.2.6. for buildings which are not fully sprinkler protected. The maximum travel distance to the nearest exit shall not exceed 100'. Location observed:

Second Floor ICU, patient sleeping rooms located along the South East side of the ICU appear to be provided with a travel distance to the nearest exit that appears to exceed 150 feet and does not comply with 19.2.6.2.2. The Stair located on the East end of ICU has a 46" wide corridor that does not comply with 19.2.3.3. Therefore, this Stair cannot be counted as an exit stair for the ICU.

A. Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

1. Doors were equipped with a thumbturn deadbolt retractors, thus requiring more than one door releasing operation as prohibited by 7.2.1.5.4. as observed in the following locations:

a. 1st floor, Chapel sacristy, both exits0
b. 1st floor, Doctors lounge (104)

B. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. locations include:

1. 4th floor, North End, exits signs are not provided to indicate a clear path of egress. There by producing a dead-end corridor condition.

2. 3rd floor, Corridor outside the Nursery does not contain two means of exit, creating a 76' dead-end corridor.


20224


C. Based upon random observation, the surveyors find that paths of egress within a Business Occupancy (as shown on the facility Life Safety Plans) are not provided and maintained as a protected path to a public way.

1. The Basement Level contains multiple locations where the common path of travel exceeds the maximum in order to comply with 39.2.5.3 for distance to an exit. Example locations include but are not limited to:

a. Refuse Discharge room.
b. Soiled Linen room located in the South West corner of the floor plan.
c. Corridor adjacent to the Boiler room and the Incinerator room.

D. Based on random observation during the survey walk through, there are numerous designated exit access corridors with one means of egress which does not comply with 19.2.5.9. Further the exception provided under 19.2.5.10 for permitted dead end corridors to remain does not appear to apply. Example locations observed:

1. There is a east/west exit access corridor that connects the emergency department to the "convenient care" (convenient care has limited hours) with a designated exit door at the end of the corridor. However, signage on the door states that it is "employees only". On the wall adjacent to this door is a card reader. The surveyor observed a staff member swipe her card to leave. However, the surveyor was informed that the card reader had been disabled. This corridor appears to be an extremely long dead end corridor and does not comply with 19.2.5.9 or meet the exception provided in 19.2.5.10.

2. Second Floor corridor leading to ICU and Endoscopy.

A. Based on observation, the surveyors finds that the various areas appear to be a patient sleeping suites (see K038 and K048). However, there do not appear to be two remote exit access doors to comply with 19.2.5.2. Example location observed:

1. Second Floor ICU, does not appear to have two remote exits.

2. Second Floor ICU, appears to exceed the maximum 5000 square feet permitted for a patient sleeping suite to comply with 19.2.5.6.


B. Based on observation, the surveyors finds that the various areas appear to be non-sleeping suites (see K038 and K048). However, there do not appear to be two remote exit access doors to comply with 19.2.5.2. Example location observed:

1. Second Floor Endoscopy. The exit path to the South is not permitted due to the excessive dead end corridor condition that would be produced by providing a suite at the end of a corridor. Location of the corridor is adjacent to the ICU waiting room (refer to K-Tag 038).

2. Second Floor O.R. area appears to exceed 10, 000 in order to comply with 19.2.5.7.

A. Based on random observation during the survey walk-through, not all designated or requiredfire barriers are constructed or maintained as fire resistive assemblies. Findings include;

1. Door hardware does not meet the UL rating for the door opening. The hardware can compromise the integrity of the door. Areas observed include:

a. 3rd floor, East Hall at the 2 hour rated "business" separation, the door rating is for 30 minutes and not 1 1/2 hours as required by 8.2.3.2.3.1 (1).

b. 1st floor, there are 3 sets of cross corridor doors located in 2 hour rated walls. The door hardware only latches into the top frame, instead of a 3 point latching system. It is not clear if this hardware will meet with the 2 hour fire rating.(NFPA 80, 1990, 3-8 and 4-5)

B. Duct penetration through fire rated wall and/or floor assemblies were observed that are not equipped with fire dampers as required by NFPA 101, 8.2.3.2.4.2., because access panels required by NFPA 90A (1999) 2.3.4.1 were not available. Locations observed include:

1. 7th floor, Mechanical Room 737, the two hour rated wall contains a duct penetration. The duct lacks an access panel to verify the existence of a damper at this location.

2. 6th floor, Soiled Utility room at the nursing station, contains a Main AHU trunk line that penetrates the rated wall of this hazardous area. The duct lacks an access panel to verify the existence of a damper at this location.

3. 5th floor, Mechanical Room, two large ducts penetrate the two hour rated corridor wall. The duct lacks an access panel to verify the existence of a damper at this location.

4. 3rd floor, Cross corridor doors by LDR 6, the 2 hour rated wall contains a duct penetration without an access panel to verify the existence of a damper.



20224


C. Based on random observation during the survey walk through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. Locations observed:

1. Stair referred to as Unit A Center Stair at first floor level - discharges internally to an exit passageway which contains unoccupied storage rooms directly connected to the exit passageway. This does not comply with 7.1.3.2.1 (d) for access from normally occupied spaces.

2. (complaint investigation survey dated 9/22/10) Stair referred to as Unit B West Stair contains an interior vestibule which serves as the temporary Hospital Main Entry and exits to the MOB. The provided Life Safety Floor Plans designate a 2-hour separation between the two buildings. The surveyor observed existing unrated glazing and mullions within the designated 2- hour barrier (appears that this was once an exterior wall). Location observed above the ceiling of the barrier on the Hospital side of the vestibule.
This does not comply with 19.1.2.1 and 19.1.6.2 for construction type requirements for a Hospital facility.

UPDATE: During the survey walk through (as a follow up to the complaint investigation survey dated 9/22/10) the designated 2-hour fire rated barrier was re-designated to the East wall at the Medical Office Building (MOB) side of the vestibule. The re-designation is not complete.
The temporary Hospital Main Entry is considered as part of the Hospital building and not the MOB. Therefore, refer to K-Tag 051 and K-Tag 011 for deficiencies associated with the lack of a 2-hour barrier between construction types.

A. Exterior egress paths were observed that are not provided with light fixtures containing 2 lamps. So that the failure of 1 lamp will not leave the egress path in darkness. (NFPA 101, 7.8.1.4.)

A. Emergency lighting from the linear accelerator room as part of the means of egress could not be verified to meet with a lighting level to comply with NFPA 101, 7.9.2.1.

A. Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1 and 7.10.

Exit path were not clearly identified or marked as observed due to the lack of exit signs. Locations include the 6th floor, Unit A, North end Prairie Heart, the exit path by cross corridor doors to the waiting area.

A. Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases to comply with 39.2.9 and 7.10. Location observed:

The exit sign above the main entry door was not illuminated at the time of this survey.

A. The fire evacuation plans are not posted for patients and visitors or available as part of the facilities fire drill process to comply with chp 4 of NFPA 101.

A. The facility's Life Safety Code Master Plan (latest plan-dated November 23, 2010) was unclear and not legible. Information is not available that is necessary to identify compliance with smoke barriers and complying smoke compartments.

1. Does not include the size (area) of each smoke compartment.

2. The line quality and size of the of the floor plans on the drawing sheets were difficult to read. Locations and sizes of "suites" could not be verified.

3. Designations for sprinklered and non sprinklered areas as shown on the Life Safety Code Master plan does not match what the surveyors have observed during the facility walk through.

4. The designation of hazardous areas in sprinklered and non sprinklered compartments is not complete. For example the boiler room, the incinerator room, the refuse and soiled linen discharge rooms and large storage areas.

A. Based on random observation during the survey walk-through and staff interview, not all portions of the building fire alarm system are installed in accordance with 19.3.4 findings include:

On the morning of 12/1/10, the fire alarm system within the adjacent Medical Office Building was activated. The alarm was not annunciated within the hospital. During an interview held in the Hospital's Temporary Main Lobby at the time of the incident the provider's staff and local fire department stated that the fire alarm system had been activated by a faulty smoke detector located within that Lobby. It is noted that, because it is not separated from the remainder of the Hospital by minimum 2 hour fire rated construction in accordance with 19.1.1.4.1., the Temporary Main Lobby is within the Hospital. Therefore, the activation of the smoke detector did not initiate the Hospital's fire alarm system as required by 9.6.2.1.


17659


B. By random observation the surveyor finds: The fire alarm panel in substation #1 does not have a smoke detector located above it to comply with NFPA-72-1-5.6.


20224


C. During document review and staff interview, concerning the Inspection and Testing of the Fire Alarm System a written statement under the remarks section, of a current inspection (dated 6-28-2010) read that "21 dampers could not be accessed due to construction".
During discussion with the facility representatives, the facility understood that the next testing and maintenance of these dampers will be required upon completion of the project building addition.

Therefore, the facility does not yet have a current complete Fire Alarm Inspection of the existing facility to comply with NFPA 72.

Interim Life Safety Measures are to be implemented prior to the completion of testing and maintenence.


26665


D. Based on random observation during the survey walk-through, not all portions of the facilities fire alarm system are installed in accordance with NFPA 72 1999. Elevator equipment rooms were observed without smoke detection installed in accordance with 3-9.3.7 (c).

A. Based on random observation during the document review process, documentation of annual sprinkler inspection from the floor level was not available in accordance with NFPA 25 1998 2-2.1.1.

A. Based on random observation during the survey walk-through, not all portion of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999. Findings Include:

1. 7th Floor, Southeast Storage Closet off of #10 Elevator Lobby, materials were observed being stored less than 18" below sprinkler heads as prohibited by NFPA 13, 5-6.6.


17659


B. Based on random observation during the survey walk-through not all portion of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA-13 (1999). The findings include:

1. The fire pump normal electrical service is not tapped ahead of the building main service disconnect as required by NFPA-70-695-3(a)(1).

2. The transfer switch for the fire pump is not located at the pump location as required by NFPA- 20-6-6.5, and NFPA-70-695-12.

3. The fire pump disconnect is not lockable as required by NFPA-70-695-4(b)(2).

4. The fire pump room is not equipped with a telephone outlet as required by NFPA-72-3-8.4.1.3.7.6.

5. The local and remote alarm for the fire pump does not monitor the four points required by NFPA-20-7-4.6 and 7-4.7.

6. The fire pump disconnect is not properly marked as required by NFPA-70-4(b)(3).


26665


C. Based on random observation during the survey walk-through, and fire alarm test, not all portions of the automatic sprinkler system are installed in accordance with NFPA 13 1999 and NFPA 25 1998. Findings include:

1. A sprinkler inspectors test valve was used to trigger a flow alarm which left copious amounts of water around the janitors floor sink in the 5th floor janitors closet, thus not in accordance with 5-15.4.2.

2. Control valves throughout the facility were observed chained in the open position and not electrically supervised in accordance with NFPA 13 5-14.1.1.3 (1).

3. Sprinkler control valves were observed without identification signs describing the area controlled in accordance with NFPA 25 9-3.2.

4. Sprinkler valves were observed without tags to identify the component of the sprinkler system in accordance with 3-8.3.

A. Based on random observation during the survey walk-through, not all portion of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999. Rooms and spaces within a "fully sprinklered" facility were observed that lack sprinkler protection. Area observed is the Main Entry Vestibule.


B. Due to the lack of a finished ceiling, as well as the distance of the sprinkler head from the wall, proper sprinkler coverage of the Housekeeping closet. could not be verified.

A. Based on random observation, not all portions of the automatic sprinkler system are continuously maintained and tested periodically in accordance with 19.7.6. findings include:

1. Escutcheon rings missing from recessed sprinklers NFPA 25, 1998, 2-4.1.8:

a. 3rd floor, Bath 341, all three sprinkler heads in this room were missing the escutcheon rings.

b. 3rd floor, Linen Room 377, escutcheon ring missing


B. The sprinkler heads were coated with dust as prohibited by NFPA 25, 1998, 2-2.1.1.

1. 3rd floor, Nurses Lounge / locker room

2. 3rd floor, Linen Room 377

A. Based on random observation during the survey walk through, staff interview, and document review, not all portions of the facility's air conditioning and ventilation systems are installed and maintained to comply with NFPA 90A 1999.

1. Location observed - 7th Floor MedSurg wing, 5th Floor at Central Nurses Station - 4 inch diameter through floor duct penetrations serving the induction ventilation units on floors 2 thru 7 contain a sheet metal collar and fire caulk at the floor. However, the main trunk line enters a vertical shaft enclosure without a fire rated damper installation at the shaft to comply with NFPA 90A 1999, 3-3.4.

2. Location observed - Third floor shaft enclosure directly West across the corridor from a pair of Elevators and an exit Stair. There are dampers installed at the Second Level through floor, however, where the ducts leave the shaft at the Third floor, there are no dampers installed to comply with NFPA 90A.

3. Location observed - Second floor shaft enclosure located within the "Pain Center" adjacent to a janitor closet toward the East Stair. The vertical duct installations lack damper protection at the floor or where the duct penetrates the shaft above the corridor's finished ceiling. This installation does not comply with NFPA 90A.

4. Location observed - Ground Floor Medical Records Storage adjacent to room # G-5 contains two ducts penetrating the corridor wall above the entry door which lack damper installations.

5. Location observed - Basement pump room - two large ducts penetrate the room from the corridor side for which dampers could not be verified due to the lack of access panels.

6. Location observed - Basement Laundry room (not the "old laundry room") two large ducts penetrate the south wall which lack damper installations.


26665


7. The janitors closet B-24 was observed with an exhaust duct penetrating a 2-hour wall without a fire damper installed in accordance with 3-3.1.1.

A. Based on random observation and staff interview, not all portions of the facilities commercial cooking equipment are installed and maintained in accordance with NFPA 96 1998. Findings include:

1. The dietary department grease filters in the exhaust hood were found that were not held firmly in place in accordance with 3-2.3.

2. The dietary department access to the hood exhaust duct was removed and an accumulation of dust and grease were observed. During an interview with the Maintenance Supervisor and the Director of Dietary Services it was discovered the hood had been cleaned in October 2010 by a contracted service. Cleaning in accordance with NFPA 96 8-3.1 had not been completed at the time of the survey.

A. Based upon random observation during the survey walk through that the linen and refuse chute discharge rooms located in the Basement are not protected and maintained to comply with NFPA 82 1999. Findings include the following:

1. A sheet metal duct penetrates the fire resistant wall of the Refuse room between this room and the Soiled Linen discharge room. This duct lacks a damper in order to maintain the 2-hour fire resistant ratining of the room.

2. A sheet metal duct penetrates the ceiling of the Soiled Linen discharge room. The surveyor was unable to locate the duct above this floor to determine that a through floor damper is installed.


B. Based upon random observation during the survey walk through not all linen and refuse chutes are separated from other parts of the buildings to comply with NFPA 82 1999, 3-2.4.3. It was observed that throughout the building, chute service openings are located at exit access corridors.

Example locations are First Floor, Nuclear Medicine, and Ground Floor, Corridor adjacent to Switchboard Operator's Room and 4th floor, adjacent to the Nurses Station.. The access doors lack the following requirements:

a. The doors do not lock
b The doors at most locations are not self closing
c. The doors lack a U.L. listed label to identify the fire resistance rating of the access door to comply with 8.2.3.2.3.1.

A. Based upon random observation, in multiple corridors on multiple floors, the surveyor finds that exit access corridors are obstructed by gurneys, computers on wheels, equipment, linen storage carts, etc. These objects obstruct paths of egress which does not comply with 19.2.3.3. and 7.1.10.2.2.

1. First floor Emergency Department

2. Second floor Surgery Department

3. First floor Lab

A. Based on random observation during the survey walk-through, trash and soiled linen container sizes and locations exceed the requirements of NFPA 101, 19.7.5.5. Area observed, 6th floor Cath Lab, procedure room contains 4 (32 gal carts) for linens and trash located within the same 64 square foot area.

A. The Surveyor finds that manual medical gas shutoff (zone) valves were located in the same room as the station outlets and inlets they serve which does not comply with NFPA 99 1999 4.3.1.2.3.(d).
Locations observed:

1. Second Floor - Recovery room - the manual
medical gas shutoff (zone) valve is located on the East wall of this area adjacent to office areas and is open to the station outlets within the patient bays.

2. 3rd floor, Recovery (378) the medical gas shut off is not physically seperated from the patients it serves. There is no door separating the shut off from the patient care area it serves.

A. By random observation the surveyor finds:

1. The emergency stop switches are located within the same room as the generators and do not meet the requirements of NFPA-110-3-5.5.6.

2. The generator room does not have selected receptacles located at the generator set location connected to the life safety branch of the of the emergency power system as required by NFPA-70-517-32(e).

3. The generator remote annunciator does not have all of the required remote alarm points as required by NFPA-99-3-4.1.1.15, and NFPA-110.

4. Medical air equipment and ductwork are located in the generator room which does not comply with NFPA-110 and NFPA-99. This room shall be dedicated to generator equipment only.

5. Since the load on the essential electrical system is over 150 KVA, Transfer switches are required to be dedicated to either the life safety branch, the critical branch, or the equipment branch of the emergency power system in accordance with NFPA-99-3-4.2.2.1, and NFPA-70-517-30(b)(4), and Figure 517-30(b).

A. 4.6.10 Construction, Repair, and Improvement Operations; 4.6.10.1 "Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place."

Hourly fire watches are conducted due to an ongoing construction project (which has been submitted to this Division). Due to this project, the fire alarm system is at various locations and times is shut down. The facility does monitor the system during construction; however, after 3:30pm the fire alarm system is put back on line. Documentation provided by the facility does not indicate the following:

1. A remote station (fire department) acknowledges the system being placed in trouble or when it is back on line.

2. The Fire Watch logs do not indicate deficiencies observed or abated. The Facility lacks a written protocol and schedule for all such measures.

3. The narrative does not describe all measures to be implemented, as well as the frequency with which they are to be conducted nor the manner in which the measures are to be documented.

4. Comments related to changes in the interim life safety measures to remain in place as work toward the project completion occurs are not present.


B. Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. Based on random observation during the survey walk-through the building emergency electrical system is not divided into Life Safety, Critical, and Equipment Branches as required by NFPA-99 (1999) and NFPA-70 (1999). The findings include:

1. Throughout the facility panelboards and transfer switches are not clearly labeled as life safety, critical or equipment branch, and the loads served are not limited to the specific branch of emergency power required by NFPA-99-3-4.2.2.2 and 4.2.2.3.

2. The ICU rooms have all receptacles on the bedroom headwall served from the same emergency circuit and do not have a normal power receptacle in accordance with NFPA-70-517-19(b)(1).

3. The intermediate care rooms on the fourth floor are require to have an emergency receptacle on the headwall at each bed location to meet the requirements of NFPA-99-3-4.2.2.2(c)8.a.

A. 4th floor, IMC patient room in the North Wing are not provided with emergency electrical outlets on the head wall.


17659


B. Based on random observations during the survey walk-through not all portions of the building electrical systems are installed in accordance with NFPA-70 (1999). The findings include:

1. In the basement and penthouse low voltage wiring was tied to conduit and piping rather than independently supported in accordance with NFPA-70-300-11.

2. In several location in the basement, electrical closets and substations equipment was stored around electrical panels blocking the working clearance required by NFPA-70-110.

3. The panel in the forth floor mechanical room needs blanks added were breakers are missing to comply with NFPA-70.

4. Several panels throughout the facility need panel schedules updated and in some cases such as the panel in the Pulmonary Clinic the schedule was missing. NFPA-70-384-13.

5. Panels throughout the building other than those in the seventh floor alcove adjacent to the mechanical room need to be marked as normal, life safety, critical or equipment branch to comply with NFPA-70-700-9 and NFPA-99.

6. Test records were not available for isolated power systems in accordance with NFPA-99-3-3.3.4.2.


20224


C. Based on random observation during the survey walkthrough the use of electrical chord adapters at Stage I PACU do not appear to comply with NFPA 70 1999 and NFPA 99, 1999 for a complete grounded U.L. listed assembly. Location observed: Second Floor Recovery located adjacent to the Surgery Department and Endoscopy.


26665


D. The emergency department patient exam/treatment rooms were observed with a total of 4 outlets and not 6 outlets in accordance with 517-19 (b) 1.

A. Safety Code for Elevators and Escalators ASME A17.1a - 1994 rule 1206.7 "All elevators provided with firefirghters' service shall be subjected monthly to Phase I recall and a minimum of one-floor operation on Phase II to assure the system is maintained in proper operating order. A written record of findings on the operation shall be made and kept on the premises of said operation".

1. The existing Elevator #10 was referred to as having no automatic fire department recall. This Surveyor observed the Annual inspection report from an outside vender, which indicated that all elevators within the building with the exception of the freight elevator contain both phase I and II fire fighter recall. However, the facility does not comply with 9.4.6 for a monthly documented inspection of their elevators. Upon requesting these documents and stating that a recall test could be conducted, representative for maintenance commented that they had not dealt with the elevators in 4 years. The representative was unable to clarify the primary floor level or the secondary floor level for elevator recall. Therefore, the surveyor did not conduct a test of elevator recall.

A. Improper installation of alcohol gel dispensers were observed in the following locations:

1. 7th floor, Storage room 726, the alcohol gel was adjacent to a light switch and above an electrical outlet in a room where Oxygen tanks are being stored.

2. 5th floor, Dumbwaiter, behind the corridor door the alcohol gel was above the switch to operate the dumbwaiter.

A. From random observation, the surveyors finds that fire separations between the hospital and other occupancies are incomplete, Findings include:

1. Ground Floor. Receiving Department is open to a non compliant pre-engineered building addition containing unprotected steel members and insulated infill panels which appear to be Construction Type II, 000. A continous 2-hour fire rated separation is not present between the Hospital's Construction Type I (332) in order to comply with NFPA 220 and NFPA 101 19.1.6.3.

2. First Floor, Temporary Main Entry connection between the Hospital and the Medical Office Building (MOB). This is a one story connection with a construction type of unprotected steel and infill glass panels addition that appears to be Type II (000). The surveyor was informed that this area is a Business Occupancy, however, there is no continuous 2-hour separation between the Hospital construction type (I, 332) and this area to comply with 19.1.2.1. Refer to K-Tag 044 item A.2.

A. Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. Portions of the steel structure were observed that are not covered by fire proofing materials in accordance with the designated UL Design. Location observed, 7th floor at the 2 hour separation from the Psychiatric Unit, above the cross corridor doors.

A. Based on random observation during the survey walk-through and staff interview, not all wall finishes in the corridors and exitways could be verified as carrying a flame spread rating of Class A or B in accordance with 19.3.3.1. Findings include:

1. 5th floor, East and West wings were unoccupied at the time of this inspection. The West wing is being remodeled with finish upgrades. Documentation as to what finishes have been installed, or the flame spread ratings of the current upgrades were not available for review.

2. 1st floor, Exit Access Corridors contain wood paneling, which do not appear to meet a Class A or B flame spread rating.

A. Based on random observation during the survey walk-through not all finishes in the corridors and exitways could not be verified as carrying a flame spread rating of Class A or B in accordance with 10.3. The finding is:

The fabric at the covered exitway which appears to be connected to the building (side entry) could not be verified as to is flame spread rating. (39.3.3.2.)

A. Based on random observation during the survey walk-through, not all means of egress are separated from patient use areas to comply with 7.2.1.5.4. Locations observed:

The treatment area doors were not equipped with positive latching door hardware. (39.2.2.2)

A. From random observation, the surveyor finds that spaces open to corridors do not comply with the exceptions under 19.3.6.1:

Second Floor Endoscopy (Inpatient/Outpatient) has patient recovery/holding bays that are open to the adjacent corridor. This condition does not comply with 19.3.6.1. Based upon this, the surveyor finds that this space is very likely intended to be a health care suite (treatment suite). No information is provided that identifies this space as a suite (see K048). The size and boundaries of the suite are not clearly identified.

A. Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. Findings include:

1. 7th floor, Kitchen / Dumbwaiter room, the 1 1/2 hour fire rated corridor door was observed to be damaged / defaced around the handle. The fire resistance integrity of this door can not be verified.

2. 2nd floor, Recovery contains cross corridor horizontal sliding doors, the first door is activated by a floor mat, the second door is activated from a wall plate. During the fire alarm test the 2nd door did not reset and remained open, which does not comply with 7.2.1.9.



20224


B. Based on random observation the surveyor finds that corridor doors through out the facility lack positive latching hardware to comply with 19.3.6.3.2. Example locations and conditions observed include the following:

1. 2nd Floor O. R. area, (facility life safety plans do not indicate this area to be a suite) the following corridor doors lack latching hardware to comply with 19.3.6.3.2

a. The door leading to O.R. # 3 room 266 (contains multiple combustible materials-being used as "equipment storage") lacks latching hardware and is not self closing to comply with 19.3.2.1 for a hazardous area.
b. The door leading to Suture Storage (contains multiple combustible materials) lacks latching hardware and is not self closing to comply with 19.3.2.1 for a hazardous area.
c. The door leading to Clean Storage (contains multiple combustible materials) lacks latching hardware and is not self closing to comply with 19.3.2.1 for a hazardous area.

2. 2nd Floor ICU rooms, the doors leading from each room(horizontal sliding doors) to the adjacent corridor (facility life safety plans do not indicate this area to be a suite) lacks latching hardware.

3. First Floor Emergency Dept. Fracture room, the door leading from the corridor (facility life safety plans do not indicate this area to be a suite) lacks latching hardware.

4. First Floor Lab - Multiple room doors leading from the corridor (facility life safety plans do not indicate this area to be a suite) lack latching hardware.


C. Based on random observation during the survey walk through corridor doors were observed being held open by unapproved devices which does not comply with 19.3.6.3.2. Example locations observed:

1. First floor Lab room # 1012
2. First floor Waiting # 176A
3. First floor Nuclear Med. Locker room

A. Based on random observation during the survey walk-through, not all ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. Location observed:

7th floor, Unisex bathroom by nursing station, contains a 1 1/2 hour rated access hatch. The door frame was installed on open cut block, which does not appear to be an approved UL design installation. The hatch door was not self closing (spring has been removed).(8.2.3.2.3.1)



20224


B. Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. Location observed:

2nd Floor Mechanical room 237A, 8th Floor Penthouse - approximately 20inch diameter blue colored duct extends vertically through Mechanical room 237A. Surveyor was informed that the duct "might be Exhaust #13" associated with Pharmacy Chemotherapy Hood. This duct appears to terminate in the penthouse at the 8th floor, however, it is open to various mechanical rooms on each floor. This duct does not appear to be enclosed within a continuous 2-hour fire rated shaft to comply with 8.2.5.4 (1).

A. Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. Location and condition as follows:

7th floor, Communication closet by the bank of 4 elevators. The LSC drawing indicates the closet containing one hour rated corridor walls. A large unsealed penetration was observed on the North wall of the closet.

A. Based on random observation during the survey walk through, not all areas having a degree of hazard greater than that normal to the general occupancy, are separated from the remainder of the building to comply with 19.3.2.1. Findings as follows:

1. Blanket warmers which are considered to be potentially fire / smoke-producing pieces of equipment, were observed that are in areas open to an exit access corridor which does not comply with 19.3.2.1.

a. 4th floor by Mechanical Room (437A) a blanket warmer is located in the exit acces corridor of a non-sprinkler protected area.

b. 2nd floor, there is a blanket warmer located through the exit corridor wall by Room 383.

2. 3rd floor, Soiled Utility (385) is a hazardous area enclosed by one hour rated construction. The fire rating labels located on the top of both doors, have been painted. The door ratings could not be verified as meeting NFPA 101, 8.2.3.2.3.1.

3. 5th floor, Pulmonary Clinic, appears to be a business use within a hospital occupancy. The clinic contains a large fire load due to the number of files being stored in this area. The clinic is not separated by 2 hour rated construction as required by 19.1.2.3 or 1 hour required for a hazardous area (19.3.2.1) the space is not provided with sprinkler protection

B. 5th floor, Pulmonary Clinic, is a business use within a hospital occupancy. The clinic "suite" contains a large fire load due to the number of files being stored in this area. The clinic is not separated by 2 hour rated construction as required by 19.1.2.3 or 1 hour required for a hazardous area (19.3.2.1) the space is not provided with sprinkler protection.



20224


C. Based on random observation during the survey walk through, not all areas having a degree of hazard greater than that normal to the general occupancy, are separated from the remainder of the building to comply with 19.3.2.1.

1. Basement Level: Storage room adjacent to Room B-9 Maintenance Repair, the corridor wall contains an approximate 10"x12" through wall transfer grill. This installation does not comply with 19.3.6.4. "Regardless of whether they are protected by fusible link - operated dampers", transfer grills are not allowed within corridor walls.

2. Basement Level: (The compartment containing the "Old Laundry and the exit access corridor is not fully sprinkler protected). "Old Laundry" area currently under construction, lacks separation from the exit access corridor due to two openings in the North wall (3'x7' and 3'x3') which contain plastic fabric tarps to separate the construction from the corridor. The construction area is a hazardous location and lacks a fire rated separation to comply with 8.4.1.1 (1).

3. Basement Level: "Incinerator Room" located adjacent to the Boiler room, contains multiple holes in the fire rated perimeter wall. The holes are located above the entry door from the exit access corridor.

D. Based on random observation during the survey walk through, not all areas having a degree of hazard greater than that normal to the general occupancy, are separated from the remainder of the building to comply with 19.3.2.1. Due to the lack of complying corridor entry doors the following hazardous areas are not compliant:

1. Basement Level: Storage room adjacent to Room B-9 Maintenance Repair lacks a self closing door.

2. Basement Level: Fire Pump room lacks a fire rated U.L. labeled door.

3. Basement Level: Boiler room upper level adjacent to the incinerator chimney, contains a storage room with a door containing a noncompliant hold open device (a string tied to the door handle and attached to the wall) and is not self closing due to the lack of a door closer.

E. Based on random observation during the survey walk through, not all hazardous areas are separated from the exit access route. The Facility Life Safety Plans designate the Basement Level as a Business Occupancy (the Basement is not fully sprinkler protected). The Life Safety plans do not distinguish between walls and fences for the separation of hazardous areas. The surveyor observed spaces greater than 100 square feet with a fence used for separation from the exit access route. The amount of stored combustible items open to the designated exit route does not comply with 39.3.2 and 8.4 for a means of fire rated separation.

A. Based on random observation during the survey walk-through, not all hazardous area were separated as required by NFPA 101, 39.3.2.1 and 8.4. Observations include;

Front mechanical room contains unsealed wall penetrations on the East and West walls. The corrugated metal ceiling to wall connection could not be verified as being sealed to maintain the fire/smoke separation.

A. Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. Locations observed:

1. Stair referred to as Unit A, North Stair contains direct entry to mechanical rooms at two separate levels (3rd and 4th) which does not comply with 7.1.3.2.1.

2. The facility does not comply with 7.7.1 or 7.7.2 for the required number of exits permitted to discharge through areas on the level of exit discharge. Of the five stairs observed, three contain non compliant exit components. Stairs serving upper floor levels discharge as follows:
A. Unit B Central stair discharges to the interior of the building on the first floor.
B. Unit B East Stair discharges to an exit passageway.
C. Unit B West Stair discharges on the first floor to the MOB with a deficient discharge.
D. Unit A Center stair discharges interior to a non compliant exit passageway.
E. Unit A North Stair discharges interior to a non compliant exterior discharge.

B. Based on random observation during the survey walk through it was noted that not all exit components are provided with elements which maintain the fire resistant rating of the enclosure. Surveyor observed in numerous locations exit door hardware components which contained a brass knob.
Example locations observed:

1. First floor level "Forum" Stair entry door.

C. Based on random observation during the survey walk through not all exit components are protected from exposure to wall openings in other parts of the building. Location observed:

Basement floor level and all levels above - Exiting Stair from Basement "Laurndry" contains windows within the stairway which are not fire resistant to maintain the stair enclosure. These windows do not comply with 8.2.5.4 and 7.2.2.5.2 for exposure to building window openings that are within 10 feet of the stair and at an angle of less than 180 degrees.

D. Based upon random observation ,the surveyor finds that vertical opening and protection of vertical openings are not installed and maintained in accordance with Section 8.2.3.2 and 8.2.5: Location observed: Basement Floor, Stair adjacent to Paint shop, contains ductwork passing through the Stair that do not serve the stair. Due to the location of the duct penetration within the Paint Shop wall the surveyor was unable to determine the presence of a damper installation.

A. Based on random observation during the survey walk-through, the stair identification signs in stairs serving five or more stories were not installed in the proper location or provided with the information required by NFPA 101, 7.2.2.5.4. Findings include:

1. Stair identification signs throughout the facility were observed to be improperly placed because they are not readily visible whether the door is in the open or closed position. They are also required to be located 5'-0" above the finished floor.

2. Stair identification signs throughout the facility were observed to not include all required information. The signs must include, Stair Identification, indicate the floor level of the landing, where the stairwell terminates at the top and bottom, identify and show the direction to the exit discharge.

A. Based upon random observation during the survey walk through, travel distances to exits do not appear to comply with 19.2.6. for buildings which are not fully sprinkler protected. The maximum travel distance to the nearest exit shall not exceed 100'. Location observed:

Second Floor ICU, patient sleeping rooms located along the South East side of the ICU appear to be provided with a travel distance to the nearest exit that appears to exceed 150 feet and does not comply with 19.2.6.2.2. The Stair located on the East end of ICU has a 46" wide corridor that does not comply with 19.2.3.3. Therefore, this Stair cannot be counted as an exit stair for the ICU.

A. Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

1. Doors were equipped with a thumbturn deadbolt retractors, thus requiring more than one door releasing operation as prohibited by 7.2.1.5.4. as observed in the following locations:

a. 1st floor, Chapel sacristy, both exits0
b. 1st floor, Doctors lounge (104)

B. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. locations include:

1. 4th floor, North End, exits signs are not provided to indicate a clear path of egress. There by producing a dead-end corridor condition.

2. 3rd floor, Corridor outside the Nursery does not contain two means of exit, creating a 76' dead-end corridor.


20224


C. Based upon random observation, the surveyors find that paths of egress within a Business Occupancy (as shown on the facility Life Safety Plans) are not provided and maintained as a protected path to a public way.

1. The Basement Level contains multiple locations where the common path of travel exceeds the maximum in order to comply with 39.2.5.3 for distance to an exit. Example locations include but are not limited to:

a. Refuse Discharge room.
b. Soiled Linen room located in the South West corner of the floor plan.
c. Corridor adjacent to the Boiler room and the Incinerator room.

D. Based on random observation during the survey walk through, there are numerous designated exit access corridors with one means of egress which does not comply with 19.2.5.9. Further the exception provided under 19.2.5.10 for permitted dead end corridors to remain does not appear to apply. Example locations observed:

1. There is a east/west exit access corridor that connects the emergency department to the "convenient care" (convenient care has limited hours) with a designated exit door at the end of the corridor. However, signage on the door states that it is "employees only". On the wall adjacent to this door is a card reader. The surveyor observed a staff member swipe her card to leave. However, the surveyor was informed that the card reader had been disabled. This corridor appears to be an extremely long dead end corridor and does not comply with 19.2.5.9 or meet the exception provided in 19.2.5.10.

2. Second Floor corridor leading to ICU and Endoscopy.

A. Based on observation, the surveyors finds that the various areas appear to be a patient sleeping suites (see K038 and K048). However, there do not appear to be two remote exit access doors to comply with 19.2.5.2. Example location observed:

1. Second Floor ICU, does not appear to have two remote exits.

2. Second Floor ICU, appears to exceed the maximum 5000 square feet permitted for a patient sleeping suite to comply with 19.2.5.6.


B. Based on observation, the surveyors finds that the various areas appear to be non-sleeping suites (see K038 and K048). However, there do not appear to be two remote exit access doors to comply with 19.2.5.2. Example location observed:

1. Second Floor Endoscopy. The exit path to the South is not permitted due to the excessive dead end corridor condition that would be produced by providing a suite at the end of a corridor. Location of the corridor is adjacent to the ICU waiting room (refer to K-Tag 038).

2. Second Floor O.R. area appears to exceed 10, 000 in order to comply with 19.2.5.7.

A. Based on random observation during the survey walk-through, not all designated or requiredfire barriers are constructed or maintained as fire resistive assemblies. Findings include;

1. Door hardware does not meet the UL rating for the door opening. The hardware can compromise the integrity of the door. Areas observed include:

a. 3rd floor, East Hall at the 2 hour rated "business" separation, the door rating is for 30 minutes and not 1 1/2 hours as required by 8.2.3.2.3.1 (1).

b. 1st floor, there are 3 sets of cross corridor doors located in 2 hour rated walls. The door hardware only latches into the top frame, instead of a 3 point latching system. It is not clear if this hardware will meet with the 2 hour fire rating.(NFPA 80, 1990, 3-8 and 4-5)

B. Duct penetration through fire rated wall and/or floor assemblies were observed that are not equipped with fire dampers as required by NFPA 101, 8.2.3.2.4.2., because access panels required by NFPA 90A (1999) 2.3.4.1 were not available. Locations observed include:

1. 7th floor, Mechanical Room 737, the two hour rated wall contains a duct penetration. The duct lacks an access panel to verify the existence of a damper at this location.

2. 6th floor, Soiled Utility room at the nursing station, contains a Main AHU trunk line that penetrates the rated wall of this hazardous area. The duct lacks an access panel to verify the existence of a damper at this location.

3. 5th floor, Mechanical Room, two large ducts penetrate the two hour rated corridor wall. The duct lacks an access panel to verify the existence of a damper at this location.

4. 3rd floor, Cross corridor doors by LDR 6, the 2 hour rated wall contains a duct penetration without an access panel to verify the existence of a damper.



20224


C. Based on random observation during the survey walk through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. Locations observed:

1. Stair referred to as Unit A Center Stair at first floor level - discharges internally to an exit passageway which contains unoccupied storage rooms directly connected to the exit passageway. This does not comply with 7.1.3.2.1 (d) for access from normally occupied spaces.

2. (complaint investigation survey dated 9/22/10) Stair referred to as Unit B West Stair contains an interior vestibule which serves as the temporary Hospital Main Entry and exits to the MOB. The provided Life Safety Floor Plans designate a 2-hour separation between the two buildings. The surveyor observed existing unrated glazing and mullions within the designated 2- hour barrier (appears that this was once an exterior wall). Location observed above the ceiling of the barrier on the Hospital side of the vestibule.
This does not comply with 19.1.2.1 and 19.1.6.2 for construction type requirements for a Hospital facility.

UPDATE: During the survey walk through (as a follow up to the complaint investigation survey dated 9/22/10) the designated 2-hour fire rated barrier was re-designated to the East wall at the Medical Office Building (MOB) side of the vestibule. The re-designation is not complete.
The temporary Hospital Main Entry is considered as part of the Hospital building and not the MOB. Therefore, refer to K-Tag 051 and K-Tag 011 for deficiencies associated with the lack of a 2-hour barrier between construction types.

A. Exterior egress paths were observed that are not provided with light fixtures containing 2 lamps. So that the failure of 1 lamp will not leave the egress path in darkness. (NFPA 101, 7.8.1.4.)

A. Emergency lighting from the linear accelerator room as part of the means of egress could not be verified to meet with a lighting level to comply with NFPA 101, 7.9.2.1.

A. Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1 and 7.10.

Exit path were not clearly identified or marked as observed due to the lack of exit signs. Locations include the 6th floor, Unit A, North end Prairie Heart, the exit path by cross corridor doors to the waiting area.

A. Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases to comply with 39.2.9 and 7.10. Location observed:

The exit sign above the main entry door was not illuminated at the time of this survey.

A. The fire evacuation plans are not posted for patients and visitors or available as part of the facilities fire drill process to comply with chp 4 of NFPA 101.

A. The facility's Life Safety Code Master Plan (latest plan-dated November 23, 2010) was unclear and not legible. Information is not available that is necessary to identify compliance with smoke barriers and complying smoke compartments.

1. Does not include the size (area) of each smoke compartment.

2. The line quality and size of the of the floor plans on the drawing sheets were difficult to read. Locations and sizes of "suites" could not be verified.

3. Designations for sprinklered and non sprinklered areas as shown on the Life Safety Code Master plan does not match what the surveyors have observed during the facility walk through.

4. The designation of hazardous areas in sprinklered and non sprinklered compartments is not complete. For example the boiler room, the incinerator room, the refuse and soiled linen discharge rooms and large storage areas.

A. Based on random observation during the survey walk-through and staff interview, not all portions of the building fire alarm system are installed in accordance with 19.3.4 findings include:

On the morning of 12/1/10, the fire alarm system within the adjacent Medical Office Building was activated. The alarm was not annunciated within the hospital. During an interview held in the Hospital's Temporary Main Lobby at the time of the incident the provider's staff and local fire department stated that the fire alarm system had been activated by a faulty smoke detector located within that Lobby. It is noted that, because it is not separated from the remainder of the Hospital by minimum 2 hour fire rated construction in accordance with 19.1.1.4.1., the Temporary Main Lobby is within the Hospital. Therefore, the activation of the smoke detector did not initiate the Hospital's fire alarm system as required by 9.6.2.1.


17659


B. By random observation the surveyor finds: The fire alarm panel in substation #1 does not have a smoke detector located above it to comply with NFPA-72-1-5.6.


20224


C. During document review and staff interview, concerning the Inspection and Testing of the Fire Alarm System a written statement under the remarks section, of a current inspection (dated 6-28-2010) read that "21 dampers could not be accessed due to construction".
During discussion with the facility representatives, the facility understood that the next testing and maintenance of these dampers will be required upon completion of the project building addition.

Therefore, the facility does not yet have a current complete Fire Alarm Inspection of the existing facility to comply with NFPA 72.

Interim Life Safety Measures are to be implemented prior to the completion of testing and maintenence.


26665


D. Based on random observation during the survey walk-through, not all portions of the facilities fire alarm system are installed in accordance with NFPA 72 1999. Elevator equipment rooms were observed without smoke detection installed in accordance with 3-9.3.7 (c).

A. Based on random observation during the document review process, documentation of annual sprinkler inspection from the floor level was not available in accordance with NFPA 25 1998 2-2.1.1.

A. Based on random observation during the survey walk-through, not all portion of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999. Findings Include:

1. 7th Floor, Southeast Storage Closet off of #10 Elevator Lobby, materials were observed being stored less than 18" below sprinkler heads as prohibited by NFPA 13, 5-6.6.


17659


B. Based on random observation during the survey walk-through not all portion of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA-13 (1999). The findings include:

1. The fire pump normal electrical service is not tapped ahead of the building main service disconnect as required by NFPA-70-695-3(a)(1).

2. The transfer switch for the fire pump is not located at the pump location as required by NFPA- 20-6-6.5, and NFPA-70-695-12.

3. The fire pump disconnect is not lockable as required by NFPA-70-695-4(b)(2).

4. The fire pump room is not equipped with a telephone outlet as required by NFPA-72-3-8.4.1.3.7.6.

5. The local and remote alarm for the fire pump does not monitor the four points required by NFPA-20-7-4.6 and 7-4.7.

6. The fire pump disconnect is not properly marked as required by NFPA-70-4(b)(3).


26665


C. Based on random observation during the survey walk-through, and fire alarm test, not all portions of the automatic sprinkler system are installed in accordance with NFPA 13 1999 and NFPA 25 1998. Findings include:

1. A sprinkler inspectors test valve was used to trigger a flow alarm which left copious amounts of water around the janitors floor sink in the 5th floor janitors closet, thus not in accordance with 5-15.4.2.

2. Control valves throughout the facility were observed chained in the open position and not electrically supervised in accordance with NFPA 13 5-14.1.1.3 (1).

3. Sprinkler control valves were observed without identification signs describing the area controlled in accordance with NFPA 25 9-3.2.

4. Sprinkler valves were observed without tags to identify the component of the sprinkler system in accordance with 3-8.3.

A. Based on random observation during the survey walk-through, not all portion of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999. Rooms and spaces within a "fully sprinklered" facility were observed that lack sprinkler protection. Area observed is the Main Entry Vestibule.


B. Due to the lack of a finished ceiling, as well as the distance of the sprinkler head from the wall, proper sprinkler coverage of the Housekeeping closet. could not be verified.

A. Based on random observation, not all portions of the automatic sprinkler system are continuously maintained and tested periodically in accordance with 19.7.6. findings include:

1. Escutcheon rings missing from recessed sprinklers NFPA 25, 1998, 2-4.1.8:

a. 3rd floor, Bath 341, all three sprinkler heads in this room were missing the escutcheon rings.

b. 3rd floor, Linen Room 377, escutcheon ring missing


B. The sprinkler heads were coated with dust as prohibited by NFPA 25, 1998, 2-2.1.1.

1. 3rd floor, Nurses Lounge / locker room

2. 3rd floor, Linen Room 377

A. Based on random observation during the survey walk through, staff interview, and document review, not all portions of the facility's air conditioning and ventilation systems are installed and maintained to comply with NFPA 90A 1999.

1. Location observed - 7th Floor MedSurg wing, 5th Floor at Central Nurses Station - 4 inch diameter through floor duct penetrations serving the induction ventilation units on floors 2 thru 7 contain a sheet metal collar and fire caulk at the floor. However, the main trunk line enters a vertical shaft enclosure without a fire rated damper installation at the shaft to comply with NFPA 90A 1999, 3-3.4.

2. Location observed - Third floor shaft enclosure directly West across the corridor from a pair of Elevators and an exit Stair. There are dampers installed at the Second Level through floor, however, where the ducts leave the shaft at the Third floor, there are no dampers installed to comply with NFPA 90A.

3. Location observed - Second floor shaft enclosure located within the "Pain Center" adjacent to a janitor closet toward the East Stair. The vertical duct installations lack damper protection at the floor or where the duct penetrates the shaft above the corridor's finished ceiling. This installation does not comply with NFPA 90A.

4. Location observed - Ground Floor Medical Records Storage adjacent to room # G-5 contains two ducts penetrating the corridor wall above the entry door which lack damper installations.

5. Location observed - Basement pump room - two large ducts penetrate the room from the corridor side for which dampers could not be verified due to the lack of access panels.

6. Location observed - Basement Laundry room (not the "old laundry room") two large ducts penetrate the south wall which lack damper installations.


26665


7. The janitors closet B-24 was observed with an exhaust duct penetrating a 2-hour wall without a fire damper installed in accordance with 3-3.1.1.

A. Based on random observation and staff interview, not all portions of the facilities commercial cooking equipment are installed and maintained in accordance with NFPA 96 1998. Findings include:

1. The dietary department grease filters in the exhaust hood were found that were not held firmly in place in accordance with 3-2.3.

2. The dietary department access to the hood exhaust duct was removed and an accumulation of dust and grease were observed. During an interview with the Maintenance Supervisor and the Director of Dietary Services it was discovered the hood had been cleaned in October 2010 by a contracted service. Cleaning in accordance with NFPA 96 8-3.1 had not been completed at the time of the survey.

A. Based upon random observation during the survey walk through that the linen and refuse chute discharge rooms located in the Basement are not protected and maintained to comply with NFPA 82 1999. Findings include the following:

1. A sheet metal duct penetrates the fire resistant wall of the Refuse room between this room and the Soiled Linen discharge room. This duct lacks a damper in order to maintain the 2-hour fire resistant ratining of the room.

2. A sheet metal duct penetrates the ceiling of the Soiled Linen discharge room. The surveyor was unable to locate the duct above this floor to determine that a through floor damper is installed.


B. Based upon random observation during the survey walk through not all linen and refuse chutes are separated from other parts of the buildings to comply with NFPA 82 1999, 3-2.4.3. It was observed that throughout the building, chute service openings are located at exit access corridors.

Example locations are First Floor, Nuclear Medicine, and Ground Floor, Corridor adjacent to Switchboard Operator's Room and 4th floor, adjacent to the Nurses Station.. The access doors lack the following requirements:

a. The doors do not lock
b The doors at most locations are not self closing
c. The doors lack a U.L. listed label to identify the fire resistance rating of the access door to comply with 8.2.3.2.3.1.

A. Based upon random observation, in multiple corridors on multiple floors, the surveyor finds that exit access corridors are obstructed by gurneys, computers on wheels, equipment, linen storage carts, etc. These objects obstruct paths of egress which does not comply with 19.2.3.3. and 7.1.10.2.2.

1. First floor Emergency Department

2. Second floor Surgery Department

3. First floor Lab

A. Based on random observation during the survey walk-through, trash and soiled linen container sizes and locations exceed the requirements of NFPA 101, 19.7.5.5. Area observed, 6th floor Cath Lab, procedure room contains 4 (32 gal carts) for linens and trash located within the same 64 square foot area.

A. The Surveyor finds that manual medical gas shutoff (zone) valves were located in the same room as the station outlets and inlets they serve which does not comply with NFPA 99 1999 4.3.1.2.3.(d).
Locations observed:

1. Second Floor - Recovery room - the manual
medical gas shutoff (zone) valve is located on the East wall of this area adjacent to office areas and is open to the station outlets within the patient bays.

2. 3rd floor, Recovery (378) the medical gas shut off is not physically seperated from the patients it serves. There is no door separating the shut off from the patient care area it serves.

A. By random observation the surveyor finds:

1. The emergency stop switches are located within the same room as the generators and do not meet the requirements of NFPA-110-3-5.5.6.

2. The generator room does not have selected receptacles located at the generator set location connected to the life safety branch of the of the emergency power system as required by NFPA-70-517-32(e).

3. The generator remote annunciator does not have all of the required remote alarm points as required by NFPA-99-3-4.1.1.15, and NFPA-110.

4. Medical air equipment and ductwork are located in the generator room which does not comply with NFPA-110 and NFPA-99. This room shall be dedicated to generator equipment only.

5. Since the load on the essential electrical system is over 150 KVA, Transfer switches are required to be dedicated to either the life safety branch, the critical branch, or the equipment branch of the emergency power system in accordance with NFPA-99-3-4.2.2.1, and NFPA-70-517-30(b)(4), and Figure 517-30(b).

A. 4.6.10 Construction, Repair, and Improvement Operations; 4.6.10.1 "Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place."

Hourly fire watches are conducted due to an ongoing construction project (which has been submitted to this Division). Due to this project, the fire alarm system is at various locations and times is shut down. The facility does monitor the system during construction; however, after 3:30pm the fire alarm system is put back on line. Documentation provided by the facility does not indicate the following:

1. A remote station (fire department) acknowledges the system being placed in trouble or when it is back on line.

2. The Fire Watch logs do not indicate deficiencies observed or abated. The Facility lacks a written protocol and schedule for all such measures.

3. The narrative does not describe all measures to be implemented, as well as the frequency with which they are to be conducted nor the manner in which the measures are to be documented.

4. Comments related to changes in the interim life safety measures to remain in place as work toward the project completion occurs are not present.


B. Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. Based on random observation during the survey walk-through the building emergency electrical system is not divided into Life Safety, Critical, and Equipment Branches as required by NFPA-99 (1999) and NFPA-70 (1999). The findings include:

1. Throughout the facility panelboards and transfer switches are not clearly labeled as life safety, critical or equipment branch, and the loads served are not limited to the specific branch of emergency power required by NFPA-99-3-4.2.2.2 and 4.2.2.3.

2. The ICU rooms have all receptacles on the bedroom headwall served from the same emergency circuit and do not have a normal power receptacle in accordance with NFPA-70-517-19(b)(1).

3. The intermediate care rooms on the fourth floor are require to have an emergency receptacle on the headwall at each bed location to meet the requirements of NFPA-99-3-4.2.2.2(c)8.a.

A. 4th floor, IMC patient room in the North Wing are not provided with emergency electrical outlets on the head wall.


17659


B. Based on random observations during the survey walk-through not all portions of the building electrical systems are installed in accordance with NFPA-70 (1999). The findings include:

1. In the basement and penthouse low voltage wiring was tied to conduit and piping rather than independently supported in accordance with NFPA-70-300-11.

2. In several location in the basement, electrical closets and substations equipment was stored around electrical panels blocking the working clearance required by NFPA-70-110.

3. The panel in the forth floor mechanical room needs blanks added were breakers are missing to comply with NFPA-70.

4. Several panels throughout the facility need panel schedules updated and in some cases such as the panel in the Pulmonary Clinic the schedule was missing. NFPA-70-384-13.

5. Panels throughout the building other than those in the seventh floor alcove adjacent to the mechanical room need to be marked as normal, life safety, critical or equipment branch to comply with NFPA-70-700-9 and NFPA-99.

6. Test records were not available for isolated power systems in accordance with NFPA-99-3-3.3.4.2.


20224


C. Based on random observation during the survey walkthrough the use of electrical chord adapters at Stage I PACU do not appear to comply with NFPA 70 1999 and NFPA 99, 1999 for a complete grounded U.L. listed assembly. Location observed: Second Floor Recovery located adjacent to the Surgery Department and Endoscopy.


26665


D. The emergency department patient exam/treatment rooms were observed with a total of 4 outlets and not 6 outlets in accordance with 517-19 (b) 1.

A. Safety Code for Elevators and Escalators ASME A17.1a - 1994 rule 1206.7 "All elevators provided with firefirghters' service shall be subjected monthly to Phase I recall and a minimum of one-floor operation on Phase II to assure the system is maintained in proper operating order. A written record of findings on the operation shall be made and kept on the premises of said operation".

1. The existing Elevator #10 was referred to as having no automatic fire department recall. This Surveyor observed the Annual inspection report from an outside vender, which indicated that all elevators within the building with the exception of the freight elevator contain both phase I and II fire fighter recall. However, the facility does not comply with 9.4.6 for a monthly documented inspection of their elevators. Upon requesting these documents and stating that a recall test could be conducted, representative for maintenance commented that they had not dealt with the elevators in 4 years. The representative was unable to clarify the primary floor level or the secondary floor level for elevator recall. Therefore, the surveyor did not conduct a test of elevator recall.