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Based on observations and staff interviews, the facility failed to ensure fire barriers in a common wall between two buildings, maintained at least a 2 hour fire resistance rating, and failed to ensure these communicating openings were protected by approved self-closing doors in accordance with the code at 19.1.1.4.1 and 19.1.1.4.2. This affected two floors of the facility and six areas. The facility has a total of 771 beds and a census of 433 patients.

Findings include:

A tour was conducted from 10/01/12 through 10/03/12 and on 10/09/12 with Staff AA, BB, CC, and DD. During this tour, the following fire doors in the communicating openings between buildings failed to close and latch when released from the magnetic hold open devices and/or the two hour fire rated barrier was observed with penetrations:

On the ground floor:

a) On 10/03/12 at 2:40 P.M., by waiting room G223 on the ground floor, the 2 hour fire rated barrier was observed with 5 curved conduits each of which measured 3/4 inch in diameter and contained wires. The inside of the conduits was observed open around the wires.

b) On the ground floor, between the radiology waiting room and the main hallway on 10/03/12 at 2:34 P.M., the 1 and 1/2 hour fire rated doors failed to latch when tested. The two hour fire rated barrier over the receptionist desk was observed with a 3/4 inch open conduit.

c) On 10/03/12 at 2:57 P.M., on the ground floor between the Radiology and Medical Science Building. Staff AA verified the electrified strike plate was working improperly, resulting in the fire doors not latching into the frame.

On the Basement level:

d) On 10/03/12 at 2:55 P.M., the two hour fire wall by B101 at the CCP building, was observed with a one foot high by 8 inch wide opening around the tube system.

e) The malfunctioning fire doors in the two hour fire rated barrier by Stair 6-B, failed to latch when tested on 10/03/12 at 4:20 P.M.

These doors and fire wall penetrations were verified with Staff AA, BB, CC, and DD during tour. Staff CC stated these fire doors had a preventative maintenance sticker on them with a date of 09/2012 when they had been inspected by the facility.

Based on interview and observation, the facility failed to ensure each dutch door that opened onto a corridor was equipped with a latching device on both the upper and lower leaf, in accordance with NFPA 101, 19.3.6.3.6. This has the potential to affect all 443 patients and their visitors.

Findings:
On 10/02/12 at 2:00 P.M. the third floor was toured with Staff HH and II. The tour revealed the floor contained a neonatal intensive care unit consisting of a suite of multiple bassinettes. The tour revealed a pharmacy with a door that opened onto corridor 3013. The door was a dutch door. The upper part of the dutch door was observed not to have a latching device.
On 10/02/12 at 2:00 P.M. in an interview Staff II confirmed the finding.

Based on observation and interview, the facility failed to ensure either the door to the chute room (2007A) or to the chute itself was maintained in accordance with NFPA 101, 9.5.2, and NFPA 82 (3-2.1). This has the potential to affect all patients and family present for same day surgery.
Findings:
On 10/10/12 at 3:30 P.M. a tour was conducted on the second floor of the building with Staff HH and II. The tour revealed the door to the chute room unlocked.
In an interview during the tour, Staff HH confirmed the observation.

Based on observations and staff interviews, the facility failed to ensure one stairwell door automatically closed and latched when tested in accordance with the code at 19.2.2.2.6.. This door was located on the on the 6th floor of the the facility. University Hospital has a capacity of 771 with a census of 433 at the time of survey.

Findings include:

On 10/05/12, between 10:15 A.M. and 12:50 A.M., a tour was conducted of the facility with Staff AA, BB, LLC, and MM. The stairwell door for Stair 6, located by patient room 676 failed to close automatically and latch into the frame when tested at 11:30 A.M.

This stairwell door was verified with the aforementioned staff on tour. Staff LL stated the door should have latched when tested.

Based on observations and staff interviews, the facility failed to ensure access to exits was marked in accordance with the code at 7.10.1.4 with approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent. This affected 3 exit access doors. The facility has a total of 771 beds and a census of 433 patients.

Findings include:

On 10/05/12, between 10:15 A.M. and 12:50 A.M., a tour was conducted of the facility with Staff AA, BB, LLC, and MM.

During the tour, observations revealed the exit access doors, located in the corridor by patient room 760 and 560 lacked an approved readily visible exit sign. These exit access doors were located approximately 9 feet from the next exit access door which was equipped with an exit sign. This exit sign was not readily visible from inside the other exit access door by patient room 760 or 560. Both of these exit access doors led to an elevator lobby and Stair 4.

On the seventh floor, an exit access door located by patient room 791 lacked an exit sign. Staff A verified this was a designated exit, stating the door should have an exit sign located above it.

The lack of these exit signs was verified by Staff AA on tour. This employee stated these exit access doors were designated exits and should have exit signs in place.

Based on observation and interview, the facility failed to ensure the integrity of the smoke barriers on the ground, 2nd, 3rd, 6th, 8th, and 9th floors. This has the potential to affect all 443 patients and their visitors.

Findings:
On 10/01/12 at 2:10 P.M. a tour was conducted of the 9th floor with Staff II and HH. The tour revealed a penetration in the south wall of room 9051, which is a part of the smoke barrier dividing the floor used for sleeping patients. The penetration was above a return air duct.
On 10/01/12 at 2:10 P.M. in an interview Staff HH confirmed the finding.
On 10/02/12 at 8:25 A.M. the tour of the 8th floor with Staff II and HH was continued. The tour revealed the floor is used for sleeping patients and is divided by a smoke barrier running from the southwest to the northeast. Over the double doors near room 8012 (on the schematic) was a fist-sized opening above a cable conduit tray.
Over the door perpendicular to room 8058 (on the schematic) an open junction box was observed. The open box had a conduit leading into it from the smoke barrier. The conduit was unsealed.
Over the double doors near room 8032 (on the schematic) there was an annular space surrounding blue wire.
On 10/02/12 at 8:25 A.M. this observation was confirmed by Staff HH during the tour.
On 10/02/12 at 9:45 A.M. a tour was conducted of the 6th floor with Staff II and HH. The tour revealed the floor in use by sleeping patients, and was divided by a smoke barrier running east to west. The tour revealed that part of the barrier in room 6042 contained an open junction box with an unstopped conduit leading to it from the barrier.
On 10/02/12 at 9:45 A.M. the observation was confirmed by Staff HH.
On 10/02/12 at 2:00 P.M. a tour of the 3rd floor was conducted with Staff HH and II. The tour revealed the floor contained a neonatal intensive care unit consisting of a single suite with multiple bassinettes.
Review of the floor ' s schematic revealed the floor was divided by a smoke barrier that ran, roughly, from the northwest to the northeast.
The tour revealed in the smoke barrier near room 3011 revealed a conduit with blue wiring and a fist-sized opening.
On 10/02/12 at 2:00 P.M. in an interview Staff HH found a fire stopping bag and said the contractor forgot to put it back into the conduit.
On 10/03/12 at 9:00 A.M. a tour was conducted of the 2nd floor with Staff HH and II. The tour revealed the floor to contain a surgical intensive care unit and waiting area. Based on tour and review of the floor ' s schematic, the floor was observed to be divided by a smoke barrier that ran from east to west. Near room 2141 the barrier was observed to be pierced by an abandoned tube station tube.
Above the double doors, and above the door closest to room 2062, a penetration approximately two feet in length above a heating and ventilation duct was observed.
In an interview during the tour on 10/03/12 at 9:00 A.M. Staff HH confirmed the findings on the 2nd floor.
On 10/03/12 at 10:55 A.M. a tour was conducted of the ground floor with Staff HH and II. Review of the floor ' s schematic and observation revealed the floor contained suites to treat emergency room patients and was divided by a smoke barrier that ran from the northwest quadrant to the southeast quadrant.
During the tour, room G045, an area used by social workers, was observed to share a wall with the smoke barrier. That part of the wall was observed to have a two inch by two inch square and flexible conduit without fire stopping material.
During the tour the smoke barrier was observed to separate the triage area from the care area by a door and wall above it. Observation of the wall above it revealed a conduit with approximately a two inch annular space around it.
In an interview during the tour of 10/03/12 at 10:55 A.M. Staff HH confirmed the findings on the ground floor.

Based on observations and staff interviews, the facility failed ensure one of four smoke barrier doors were self-closing in accordance with 19.2.2.2.6. The facility has a total of 771 beds and a census of 433 patients.

Findings include:

A tour was conducted on 10/09/12, between 12:55 A.M. and 3:10 P.M., with Staff AA, BB, CC, DD, and RR. During this tour, the following smoke barrier doors located by operating room 21 and the scrub area 2105 failed to close and latch when released from the automatic hold open device. These doors were located in the corridor in the operating room area of the building on the second floor.

The aforementioned staff verified these smoke barrier doors should have latched, but failed to latch when tested.

Based on observations and staff interview, the facility failed to ensure one soiled utility room on the seventh floor was equipped with a self-closing device in accordance with the code at 19.3.2.1. The facility has a total of 771 beds and a census of 433 patients. The number of inpatient psychiatric beds in this facility (Deaconess West) was 72.

Findings include:

On 10/05/12, between 10:15 A.M. and 12:50 A.M., a tour was conducted of the facility with Staff AA, BB, LLC, MM, and NN. The soiled utility room 736 was labeled biohazard, and was observed with soiled linen and biohazard trash. The door lacked a self-closing device in order to self close and latch the door into the frame. Staff NN stated this room was routinely used to store biohazard trash and soiled linen.

Based on observations and staff interviews, the facility failed to ensure exit access was arranged so that exits were readily accessible at all times in accordance with code section 7.1. The exit accesses were located in the Deaconess West inpatient psychiatric building. This involved 3 of 3 inpatient floors which had two delayed egress locks in the path of egress. The facility has a total of 771 beds and a census of 433 patients. The number of inpatient psychiatric beds in this facility (Deaconess West) was 72.

Findings include:

On 10/05/12, between 10:15 A.M. and 12:50 A.M., a tour was conducted of the facility with Staff AA, BB, LLC, MM, and NN. During the tour, observations revealed on each of the three inpatient floors (5th, 6th, and 7th) the egress corridors were equipped with two exit access doors each which were located approximately 9 feet apart. These doors were located on each of the three inpatient floors (5th, 6th, and 7th) by rooms 560, 660, and 760. Each of these exit access doors required a staff member to use a key to unlock the doors.

Interview with Staff NN, during tour, revealed the facility policy was for staff to unlock only one door at a time, then relock that door before unlocking the second door, in order to prevent patients from leaving the inpatient units. During tour, staff were observed exiting the inpatient units by unlocking only one door at at time, and relocking the door before proceeding to unlock the next exit access door in the path of egress.

Based on observation and interview, the facility failed to maintain a suite of rooms for the neonatal intensive care unit on the third floor, the surgical intensive care unit on the second floor, and for the emergency department on the ground floor, to less than 5000 square feet according to National Fire Protection Association 101 Chapter 19.2.5.6. This has the potential to affect all 443 patients and their visitors.
Findings:
On 10/2/12 at 2:00 P.M. a tour was conducted of the third floor with Staff HH and II. The tour revealed the floor to contain a neonatal intensive care unit. The review revealed the floor to contain its bassinettes throughout a suite. Review of the schematic revealed the area of the suite to be 16,728 square feet.
In an interview during the tour, Staff HH and II confirmed the nature of the bassinettes distributed throughout the suite.
On 10/11/12 at 9:45 A.M. a tour was conducted of the second floor with Staff BB and Staff II. Review of the schematic and observation revealed the floor was used for surgical intensive care patients.
In an interview with Staff II and BB during the tour, they stated the suite of surgical intensive care beds was 8,893 square feet.
On 10/11/12 at 10:05 a tour was conducted of the ground floor of the building. The tour revealed the area was used for the treatment of emergency patients divided into three sections called Pod A, B, and D. These pods were observed to contain multiple curtained areas with patient beds within used for treatment.
In an interview with Staff II and BB during the tour, they stated the POD A, B, and D area comprised 10,166 square feet within the emergency room.

Based on observations and staff interviews, the facility failed to ensure one exit discharge was arranged so that the failure of any single lighting fixture would not leave the area in darkness in accordance with section 19.2.8. and 7.8.1.3. The facility has a total of 771 beds and a census of 433 patients.

Findings include:

During tour of the facility on 10/03/12 at 11:40 AM, a tour was conducted with Staff BB in the Wall Street Deli. An exit discharge was observed at the west end of the dining area. Located directly outside the exit discharge were three steps leading up to a sidewalk that turned left (180 degrees). The travel distance was then approximately 9 more feet to the public way. There was no evidence of exit discharge lighting outside the exit and to the public way. This was verified with Staff BB on tour

Based on observation and interview, the facility failed to ensure to have an exit sign marking an additional path of egress from the same day surgery suite. This has the potential to affect all patients and family present for same day surgery.
Finding:
On 10/10/12 at 3:30 P.M. a tour was conducted on the second floor of the building with Staff HH and II. The tour revealed a same day surgery suite that had two paths of egress: a northern one that led to stair 1, and a south one that led out of the suite to a corridor that led to stairway 6. This southern path of egress did not have an exit sign within the suite.
In an interview during the tour on 10/10/12 at 3:30 P.M. Staff II confirmed the finding.

Based on review of fire drills and staff interviews, the facility failed to fire drills were conducted quarterly on each shift in accordance with the code at 19.7.1.2. This involved the first shift in the second quarter and on the second shift of the first quarter of 2012 for the 5th floor. The facility has a total of 771 beds and a census of 433 patients. The number of inpatient psychiatric beds in this facility (Deaconess West) was 72.

Findings include:

On 10/05/12, between 10:15 A.M. and 12:50 A.M., a review of fire drills was conducted in the presence of Staff LL, AA, BB, and MM. There was no documentation of a fire drill conducted on the first shift of the second quarter of 2012 for the 5th floor inpatient unit. The facility also lacked documentation of a fire drill on the second shift of the first quarter of 2012 for 5 Frersing unit. This was verified with Staff LL at the time of tour who stated fire drills should be conducted on each of the three shifts on a quarterly basis. An interview was conducted with Staff WW (Safety Officer) on 10/12/12 at 10:00 A.M. Staff WW stated there was no documentation of these aforementioned fire drills.

Based on observation and interview, the facility failed to ensure the cleanliness of sprinkler heads located on the 4th and ground floors. This has the potential to affect all 443 patients and their visitors.
Findings:
On 10/02/12 at 1:33 P.M. the 4th floor was toured with Staff HH and II. Tour of the floor revealed room 4021, a conference room, to contain three sprinkler heads coated with dust, each located near a ventilation vent.
On 10/02/12 at 1:33 P.M. the observation of the 4th floor was confirmed by Staff HH.
On 10/03/12 at 10:55 A.M. a tour was conducted of the ground floor with Staff HH and II. During the tour room G017, a biohazard room, room G015, a bathroom, and room G014, an environmental services closet, were observed to have dirty sprinkler heads.
In an interview during the tour on 10/03/12 at 10:55 A.M. Staff HH confirmed the observations of the ground floor.
On 10/11/12 at 10:05 A.M. a second tour was conducted of the ground floor with Staff II and Staff BB. During the tour dusty sprinkler heads were observed in room G031/curtain 11 in Pod A, and at the nursing station in Pod D.
In an interview during the tour, Staff BB confirmed the additional findings of the ground floor.

Based on observations and staff interviews, the facility failed to ensure fire inspections were conducted at approximately 30-day intervals in accordance with NFPA 10, 4-3.1. The facility also failed to ensure fire extinguishers were located where they were readily accessible and immediately available in the event of a fire in accordance with NFPA 10, 1-6.3. This affected fire extinguishers on three floors of the building. The facility has a total of 771 beds and a census of 433 patients.

Findings include:

A tour was conducted from 10/01/12 through 10/03/12 and 10/09/12 with Staff AA, BB, CC, and DD. During this tour, the following fire extinguishers were observed with an inspection tag which revealed they had not been inspected by staff at approximately 30-day intervals:

On the first floor, on 10/03/12, between 9:08 A.M. and 10:30 A.M.,
a) the carbon dioxide extinguisher, located in the kitchen by the ingredient assembly room, was not inspected in July, 2012.
b) The K extinguisher in Mark Pi's restaurant, by the kitchen, was not inspected in April, 2012.
c) The ABC type fire extinguisher in Au Bon Pain Restaurant, by the dining area, was silent to inspections in February, April, May, and July 2012.
d) During tour on 10/03/12 at 11:22 A.M., the gift shop storage room, on the ground floor, the fire extinguisher had not been inspected in May, 2012.

The following fire extinguishers were blocked with equipment and carts and were not immediately accessible as follows:

d) The central pharmacy in the basement room B210, fire extinguishers were observed in two different locations. These extinguishers were blocked by carts, and one location lacked a sign indicating fire extinguishers were present. This was verified with Staff VV (Interim Pharmacy Director) on 10/03/12 at 3:05 P.M.

These fire extinguishers were verified with Staff AA during tour.

Based on observation and interview, the facility failed to ensure each patient sleeping area did not contain space heaters. This has the potential to affect all 443 patients and their visitors.

Findings:
On 10/01/12 at 2:10 P.M. a tour was conducted of the 9th floor with Staff II and HH. In an employee ' s office, designated room 944 on the schematic, a space heater was found. The employee ' s office shares a wall with patient room number 9041, and is located among eight other patient rooms on the west side of the floor ' s smoke barrier.
On 10/01/12 at 2:10 P.M. this observation was confirmed by Staff HH.

Based on observations and staff interview, the trash chute door on two floors of the facility in which patient care was being conducted, failed to self close and latch when tested. NFPA 82, 3-2.4.1 requires gravity chute loading doors to be self-closing and positive latching. The facility has a total of 771 beds and a census of 433 during the survey.

Findings include:

A tour was conducted on 10/09/12, between 12:55 A.M. and 3:10 P.M., with Staff AA, BB, CC, and DD. Two trash chute rooms were observed each with a trash chute loading door which failed to close and latch when tested. Staff AA stated the spring of the chute loading doors was either broken or not working properly. These chute rooms were located on the second floor in room 2102 and on the third floor in room 3012.

Based on observation and interview, the facility failed to ensure no more than 300 cubic feet of medical gas was stored in the smoke compartment of the 5th floor and failed to ensure three H-sized cylinders were secured to the wall on the 4th floor. This has the potential to affect all 443 patients and their visitors.

Findings:
On 10/02/12 at 11:00 A.M. a tour was conducted of the 5th floor with Staff HH and II. The floor was observed to consistent of one smoke barrier and contained 14 E-sized oxygen cylinders, 12 in the east side and two in the west side of room 5007.
On 10/02/12 at 11:00 A.M. Staff HH confirmed the observation.
On 10/02/12 at 11:15 A.M. a tour was conducted of the 4th floor with Staff HH and II. Storage room 4002 was observed to contain medical gases in H-sized cylinders placed in a manifold system for delivery. Three of the H-sized oxygen tanks were observed to have their metal brackets around them unsecured; therefore, the tanks were unsecured to the wall.

Based on observations and staff interviews, the facility failed to ensure medical gas shutoff valves located outside each anesthetizing location, were readily accessible at all times for use in an emergency in accordance with the code at NPFA 99, 4-3.1.2.3 (n). This involved 3 of 12 operating rooms (ORs #7, 10, and 2) which had piped-in medical gases in which their shutoff valves were located in the Sterile Core room 2054. The facility has a total of 771 beds and a census of 433 during the survey.

Findings include:

A tour was conducted on 10/09/12, between 12:55 P.M. and 3:10 P.M., with Staff AA, BB, CC, and DD. The sterile core room 2054 was observed with individual medical gas shutoff valves for twelve ORs (#1 through #12). The medical gas shutoff valve for OR #7 was not visible. Shutoff valves for ORs 2 and 10 were blocked by carts.

Staff SS stated each OR has a medical gas shutoff valve, and proceeded to move a large supply cart for OR #7 when questioned by the surveyor about the location of the shutoff valve. When the cart was pulled out from the wall by Staff SS, the medical gas shut off valves were observed located on the wall behind where the large cart had been previously located.

During tour, Staff AA and SS verified these aforementioned medical gas shutoff valves were not readily accessible.

Based on interview and observation, the facility failed to ensure blue wiring that was run through a one hour fire barrier had fire stopping material around them to prevent the passage of smoke between compartments. This has the potential to affect all patients and family present for same day surgery.
Findings:
On 10/10/12 at 3:30 P.M. a tour was conducted on the second floor of the building with Staff HH and II.
The tour revealed a penetration of blue wires without fire stopping material in the one-hour fire barrier wall in the post anesthesia care unit near area five.
The tour revealed a penetration of the one hour fire barrier above the door connecting room 2005 and 2006. The penetration involved blue wires without fire stopping material put around them.
In an interview during the tour, Staff HH confirmed the observations.

Based on observations and staff interviews, failed to ensure two exit access doors were marked with approved, readily visible signs in accordance with the code at 30.2.10 and 7.10.1.4, the facility failed to ensure two horizontal doors latched when tested in accordance the code at 39.2.2.5 and 7.2.4.3.8, and failed to ensure one stairwell door was self-closing and latching in accordance with the code at 39.2.2.3.1 and 7.2.1.8.2. University Hospital has a capacity of 771 with a census of 433 at the time of survey.

Findings include:

A tour of the facility was conducted on 10/09/12 between 10:02 A.M. and 11:03 A.M. Staff who accompanied the surveyor on tour were Staff AA, BB, CC, and HH.

On the third floor, two exit access doors lacked visible approved exit sign. These doors were in a designated path of egress. One of the doors was located at the end of an egress corridor by Ultrasound room 3022. The second exit access door was located by Dressing room 3008A. Both areas in which these exit access doors were located also contained additional rooms in which a person could enter during a fire and smoke.

During this tour, the horizontal exit doors located on the second floor by the North Stair 201A and by Stair 202B (South end of building) failed to close and latch when released from the magnetic hold open devices. These doors were each located in a 2 hour fire barrier.

On the first floor, an exit access door was observed between Corridor 107 and Corridor 105 (which led to the exit discharge door. This exit access door was located at the bottom of Stairwell 105A. The Corridor 105 side of the door was observed equipped with an electronic device which allowed staff to activate with a special badge in order to enter into the 107 corridor. The door was in the closed position when tested from Corridor 107. There was no latching mechanism in place to hold the stair door in the closed position. This was verified with Staff CC during tour. This employee stated someone changed the locking mechanism and did not tell facility staff responsible for ensuring this door latched. Staff CC and AA stated the door should have latched after closing.

These areas were verified with the aforementioned staff.

Based on observations and staff interviews, the facility failed to ensure 4 areas where emergency supplemental oxygen tanks were stored, contained precautionary signs in accordance with the code at 8-6.4.2. The facility has a total of 771 beds and a census of 433 patients.

Findings include:

A tour was conducted from 10/01/12 through 10/03/12 and on 10/09/12 with Staff AA, BB, CC, DD, and HH. During this tour, four routine storage areas were observed with E-tanks of oxygen; however, the rooms lacked precautionary signs for the oxygen. These areas were located as follows:

a) in room 8403, observed on 10/01/12 at 2:10 P.M.,
b) in room 6162, observed on 10/01/12 at 3:43 P.M.,
c) in room 6227, observed on 10/01/12 at 3:55 P.M.,
d) in room 6100, observed on 10/01/12, at 4:23 P.M.,
e) in room 4321, observed on 10/02/12 at 11:05 A.M.

The lack of these signs were verified with the
staff who accompanied the surveyor during the tour.

Based on observation of the 9th and 8th floor, and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular. This has the potential to affect all 443 patients and their visitors.
Findings:
On 10/01/12 at 2:10 P.M. a tour was conducted of the 9th floor with Staff II and HH. The tour revealed at the nursing station three power strips daisy-chained together. Beginning from the wall, the first power strip had all receptacles occupied with computer equipment and the last receptacle in use by the second power strip. The second power strip had two cell phone chargers plugged into it, plus a third power strip that was not in use.
Also in the area, but under the clerk ' s desk, a power strip and an ordinary extension cord were daisy-chained together. Beginning from the wall, the first power strip had three appliances plugged into it plus an ordinary extension cord. This extension cord then had two appliances plugged into it.
On 10/01/12 at 2:10 P.M. this observation was confirmed by Staff HH.

On 10/01/12 at 3:30 P.M. a tour was conducted of the 8th floor with Staff II and HH. The tour revealed in the medication room two power strips daisy chained together. Starting from the wall, the first power strip had four receptacles in use, plus one in use by another power strip. In that power strip there were two addition electrical appliances plugged in.
On 10/01/12 at 2:10 P.M. this observation was confirmed by Staff HH.