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Based on observation and interview, the facility failed to maintain a two hour fire barrier between the building and nonconforming buildings with which it shares a barrier. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients at the time of the survey.

Findings include:

On 09/16/15 at 2:15 PM observation above the drop down ceiling of the second floor, at grid position m 18, of the two hour fire rated building separation revealed three half inch open conduits, one holding two red wires, and the other two holding grey wires. At the corner an annular space was observed between a sprinkler line and the sleeve that held it, and a junction box with a missing knock-out that had a conduit traveling from it into the south barrier.

On 09/16/15 at 2:15 PM in an interview, Staff R confirmed the observation.

31007

Based on medicalrecord review, occupancy permit review and staff interview the facility failed to ensure the construction type met the requirements for a two story fully sprinklered building. This has the potential to affect all patients receiving services at the facility. The facility 12 month census was 6,879.

Findings include:

Observation of the building completed on 09/14/15 revealed other occupancies including a physicians office space and a radiology department. It also revealed a second floor.

Review of the occupancy permit revealed a construction type of type II (000).

Medical record review for Patient #1A completed on 09/15/15 revealed Pre-operative holding documentation dated 09/09/15 at 6:36 AM. Review of the Oberservation Record dated 09/10/15 at 7:30 AM revealed the patient was discharged at this time. This was confirmed by Staff A at the time of the observation.

Based on observation and interview, the facility failed to ensure doors with latching hardware that opened onto corridors closed and latched. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients.

Findings include:

On 09/16/15 at 3:46 PM observation of the seventh floor of the double doors to the clean supply room across from the bank of elevators revealed the doors had latching hardware that did not close and latch the door when tested.

On 09/16/15 at 3:46 PM in an interview, Staff S confirmed the observation.

Based on observation and interview, the facility failed to ensure doors with latching hardware that opened onto corridors closed and latched. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients.

Findings include:

1. On 09/16/15 at 9:38 AM a tour was conducted of the fourth floor with Staff Q, R, and S. During the tour, a fire alarm sounded on the floor. Doors to patient rooms 456, 460, 462, 467, and 488 were found to close but the latching hardware did not latch to keep the doors close. When the door to patient room 488 was closed, two people needed to reopen it.

On 09/16/15 at 9:38 AM in an interview, Staff Q and S confirmed the observations.

2. On 09/16/15 at 3:38 PM on the first floor, observation of double doors to the chapel revealed they had closing latching hardware. However, upon testing of the latching hardware, the doors did not close.

On 09/16/15 at 3:38 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors that protect vertical openings were in accordance with 8.2.5 of National Fire Protection Association 101, 2000 edition. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients.

Findings include:

1. On 09/15/15 at 10:36 AM observation of the linen chute in the basement revealed a cart to catch the bags of linen below the linen chute's termination point was full and laundry was backing up into the chute itself. The chute door was observed to self close upon activation of a fusible link. The backed up laundry would prohibit its closing.

On 09/14/15 at 10:36 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to maintain the ratings of the barriers that protect vertical openings and failed to ensure doors that protect vertical openings were in accordance with 8.2.5 of National Fire Protection Association 101, 2000 edition. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients.

Findings include:

1. On 09/14/15 at 11:45 AM a tour was taken of the facility's tenth floor with Staff Q and R. Observation of the fire door, with latching hardware and a self closer, up stairwell two leading to a mechanical space revealed the door was propped open by a cardboard box.

On 09/14/15 at 11:45 AM in an interview, Staff Q confirmed the finding.

2. On 09/15/15 at 11:29 AM a tour was conducted of the seventh floor with Staff Q and R. Observation of the clean supply room located at grid position H13 revealed three penetrations to the vertical opening behind the wall: on the right as the room is entered, there was an open junction box and a half inch open conduit holding two grey wires, and on the left, another open junction box.

On 09/15/15 at 11:29 AM in an interview, Staff R confirmed the observation.

3. On 09/15/15 at 1:53 PM observation of the fire door protecting the end of the trash chute in room 1961 revealed the gap between it and the opening of the chute was approximately one inch. Observation of the soiled linen room next to it revealed the gap between that door and the opening of that chute was greater than one inch.

On 09/15/15 at 11:53 PM in an interview, Staff Q confirmed the observations.

4. On 09/15/15 at 1:58 PM observation of linen chute F revealed bags of laundry had filled the receptacle under the chute and were backing up into the chute itself thereby preventing the door from self closing.

On 09/15/15 at 1:58 PM in an interview, Staff Q confirmed the finding.

5. On 09/15/15 at 2:09 PM observation of the linen chute D revealed bags of laundry had filled the receptacle under the chute and were backing up into the chute itself thereby preventing the door from self closing.

On 09/15/15 at 2:09 PM in an interview, Staff Q confirmed the finding.

6. On 09/15/15 at 2:14 PM observation of linen chute C revealed bags of laundry had filled the receptacle under the chute and were backing up into the chute itself thereby preventing the door from self closing.

On 09/15/15 at 2:14 PM in an interview, Staff Q confirmed the finding.

7. On 09/15/15 at 2:41 PM observation above the drop down ceiling of the two hour rated construction surrounding Stair D in the CCU suite revealed a two inch open pipe that had been stopped with a paper towel.

On 09/15/15 at 2:41 PM in an interview, Staff R confirmed the observation.

8. On 09/15/15 at 3:06 PM observation above the drop down ceiling of the two hour rated construction surrounding a vertical opening near the support coordinators office revealed an open junction box with a conduit running through the wall.

On 09/15/15 at 3:06 PM in an interview, Staff R confirmed the observation.

9. On 09/15/15 at 3:19 PM observation of a vertical opening door in a supervisor office at grid position H7 revealed the door was unrated.

On 09/15/15 at 3:19 PM in an interview, Staff S confirmed the observation.

10. On 09/15/15 at 3:24 PM observation within the same vertical opening at the same supervisor office revealed a one foot by one foot square cut from the west wall.

On 09/15/15 at 3:24 PM in an interview, Staff S confirmed the observation.

Based on observation and interview, the facility failed to ensure each door in its smoke barrier closed completely. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients at the time of the survey.

Findings include:

On 09/16/15 at 9:38 AM a tour was conducted of the fourth floor with Staff Q, R, and S. During the tour, a fire alarm sounded on the floor. Observation of the double doors in the smoke barrier perpendicular to room 453 and the double doors in the barrier separating the pulmonary function area from the patient care area, revealed they had not completely closed.

On 09/16/15 at 9:38 AM in an interview, Staff S confirmed the observation.

31007

Based on schematic review, observation, and staff interview the facility failed to ensure doors in each hazardous area was on a hold open device that released when the fire alarm was initiated, the doors of a 3/4 hour rating, and the walls were constructed of at least a 1 hour protection rating. This has the potential to affect all patients, staff, and visitors in the facility.

Findings include:

Review of the schematic of the first floor provided by the facility revealed Parkway Cafe and the pharmacy were identified as hazardous areas with 1 hour fire rated walls. This was confirmed by Staff C at the time of the schematic review.

Observation of the door from the pharmacy storage area to the identified Staff Work area and Male staff locker room completed on 09/15/15 revealed the door did not have a tag with a fire rating. This was verified by Staff C on 09/15/15 at 2:20 PM.

Observation of the Parkway Cafe located at entrance #4 completed on 09/16/15 revealed it had double doors with glass panels approximately 6 feet by 2 feet in each and no tag showing the rating of the doors. The doors were also noted at the time of the observation to have self closer's and on hold open devices that were not connected to the alarm system to release when the alarm was activated. These findings were confirmed by Staff C on 09/16/15 at 10:40 AM.

Observation of the wall between the Lobby and the Parkway Cafe completed on 09/16/15 revealed 2 glass panels approximately 6 feet by 4 feet with no rating written on the glass. Requested documentation of the rating of the glass panels from Staff C on 09/16/15 at 10:40 AM.

Based on observation and staff verification the facility failed to ensure the gift shop greater than 1,000 square feet was not open to the main dining area. This has the potential to affect all patients receiving services at the facility.


Findings include:


Observation of the gift shop located at the main dining area complete on 09/15/16 revealed an approximate 12 foot by 8 foot opening. A role down gate was noted, for the opening, above the gift shop ceiling with empty space between the steel lattice of approximately 8 inches by 2 inches. This was verified by Staff C on 09/15/15 at 2:40 PM.

Based on observation and interview, the facility failed to ensure its sprinklers were tested in accordance with National Fire Protection Association 25, Chapter 10, 1999 edition. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients at the time of the survey.

Findings include:

On 09/17/15 a review of the facility's sprinkler system testing documentation was completed. The review revealed a main drain test was conducted on 08/04/15. The documentation did not reveal any other main drain test to compare it with.

On 09/17/15 at 1:20 PM in an interview, Staff M confirmed an internal pipe inspection has not been done on the sprinkler system.

Based on observation and interview, the facility failed to have its automatic sprinkler system maintained in accordance with National Fire Protection Association 25, 1999 edition, 2-4. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients at the time of the survey.

Findings include:

On 09/17/15 at 11:00 AM in an interview, Staff Z, a representative from the local company who inspects the facility's sprinkler system, stated the first place he/she would look for spare sprinkler heads for the facility would be at the pump room.

On 09/17/15 at 11:20 AM Staff Z and the surveyor were unable to locate a sample of spare sprinkler heads of each kind in use at the facility at the pump room.

Based on observation and interview, the facility failed to ensure its trash chutes discharged into a trash collection room protected in accordance with National Fire Protection Association 101, 8.4. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients.

Findings include:

1. On 09/15/15 at 1:58 PM the room where trash chute #3 terminated was observed to have its door propped open by the trash receptacle that was positioned to catch the trash after it left the end of the chute.

On 09/15/15 at 1:58 PM in an interview, Staff Q confirmed the finding.

2. On 09/15/15 at 2:06 PM observation of the double in the protective construction surrounding trash chute #2 did not close on a coordinator, leaving a gap between them.

On 09/15/15 at 2:06 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.2.2.6 for not having medical gas zone shut off valves readily accessible. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients at the time of the survey.

Findings include:

On 09/16/15 at 11:10 AM observation of the fourth floor revealed the medical gas shutoff valves, specifically the vacuum shut off valves, remain in the ceiling and out of reach for personnel to shut off in an emergency.

On 09/16/15 at 11:10 AM in an interview, Staff Q confirmed the finding.

31007

National Fire Protection Association 101

21.1.2.1*
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to serve ambulatory health care occupants for purposes of treatment or customary access by patients incapable of self-preservation.
(2) They are separated from areas of ambulatory health care occupancies by construction having a fire resistance rating of not less than 1 hour.


Based on schematic review and staff verification the facility failed to ensure all parts of the Ambulatory Surgery Center were seperated from other tenant spaces by a 1 hour fire rated structure. This has the potential to affect all patient receiving services from the facility. The facility performed 12,773 procedures in a 12 month period.


Findings include:


Review of the facilty schematic provided by the facility completed on 09/14/15 revealed the 1 fire rated occupancy seperation was moved and does not include the facilities waiting room. This was verified on 09/14/15 at 2:20 PM.

19.2.7 Discharge from Exits.
Discharge from exits shall be arranged in accordance with Section 7.7.

Based on observation and interview, the facility failed to ensure not more than 50 percent of the required number of exits discharged through areas on the level of exit discharge. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients at the time of the survey.

Findings include:

On 09/17/15 at 9:12 AM a tour was taken of the unit on the fifth floor with Staff Q. Observation of the unit revealed two exits in the form of stairwells. Following the exits to their terminus revealed neither discharged to the outside and both discharged to the elevator lobby.

On 09/17/15 at 9:12 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure power strips were used in accordance with National Fire Protection Association 70, 1999 edition. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients at the time of the survey.

Findings include:

On 09/15/15 at 3:35 PM observation of the office space leading to the decommissioned chute on the sixth floor, grid position H18, revealed a microwave and refridgerator was plugged into a power strip, that was plugged into another power strip, that was plugged into another power strip with five of five receptacles in use, that was plugged into the wall receptacle, which had four out of four receptacles in use.

On 09/15/15 at 3:35 PM in an interview, Staff Q confirmed the finding.

Based on observation and staff verification the facility failed to ensure the gift shop greater than 1,000 square feet was not open to the main dining area. This has the potential to affect all patients receiving services at the facility.


Findings include:


Observation of the gift shop located at the main dining area complete on 09/15/16 revealed an approximate 12 foot by 8 foot opening. A role down gate was noted, for the opening, above the gift shop ceiling with empty space between the steel lattice of approximately 8 inches by 2 inches. This was verified by Staff C on 09/15/15 at 2:40 PM.

Based on observation and interview, the facility failed to ensure its trash chutes discharged into a trash collection room protected in accordance with National Fire Protection Association 101, 8.4. This has the potential to affect all patients receiving services at the facility. The facility had a census of 502 patients.

Findings include:

1. On 09/15/15 at 1:58 PM the room where trash chute #3 terminated was observed to have its door propped open by the trash receptacle that was positioned to catch the trash after it left the end of the chute.

On 09/15/15 at 1:58 PM in an interview, Staff Q confirmed the finding.

2. On 09/15/15 at 2:06 PM observation of the double in the protective construction surrounding trash chute #2 did not close on a coordinator, leaving a gap between them.

On 09/15/15 at 2:06 PM in an interview, Staff Q confirmed the finding.