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Based on observation and interview, the facility did not provide a common separation wall with rated doors. This deficient practice could affect all patients, staff, and visitors in 1 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 8:00 am, observation revealed on the 2nd floor in the the door going into the parking garage from the employee bridge, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4 and 8.2.3.2.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).

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27230

Based on observation and interview, the facility did not provide a common separation wall with rated wall construction, closers on all doors, and sealed wall penetrations. This deficient practice could affect all patients, staff, and visitors in 6 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 5:20 pm, observation revealed on the Sixth floor in the E612 Mechanical Room, that the separation wall was not constructed to have a 2-hour fire resistance rating because the top of the west wall that meets the new building was not fire caulked to a 2 hour fire rating. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

2. On 05/16/13 at 9:18 am, observation revealed on the Second floor in Stair #24, that penetration(s) were not sealed according to an approved method. The deficiency included a hole in the wall above the door out of the ICU. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4.

3. On 05/16/13 at 9:20 am, observation revealed on the Second floor in Stair #25, that penetration(s) were not sealed according to an approved method. The deficiency included a hole above the door with wires showing. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4.

4. On 05/16/13 at 9:27 am, observation revealed on the Third floor in 3218A Equipment Room, Smoke Compartment 3E, that the separation wall was non-compliant because there was no rated door on the Equipment Room. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

5. On 05/16/13 at 2:04 pm, observation revealed on the Fourth floor in Corridor 4860 of the Family Birth Center, that penetration(s) were not sealed according to an approved method. The deficiency included holes in the Southwest ceiling wall. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4.

6. On 05/16/13 at 2:19 pm, observation revealed on the Fourth floor in Room 4802, that penetration(s) were not sealed according to an approved method. The deficiency included an uncaulked ceiling penetration in the nurse call station. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4.

7. On 05/16/13 at 10:01 am, observation revealed on the Fourth floor in Room 3029B, Data Closet, that penetration(s) were not sealed according to an approved method. The deficiency included two penetrations that were not sealed with an approved fire caulk. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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Based on observation and interview, the facility did not provide and maintain the required building construction type with sealed floor penetrations, and support steel covered with rated fire proofing. This deficient practice could affect all patients, staff, and visitors in 3 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 4:10 pm, observation revealed on the 1st floor in between doors 1208 and 1210 there is a plumbing chase, that contains penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included plumping pipes not fire caulked This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

2. On 5/16/2013 at 10:00 am, observation revealed on the basement floor the behind sterilizers in sterile processing area, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included a pipe not caulked to the sub-basement. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

3. On 5/16/2013 at 1:40 pm, observation revealed on the basement floor at the electrical vault between room WL 09 and WL10, that fire proofing was missing from the structural steel at the beam "in" the wall above the door between WL09 to WL10. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide and maintain the required building construction type with sealed floor penetrations. This deficient practice could affect all patients, staff, and visitors in 5 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 5:42 pm, observation revealed on the Second floor in Room 2226A, Smoke Compartment 2K, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included two 1-1/2 inch penetrations through the floor. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

2. On 05/16/13 at 8:21 am, observation revealed on the Second floor in Room 2440G, Smoke Compartment 2Q, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included two 3" x 3" holes in Northwest corner of ceiling. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

3. On 05/16/13 at 8:49 am, observation revealed on the Second floor in 2445A & B data closets, Smoke Compartment 2R, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included conduit wires going through the ceiling without being fire caulked. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

4. On 05/16/13 at 8:52 am, observation revealed on the Second floor in Room 2450D, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included two 4" x 5" holes in the ceiling with data wires penetrating through the hole that were not properly fire sealed. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

5. On 05/16/13 at 12:59 pm, observation revealed on the Fifth floor in Room 5039, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included penetrations in the floor and ceiling assembly. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

6. On 05/16/13 at 1:45 pm, observation revealed on the Fifth floor in the Corridor Electrical Closet, that there were penetration(s) through the floor that were not fire stopped according to an approved method. The deficiency included a penetration through the floor. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).

Based on observation and interview, that the facility did not provide corridor finishes with rated wall finish materials. This deficient practice could affect all patients, staff, and visitors in 1 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/14/2013 at 3:30 pm, observation revealed on the 3rd floor in the corridor 3811, that the facility could not confirm the wall had an appropriate rating. The corridor wall was finished with paper lining the corridor wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).

Based on observation and interview, that the facility did not provide compliant room finishes. This deficient practice could affect all patients, staff, and visitors in 3 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 10:15 AM, observation revealed on the 2nd floor in room 2157, that there is peg board mounted on the wall as a secondary finish and the facility could not confirm the peg board had the appropriate finish rating. The wood peg boards holds up scopes. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.3.1.

2. On 5/15/2013 at 4:40 PM, observation revealed on the 1st floor in the housekeeping room near stair 5, that there was peg board mounted on the wall as a secondary finish and the facility could not confirm the peg bard had the appropriate finish rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.3.1.

3. On 5/16/2013 at 9:05 AM, observation revealed on the basement floor in the PT area, that there was peg board mounted on the wall as a secondary finish and the facility could not confirm the peg board had the appropriate finish rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.3.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces, with no patient treatment in spaces that open to the corridor, no combustible material storage, and smoke detection in spaces that are open to the corridor. This deficient practice could affect all patients, staff, and visitors in 4 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 10:08 am, observation revealed on the 2nd floor in the 'overflow recovery', that the area was not separated from the exit egress corridor by wall construction and was used for the treatment of patients. The space did not have a door to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 (exception 6).

2. On 5/16/2013 at 11:30 am, observation revealed on the Basement Floor in the corridor by the Lab, that the corridor space was used for storage, and was not separated by a wall from the corridor. Storage included 3 flammable storage containers containing 55 gallon drums of alcohol and xylene This quantity of materials was deemed hazardous for storage in a corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 , and 19.7.5.5.

3. On 5/16/2013 at 11:40 am, observation revealed on the Basement Floor in the corridor by the Lab, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1.

4. On 5/16/2013 at 1:00 pm, observation revealed on the basement floor in the entrance (south entrance) to Main Lab, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with non combustible material storage and rooms open to the corridor with the required safe-guards. This deficient practice could affect all patients, staff, and visitors in 3 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/2013 at 12:30 pm, observation revealed on the Fourth floor in the Corridor 408C, that the corridor was used to store a large amount of materials and was not separated from the corridor by a compliant wall and door. Storage included a recliner, chairs,oxygen carrier and a portable toilet chair. Spaces are permitted to be open to the corridor provided they are not used as a hazardous area, per exception 6 to 19.3.6.1. The quantity of materials within the same smoke compartment was deemed hazardous for storage in a corridor. The amount stored exceeded the amount that would fit in a 50 sq. ft. room, which is the threshold for the quantity deemed hazardous under the code in 19.3.2.1(7). This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.1 (exception 6) .

2. On 05/16/2013 at 1:20 pm, observation revealed on the Fourth floor in Room 4016, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location.The room does not have a door and opens into the corridor. No smoke detector was installed in the room. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.1 .

3. On 05/16/2013 at 1:10 pm, observation revealed on the Fifth floor in Room 5011, Utility Room, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor in same smoke compartment did not have smoke detection and the entire smoke compartment did not have quick-response sprinklers. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.1 .

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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Based on observation and interview, the facility did not provide corridor separation doors with doors that would close when pushed or pulled, and positive-latching hardware. This deficient practice could affect all patients, staff, and visitors in 12 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 3:00 pm, observation revealed on the 2nd floor at door number SC203, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

2. On 5/14/2013 at 9:10 am, observation revealed on the 2nd floor at corridor door 230 to passage W228, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

3. On 5/14/2013 at 4:45 pm, observation revealed on the 3rd floor in room 3006, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

4. On 5/15/2013 at 11:10 am, observation revealed on the 1st floor at door SW100B, that the door to the corridor was held open with a electrical hold open The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.3.

5. On 5/15/2013 at 12:45 pm, observation revealed on the 1st floor at door 1116B, radiology reception, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. Also, the door did not have a door coordinator. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

6. On 5/15/2013 at 1:05 pm, observation revealed on the 1st floor in the door to suite across from Pet/CT room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

7. On 5/15/2013 at 1:50 pm, observation revealed on the 1st floor at the door to suite east of room 1037, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

8. On 5/15/2013 at 2:30 pm, observation revealed on the 1st floor in the chute room 1024, the door to corridor, would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

9. On 5/15/2013 at 3:10 pm, observation revealed on the 1st floor at the double door to room 1071, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

10. On 5/16/2013 at 8:40 am, observation revealed on the basement floor at the door SW 0011, that a pair of corridor doors did not close and latch automatically. The doors were installed with automatic closers and had an astragal to control smoke transmission, but the combination of devices prevented the doors from fully and automatically closing and latching. There was no door coordinator installed to "coordinate" closure of the two doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

11. On 5/16/2013 at 9:10 am, observation revealed on the basement floor at door SW095, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

12. On 5/16/2013 at 9:40 am, observation revealed on the basement floor at door FW002A, laundry chute room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2. .

13. On 5/16/2013 at 11:15 am, observation revealed on the basement floor at room 0023, storage, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide corridor separation doors with doors that would close when pushed or pulled, and positive-latching hardware. This deficient practice could affect all patients, staff, and visitors in 5 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 4:00 pm, observation revealed on the Third floor in the Suite 308C, Door SE344, that the corridor door would not positively self-latch. The door was equipped with a closer, which is not required by the code, but it does not hold the door in the latched position. Double doors that open into a corridor do not latch. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

2. On 05/15/13 at 4:43 pm, observation revealed on the Fourth floor,Door SE4226D , Smoke Compartment 4G, that the corridor was not compliant. The door had a bent astragal at the bottom of the door and the door coordinator was not working. These conditions prevented the door from being smoke tight. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.3.1.

3. On 05/15/13 at 4:55 pm, observation revealed on the Fifth floor in the Room 5228, Door SE5227, that the corridor door would not positively self-latch. The door was equipped with a closer, which is not required by the code, but it does not hold the door in the latched position. Double doors that open into a corridor do not latch. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

4. On 05/15/13 at 4:59 pm, observation revealed on the Fifth floor in the Room 5238, that the corridor was not compliant. There was no closer on the door leading into an equipment room. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.3.1.

5. On 05/16/13 at 12:25 pm, observation revealed on the Fourth floor in Stair #9, that the corridor door would not positively self-latch. The door was equipped with a closer, which is not required by the code, but it does not hold the door in the latched position. Stair 9 door on level four does not latch. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

6. On 05/16/13 at 1:49 pm, observation revealed on the Fourth floor in Room 4808, Smoke Compartment 4F, that the corridor door would not positively self-latch. The door was equipped with a closer, which is not required by the code, but it does not hold the door in the latched position. Door to a biohazard closet would not fully close and latch. The door opened into the corridor of the Family Birth Center. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11(Architectural Designer).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with doors with positive-latching hardware, and rated wall construction. This deficient practice could affect all patients, staff, and visitors in 20 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 12:02 pm, observation revealed on the 1st floor in the stair 23, that the door in the vertical opening would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.1.1, and 8.2.5.4, and 8.2.3.2.

2. On 5/14/2013 at 1:30 pm, observation revealed on the 8th floor in stairways 15 and 16 at the 7th floor level, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because there are electrical panels in the stair ways that are not 1 hour rated and exceed the 100 square inches in 100 square feet requirement electrical box openings for a rated wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.

3. On 5/15/2013 at 11:50 am, observation revealed on the 1st floor at door XW115S, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the HVAC and hose cabinets are not fire rated assemblies. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.

4. On 5/15/2013 at 11:55 am, observation revealed on the 1st floor at door XW115S, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the wall has a pipe going through the fire wall, parallel to the dry wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated wall construction. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 5:00 pm, observation revealed on the Fifth floor in Room 5304, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the closet shaft connected to at least two stories and the door did not have a closer or fire rating. The shaft also had straw packed into a pocket in the side wall. This observed situation is not compliant with NFPA 101 (2000 ed.), 8.2.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).

Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included an adjacent smoke detector. This deficient practice could affect all patients, staff, and visitors in 4 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 2:45 pm, observation revealed on the 2nd floor by smoke zone door 2K/2G, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

2. On 5/14/2013 at 0:11 am, observation revealed on the 2nd floor in the OR suite, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. The door is to release on the activation of the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

3. On 5/15/2013 at 10:40 am, observation revealed on the 2nd floor by the won door at the main entrance, that the won smoke fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. The door is to close on the activation of the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

4. On 5/15/2013 at 3:50 pm, observation revealed on the 1st floor at the door FC1200W, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).

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27230

Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included an adjacent smoke detector. This deficient practice could affect all patients, staff, and visitors in 4 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 2:45 pm, observation revealed on the 2nd floor by smoke zone door 2K/2G, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

2. On 5/14/2013 at 0:11 am, observation revealed on the 2nd floor in the OR suite, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. The door is to release on the activation of the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

3. On 5/15/2013 at 10:40 am, observation revealed on the 2nd floor by the won door at the main entrance, that the won smoke fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. The door is to close on the activation of the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

4. On 5/15/2013 at 3:50 pm, observation revealed on the 1st floor at the door FC1200W, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage and "no-exit" signs at that may be confused as exits. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 12:08 pm, observation revealed on the 1st floor at the side exits to revolving doors of south tower, that the path of egress was not readily apparent and an exit sign was not provided near the side exit doors of the revolving doors visible from straight on (to the north). This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4.

2. On 5/13/2013 at 1:58 pm, observation revealed on the 2nd floor at the exit from corridor 207C into room S-221 (lobby), one cannot exit from a corridor into a room, and that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1.

3. On 5/13/2013 at 2:07 pm, observation revealed on the 2nd floor by door st 201, that an exit sign was installed at a location that the facility confirmed was not an exit. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4.

4. On 5/14/2013 at 4:10 pm, observation revealed on the 3rd floor at door ST 300, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1.

5. On 5/15/2013 at 3:00 pm, observation revealed on the 1st floor in stair 12, going west, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1.

6. On 5/16/2013 at 4:10 pm, observation revealed on the 3rd floor, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. These doors could be locked at all times, at night or when a baby bracelet was within the vacinity of the locking device sensor. Locations include the following: a) from corridor 330C to corridor 336C; b) from corridor 330C to corridor 335C; c) from corridor 315C to corridor 316C d) from corridor 315C to corridor 311C; e) from corridor 313C to waiting area 312C; f) from waiting area 312C to corridor 312C; and g) from corridor 3800A to corridor 3800B. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent. This deficient practice could affect all patients, staff, and visitors in 2 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/13 at 8:55 am, observation revealed on the Second floor in Stair #13, Smoke Compartment 2R, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near Stair #13. The stairway needed to have a light exit sign and there was no exit sign. This observed situation is not compliant with NFPA 101 (2000 ed.), 7.10.1.4.

2. On 05/16/13 at 10:35 am, observation revealed on the Third floor in Room 3041, that signage was installed in the egress path that made the exact exit route confusing. There were two exit signs in a storage room above doors that were inaccessible. Other exits were clearly marked outside the room by the stairway and through the corridor area. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.2.10; 7.10.1.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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Based on observation and interview, the facility did not provide smoke compartments of the appropriate layout or egress configuration. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 2:50 pm, observation revealed on the 1st floor in the stair 15 exit passage, that the smoke compartment was not compliant. There is not enough room in the exit passage of stair 15 for all the patient and staff from the smoke zone to the north (to stay in the exit passage way) since the door to the old main entrance area is locked. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.1.

2. On 5/162013 at 4;00 pm, observation revealed on the 3rd floor at corridor 320C (also family waiting W305), that one could not cross into another smoke compartment. The across corridor doors to the OBYGN unit were locked and the exit doors to the pediatric walkway are not a smoke barrier in the hospital.

3. On 5/15/2013 at 2:52 pm, observation revealed on the 1st floor in the Stair 16 exit passage, that the smoke compartment was not compliant. There is not enough room in the exit passage of Stair 16 for all the patient and staff from the smoke zone to the north (to stay in the exit passage way) since the door to the south is locked. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.1.

4. On 5/16/2013 at 4:30 pm, observation revealed on the 1st floor at the entrance to the professional building (NW corner of the hospital by Mechanical space 1093), that the travel distance to the nearest adjacent smoke barrier door was 260 feet. This exceeds the maximum travel distance of 200 feet. Health care occupancies must have a "defend-in-place" design that use horizontal evacuation within the facility as the first priority rather than exiting directly to the exterior. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations, and rated wall construction. This deficient practice could affect all patients, staff, and visitors in 4 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/14/2013 at 10:40 am, observation revealed on the 2nd floor in room 14 (2101), that penetration(s) were not sealed according to an approved method. The deficiency included medical gas and electrical outlets of 180 square inches in 100 square feet of wall. A maximum of 100 square inches in allowed in a rated wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

2. On 5/15/2013 at 5:00 pm, observation revealed on the 1st floor in the wall between the kitchen and dining room, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because has an electrical panel in it that is greater than 100 square inches in 100 square feet of area. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with closers on all doors, smoke-tight seals at meeting edges, and an adjacent smoke detector. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/14/2013 at 10:50 am, observation revealed on the 2nd floor in the bathroom door, SW241, that the smoke barrier door would not self-close because there was no closer on the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.6.

2. On 5/14/2013 at 4:20 pm, observation revealed on the 3rd floor in the Labor/ Delivery Triage area by reception desk, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. There are two set of doors in this area. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.6 and 8.3.4.

3. On 5/15/2013 at 4:50 pm, observation revealed on the 1st floor at the fire shutter between kitchen and dining room, that the fire shutter (smoke barrier) door was magnetically held open and did not have a smoke detector located less than five feet away from the shutter. In addition the shutter does not fall on general fire alarm. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.6 and 19.2.2.2.6, and NFPA 72 (1999 ed.), 2-10.6.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not enclose hazardous rooms with doors with positive-latching hardware, rated wall construction, closers on all doors, and localized smoke detection device. This deficient practice could affect all patients, staff, and visitors in 15 of the 92 smoke compartments.

FINDINGS INCLUDE:

1.1. On 5/13/2013 at 4:15 pm, observation revealed on the 2nd floor in the Vascular Storage Room (2331), that the door would not self-close because there was no closer on the door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

1.2. On 5/13/2013 at 4:50 pm, observation revealed on the 2nd floor in the Storage Room A218/2040B, that the door would not self-close because there was no closer on the door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

1.3. On 5/14/2013 at 8:30 am, observation revealed on the 2nd floor in the Recovery- Soiled Utility Room (2025D), that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

1.4. On 5/14/2013 at 9:45 am, observation revealed on the 2nd floor at the Sterile Storage Room 2064, the door would not self-close because there was no closer on the door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

1.5. On 5/14/2013 at 2:30 pm, observation revealed on the 3rd floor in the Transport Equipment Room 3812, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall has a steel strut passing thought the one hour wall holding up a duct, and the strut is supported on each side of the one hour wall. If the support for the strut was to fail on one side of the wall, there is the possibility of the 1 hour wall failing. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

1.6. On 5/14/2013 at 3:20 pm, observation revealed on the 3rd floor in the Room 3814, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall has a 33" by 22" electrical panel located in the one hour rated wall which exceed the 100 square inches of electrical box in a 100 square foot area of the 1 hour wall. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

1.7. On 5/15/2013 at 11:40 am, observation revealed on the 1st floor in the Storage Room 1001G, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall were not 1 hour rated and ceiling does not connect to the "1" hour wall The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

1.8. On 5/15/2013 at 1:25 pm, observation revealed on the 1st floor in the Radiology Film Processing Room (1041F), that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

1.9. On 5/15/2013 at 4:20 pm, observation revealed on the 1st floor in the New Storage Room 1214, that the door would not self-close because there was no closer on the door. In addition, the door was not rated. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

1.10. On 5/16/2013 at 1:10 pm, observation revealed on the Basement Floor at the door to Storage Room 0056D of Clinical Lab, that the door to this hazardous room was equipped with a magnetic hold-open device but no a local smoke detector was installed on either side for "door release" requirement. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101(2000 ed.), 19.2.2.2.6, 7.2.1.8.2, and NFPA 72(1999 ed.), 2-10.6.

2.0. On 5/16/2013 in the PM, observation revealed on the 8th Floor West Tower Building, Room 8074, Ante Room, that the door with walls were not 1-hr fire-rated per code requirements. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101(2000 ed.), 19.2.2.2.6, 7.2.1.8.2, and NFPA 72(1999 ed.), 2-10.6.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not enclose hazardous rooms with doors that had positive-latching hardware, closers on all doors, and rated doors. This deficient practice could affect all patients, staff, and visitors in 16 of the 92 smoke compartments.

FINDINGS INCLUDE:

2.1. On 05/15/13 at 2:55 pm, observation revealed on the Second Floor in Storage Room 2331A, Smoke Compartment 2L, that the door would not self-close because the double doors on the Storage Room was missing a closure and a coordinator . The room is considered hazardous because it exceeds 50 sq ft and contains a quantity of stored combustible materials considered hazardous. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

2.2. On 05/15/13 at 3:36 pm, observation revealed on the Second Floor in Dialysis Room 2236 , that the door would not self-close because the double doors on the Dialysis Room was missing a door closure and a coordinator. The room is considered hazardous because it exceeds 50 sq ft and contains a quantity of stored combustible materials considered hazardous. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

2.3. On 05/16/13 at 10:05 am, observation revealed on the Third Floor in Room 3036A, Soiled Linen Room, Smoke Compartment 3D, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The Soiled Linen door does not latch due to a missing closer. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

2.4. On 05/16/13 at 12:09 pm, observation revealed on the Fifth Floor in Room 5216C, that the door would not self-close because it was missing a closer. The room was considered hazardous because it exceeds 50 sq ft and contains a quantity of stored combustible materials considered hazardous. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

2.5. On 05/16/13 at 12:10 pm, observation revealed on the Fifth floor in Room 5216E, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The Hazardous Door will not latch closed to the corridor. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

2.6. On 05/16/13 at 12:12 pm, observation revealed on the Fifth floor in the Corridor 506C, Smoke Compartment 5C, that the hazardous room was not compliant. Double doors (SE5217) to the corridor would not latch. The room is considered hazardous because it exceeds 50 sq ft and contains a quantity of stored combustible materials considered hazardous. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

2.7. On 05/16/13 at 1:33 pm, observation revealed on the Fifth Floor in 5163A, Toilet Room, that the door would not self-close because the room was being used as a storage room and was not rated properly for a storage room. The room is considered hazardous because it exceeds 50 sq ft and contains a quantity of stored combustible materials considered hazardous. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

2.8. On 05/16/13 at 2:08 pm, observation revealed on the Sixth Floor in the South Tower Penthouse, that a Storage Room 6800 was not compliant. The room was being used as a storage room and was not part of the Air Handler Unit and the Electrical Switchgear. The room is considered hazardous because it exceeds 50 sq ft and contains a quantity of stored combustible materials considered hazardous. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).

Based on observation and interview, the facility did not provide and maintain at least 2 approved and remote exits on each floor. This deficient practice could affect all patients, staff, and visitors in 1 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 2:25 pm, observation revealed on the 2nd floor in the women's outpatient center, room 2825 exiting into the another suite (lobby) rather than into a corridor system. The other exit, into the treatment area, was locked, and therefore the egress path was not compliant. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.4.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not provide enclosures around exit stairs with exit stairwells without openings to unoccupied rooms. This deficient practice could affect all patients, staff, and visitors in 30 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 3:40 pm, observation revealed on the 1st floor in the in the exit passage containing chute room, 1096A, housekeeping room next to 1096A and Elevator H, that an opening in an exit enclosure was from an unoccupied space. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

2. On 5/16/2013 at 2:10 pm, observation revealed on the Basement floor in the stair 17, that an opening in an exit enclosure was from an unoccupied space. The unoccupied space is the basement air handler room. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide enclosures around exit stairs with doors with positive-latching hardware. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 10:06 am, observation revealed on the First floor in Room 1468 in Smoke Compartment 2-K, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door to the Soiled Utility Room would not fully latch and close. This observed situation is not compliant with NFPA 101 (2000 ed.), 8.2.3.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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Based upon observation and staff interview, the facility did not provide a stairwell exit passage that was protected in accordance with NFPA 101 Section 7.2.6. This deficient practice could affect all patients, staff, and visitors in 20 of the 29 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/2013 at 1:25 pm observation revealed that the required 1st Floor exit passage enclosing corridors 1L and 1M, had double door assemblies with meeting edge gaps that exceeded 1/8 inch. This 90 minute fire rated door assembly had an exposed meeting edge without an astragal. Similarly, another set of fire rated doors that enclosed this exit passageway also had a meeting edge without an astragal to cover the gap exceeding 1/8 inch. This exit passageway serving required exit stairs was observed to have 2 hour fire rated construction and was not in compliance with NFPA Section 7.2.6 and 7.1. Plastic gasket or brush material products are not permitted as an astragal for fire rated doors per NFPA 80.

2. On 05/15/2013 at 1:35 pm observation revealed that the required 1st Floor exit passage fire rated ceiling enclosure had unprotected penetrations. Access hatch observation revealed that approximately six (6) sprinkler pipe penetrations were rough cut through the intended two (2) hour horizontal fire rated ceiling assembly. Additionally, approximately four (4) detector heads had drilled clearance holes that were unsealed. This exit passageway serving required exit stairs was observed to have 2 hour fire rated construction and was not in compliance with NFPA Section 7.2.6 and 7.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff M4 (Director of Facilities - Elmbrook) and Staff M7 (EUA).

Based on observation and interview, the facility did not provide egress paths at all times with enough exits that discharge to the exterior, compliant egress path, doors that opened with the necessary force, door hardware that operated with a single release motion, compliant egress path, doors that were unlockable in the egress path. This deficient practice could affect all patients, staff, and visitors in 20 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 12:00 pm, observation revealed on the 1st floor in stair 23, that the egress path was not compliant. There was not a safe path to a public way. The path passed next to unprotected windows and unprotected ventilation air discharge. The rating of the walls are unknown. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.7.

2. On 5/13/2013 at 1:00 pm, observation revealed on the 1st floor in the south tower lobby, that less than 50% of the exits from the upper floors of the building discharged directly to the exterior. At the discharge of the stairs, the discharge door was not distinguishable from the 2 adjacent side window panels and therefore, the exit door was not readily identifiable. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7 and 7.7.

3. On 5/14/2013 at 8:00 am, observation revealed on the 2nd floor in the OR suite, that the egress door was locked with an access control magnetic lock that was not compliant with the code. The 'push to exit button' was not labeled on the wall next to the switch. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.2.1.6.2.

4. On 5/14/2013 at 8:10 am, observation revealed on the 2nd floor in the recovery area, that the egress path was not compliant. The double doors out of the recovery suite could not be opened manually. The doors did not latch to the corridor and the doors were held open without releasing using a local smoke detector. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.7.

5. On 5/14/2013 at 8:20 am, observation revealed on the 2nd floor in room 284 doors, that the door in the path of egress opened when a force of 31 pounds pounds was applied, which exceeded the maximum 30 pounds needed to open an exit door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.5.

6. On 5/14/2013 at 9:30 am, observation revealed on the 2nd floor in the door SW 2064, that the egress door was locked with an access control magnetic lock with a motion sensor to release, but there was not a manual release switch within 5' of the door that killed power to the magnet. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.2.1.6.2.

7. On 5/14/2013 at 10:20 am, observation revealed on the 2nd floor in the door SW 246, that the egress door was locked with an access control magnetic lock with a motion sensor to release, but there was not a manual release switch within 5' of the door that killed power to the magnet. In addition, the door did not latch to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.2.1.6.2.

8. On 5/14/2013 at 3:20 pm, observation revealed on the 3rd floor at door ST 309, that the egress door was locked with an access control magnetic lock with a motion sensor to release, but there was not a manual release switch within 5' of the door that killed power to the magnet. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.2.1.6.2.

9. On 5/14/2013 at 4:00 pm, observation revealed on the 3rd floor in the when exiting out of PNAC unit, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a push bar (panic hardware) that when pushed, did not open the door unlock the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4.

10. On 5/15/2013 at 7:40 am, observation revealed on the 2nd floor in the associate walkway door SWA2000, going east, that the door was locked from the egress side. The door going east to the hospital was locked and only openable by pass key. This is a required exit, with an exit sign above the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4.

11. On 5/15/2013 at 8:10 am, observation revealed on the 2nd floor in the the 4 exits to 51st street by the parking garage, that the door threshold on one side of the door was 7 inches to sidewalk. This floor must be level within 1/2" on both sides of a door for a distance not less than the width of the widest door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.3, exception 2.

12. On 5/15/2013 at 8:20 am, observation revealed on the 2nd floor in the the south exit to the 51street from the associate walkway, that the egress path was not compliant. There was not a safe path to a public way. The path passed next to unprotected openings were cars are parked in the garage. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7, and 7.7.

13. On 5/15/2013 at 8:30 am, observation revealed on the 2nd floor in the exit from the OR penthouse to the parking garage, that the door (gate) was locked from the egress side. A key is required to exit the rooftop. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4.

14. On 5/15/2013 at 9:30 am, observation revealed on the 1st floor in the door by old discharge lobby by the bank, that the door in the path of egress did not swing in the direction of egress travel and the occupancy load of the egress was estimated to be at least 50 persons. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.2.

15. On 5/16/2013 at 4:20 pm, observation revealed on the 3rd floor in the LDR area, that the path of egress required travel through two delayed egress locks (DEL) to exit the building. DEL's were located on the path from Elevator F to Stair 12. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4 (exception 2).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide egress paths at all times with travel interruption at stairs that go below the level of exit discharge, the required signage, and locks that release in less than 15 seconds. This deficient practice could affect all patients, staff, and visitors in 30 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/13 at 8:55 am, observation revealed on the Second floor in the Stair #13, Smoke Compartment 2R, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. The stairway was missing a gate at Level G to stop passage to other levels. This observed situation is not compliant with NFPA 101 (2000 ed.), 7.7.3.

2. On 05/16/13 at 2:01 pm, observation revealed on the Fourth floor in Stairwell S-2, Level 4, that a delayed egress lock (DEL) did not have the required signage on the door. The door is a delayed door and needs signage stating to push on the door for 15 seconds. This observed situation is not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1.

3. On 05/16/13 at 2:03 pm, observation revealed on the Fourth floor in the Corridor 4860A Exit Door,in the Family Birth Center, that a delayed egress lock (DEL) did not have the required signage on the door. The door needs to be labeled delayed egress 15 seconds. This observed situation is not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1.

4. On 05/16/13 at 9:55 am, observation revealed on the Third floor in Stair #15 and Stair #16, that a delayed egress lock (DEL) did not release within 15 seconds of activation. This observed situation is not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
______________________________________

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 2 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 4:05 pm, observation revealed on the 2nd floor in the OR corridor, that the clear and unobstructed width of the corridor was 7'-6" because a CR machine stuck out into the 8 feet wide corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3.

2. On 5/15/2013 at 9:20 am, observation revealed on the 1st floor in the across corridor sliding doors northeast of old main entrance, that the clear and unobstructed width of the corridor is 8 feet wide, but the sliding doors do not break and swing open to 41.5 inches in the clear width for each door. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
______________________________________

Based on observation and interview, the facility did not ensure corridor doors provided the required clear width. This deficient practice could affect all patients, staff, and visitors in 1 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/14/2013 at 8:11 am, observation revealed on the 2nd floor in the recovery door, that the door(s) in the exits/corridor was narrower than the required 32" minimum clear width. The door(s) were 30 inches in actual clear width. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not ensure corridor doors provided the required clear width. This deficient practice could affect all patients, staff, and visitors in 5 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/13 at 10:44 am, observation revealed on the Third floor, Door SW3050, Smoke Compartment 3B, that the door(s) in the exits/corridor was narrower than the required 32" minimum clear width. The corridor door was only 36" did not meet the 44" requirement. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.2.3.5.

2. On 05/16/13 at 12:42 pm, observation revealed on the Fifth floor in Room 5056 & 5052, that the door(s) in the exits/corridor was narrower than the required 32" minimum clear width. The doors were only 22.5" in width. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.2.3.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
______________________________________

Based on observation and interview, the facility did not provide and maintain emergency illumination of exit and directional signs with exit signs that were continuously illuminated. This deficient practice could affect all patients, staff, and visitors in 10 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 9:51 am, observation revealed on the First floor in Stair 25, that the exit sign was not continuously illuminated and was not served by the emergency lighting system. The exit sign was missing above Stair 25. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.2.8 and 7.8.

2. On 05/15/13 at 3:54 pm, observation revealed on the Third floor in Stair 4, West side, that the exit sign was not continuously illuminated and was not served by the emergency lighting system. There was no exit sign above the stairway exit door. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.2.8 and 7.8.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
______________________________________

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures. This deficiency occurred in 1 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 11:30 am, observation and inter view revealed on the 1st floor in the Orth Nurse station Staff M25 (Patient Care Associate), Staff M26 (Orth Tech) and Staff M27 (Orth Tech), that staff were not familiar with their responsibilities in the event of a fire, including when to turn off the oxygen and where the valve to shut off the oxygen is located. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not maintain a writen evacuation plan that contained all the elements of an evacuation plan by having all the required elements. This deficient practice could affect all patients, staff, and visitors in 92 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 9:36 am, observation revealed on the First floor in the Fire Command Center #1418, Smoke Compartment 1M, that there was no evacuation plan or building drawings showing designated smoke compartments in the Fire Command Center. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.7.2.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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Based on record review and staff interview, the facility did not provide fire drills at unexpected (random) times as required by NFPA 101. This deficient practice could affect all patients, staff, and visitors in 29 of the 29 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/2013 at 2:00 pm, record review of the facility's fire drills over the past twelve months, revealed that three of four First shift fire drills, four of the four Second shift drills, and three of the four Third shift drills were conducted within an hour of each other. Per NFPA 101 section 4.7.5 and Section 19.7.1.2, the facility must conduct fire drills once per quarter per shift at unexpected times. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M4 (Director of Facilities - Elmbrook) and Staff M17 (Lead Boiler).

First Shift Data:
a) Fire drill held on 1/31/12 was at 08:10 am.
b) Fire drill held on 4/30/12 was at 08:00 am.
c) Fire drill held on 7/31/12 was at 08:15 am.
d) Fire drill held on 11/12/12 was at 8:25 am.

Second Shift Data:
a) Fire drill held on 2/29/12 was at 3:55 pm.
b) Fire drill held on 6/25/12 was at 4:00 pm.
c) Fire drill held on 8/30/12 was at 3:00 pm.
d) Fire drill held on 12/11/12 was at 4:00 pm.

Third Shift Data:
a) Fire drill held on 3/23/12 was at 6:30 am.
b) Fire drill held on 5/17/12 was at 6:30 am.
c) Fire drill held on 9/26/12 was at 6:21 am.

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with a smoke detector at the main fire panel. This deficiency occurred in 20 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/16/2013 at 10:40 am, observation revealed on the basement floor in the room 0023, storage, that the main fire alarm panel was not continuously occupied and a smoke detector was not provided at the location. This observed situation was not compliant with NFPA 72 (1999 ed.), 1-5.6.

2. On 5/13/2013 at 1:42 pm, observation revealed on the 1st floor in the conference room 1826 and conference room 2828, that the fire alarm installation was not compliant because a visual fire alarm notification device was not installed in a room that has 2 or more people in the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 1-5.2.5.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).

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27230

Based on observation and interview, the facility did not provide a fire alarm system and smoke detector that was installed according to NFPA 72. This deficient practice could affect all patients, staff, and visitors in 25 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/13 at 1:05 pm, observation revealed on the Fourth floor in the Corridor W416C, that the smoke detector was not located in accordance with NFPA 72 requirements. The smoke detector was observed only 6 inches from the air supply on the ceiling. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

2. On 05/15/13 at 3:16 pm, observation revealed on the Second floor in the Elevator C, that the smoke detector was not located in accordance with NFPA 72 requirements. There was no smoke detector within 5 feet of two elevators. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2.

3. On 05/15/13 at 4:05 pm, observation revealed on the Third floor in the Room 3239A, that the electrical circuit that provided power to the fire alarm panel was not marked in red. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 1-5.2.5.2.

4. On 05/16/13 at 10:03 am, observation revealed on the Fourth floor in the Room 3029A, Data Closet, that the fire alarm installation was not compliant. The Fire Alarm box was open in a data closet. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 1-5.2.5.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11(Architectural Designer).

Based on record review and interview, the facility did not maintain the fire alarm system according to NFPA 72 requirements with required testing. This deficient practice could affect all patients, staff, and visitors in 12 of 12 smoke compartments.

FINDINGS INCLUDE:

1. On 5/15/2013 at 2:00 pm record review revealed that the maintenance and inspection records of the fire alarm system were not available to verify that fire alarm battery charger test was performed, and batteries were tested for discharge test by disconnection from charger. The 2013 testing and inspection report prepared by the Fire Detection Group showed one voltage reading for each storage battery in the fire alarm system, but did not indicate that the charger and discharge test of batteries were completed in accordance with NFPA 72 (1999) sections 7-2.2 & 7-3.2. This observed situation was not compliant with NFPA 101 section 9.6.1.7.

2. On 5/15/2013 between 2:30 pm, record review revealed that the maintenance and inspection records of the fire alarm system were not available to verify that (i) the semi-annual visual inspection of smoke detectors was performed in accordance with NFPA 72 section 7-3.1, and (ii) one semi-annual load voltage test of fire alarm panel storage batteries was performed in between the annual fire alarm testing and inspection in accordance with NFPA 72 section 7-3.2. This observed situation was not compliant with NFPA 101 section 9.6.1.7.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff M15 (EUA), and Staff M22 (Mechanic). The above deficiency was also confirmed with Staff M1 (V.P. Facilities) at an exit conference on 05/15/2013 at 4:15 pm.

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with all rooms sprinkled when the code required full sprinkling, sprinklers that were close to the ceiling, sprinklers located the appropriate distance apart, and sprinklers free of obstructions near the ceiling. This deficiency occurred in 12 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 2:17 pm, observation revealed on the 2nd floor in the closet next to room 2823C, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The closet is 12 inches deep, 8 feet wide, and 8 feet tall with a 3 foot wide entrance door. This observed situation was not compliant with NFPA 101 (2000 ed.).

2. On 5/14/2013 at 10:00 am, observation revealed on the 2nd floor in shower of room 2087 in the OR area, that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because corridor walls are not 1 hour rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.1 (exception).

3. On 5/14/2013 at 11:55 am, observation revealed on the 7th floor in the shower stalls of the patient rooms, that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because corridor walls are not 1 hour rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.1 (exception).

4. On 5/14/2013 at 2:15 pm, observation revealed on the 8th floor in the former janitor closet, room 8031, that the sprinkler was placed farther than 22" below the ceiling. The sprinkler was located 30" below the ceiling. This situation would delay release of water and does not satisfy listing requirements. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-5.4.1.

5. On 5/14/2013 at 3:00 pm, observation revealed on the 3rd floor in room 3727A, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included draw curtains hanging from the ceiling. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

6. On 5/14/2013 at 4:25 pm, observation revealed on the 3rd floor in the room 3009, that a sprinkler was located 5' 6" apart. Sprinklers cannot be closer to each other than the minimum required separation distance of 6' or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.3.

7. On 5/15/2013 at 8:50 am, observation revealed on the 2nd floor in the medical records room 2001, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included medical records that were located 12.5 inches from the bottom of the sprinklers. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

8. On 5/15/2013 at 9:00 am, observation revealed on the 2nd floor in stair 32, that the stair was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The sprinkler was missing at the bottom of the stairs. This observed situation was not compliant with NFPA 101 (2000 ed.).

9. On 5/15/2013 at 9:10 am, observation revealed on the 1st floor in the SW canopy, that the area was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. Cars (combustibles) were parked under the old main entrance canopy. 6 cars were parked there, with 3 of them remaining more than 20 minutes and 1 more than 2 hours unattended. This observed situation was not compliant with NFPA 101 (2000 ed.).

10. On 5/15/2013 at 1:40 pm, observation revealed on the 1st floor in the radiology film room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included film storage files. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

11. On 5/15/2013 at 2:10 pm, observation revealed on the 1st floor in the Uncle Joe Museum, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included book cases and film storage. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

12. On 5/15/2013 at 5:15 pm, observation revealed on the 1st floor in the walk in refrigerator, room 1306H, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included storage 10 inches down from the sprinkler. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

13. On 5/15/2013 at 5:20 pm, observation revealed on the 1st floor in the small walk in refrigerator, room G1306G, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included storage of food blocking the sprinklers. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

14. On 5/16/2013 at 8:55 am, observation revealed on the basement floor in the 'Car' room, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. Sprinkler coverage did not extend to the back porch. This observed situation was not compliant with NFPA 101 (2000 ed.).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with ceilings sealed above the sprinklers to collect heat, non-sprinkled rooms that met permitted exceptions, all rooms sprinkled when the code required full sprinkling, and sprinklers located at the appropriate distance from the ceiling. This deficient practice could affect all patients, staff, and visitors in 30 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 9:50 am, observation revealed on the First floor in room 1451A, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. A hole was observed in the large ceiling panel by the back door. This observed situation is not compliant with NFPA 25 (1998 ed.), 1-11.1.

2. On 05/15/13 at 10:03 am, observation revealed on the First floor in room 1411, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. A hole was observed in the ceiling at the Visual Acuity Nurse Station This observed situation is not compliant with NFPA 25 (1998 ed.), 1-11.1.

3. On 05/15/13 at 10:02 am, observation revealed on the First floor in the ER18, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. Sprinkler coverage was also missing towards Room #1. This observed situation is not compliant with NFPA 101 (2000 ed.).

4. On 05/15/13 at 2:59 pm, observation revealed on the Second floor in Stairwell #1, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. The Stairwell had a 1" diameter hole in the west wall. This observed situation is not compliant with NFPA 25 (1998 ed.), 1-11.1.

5. On 05/15/13 at 3:46 pm, observation revealed on the Third floor in East 362, Smoke Compartment 3G, that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with a 2-hour rated construction. The balcony of the Chapel was found not to be fully sprinkler protected. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.5.1 (exception).

6. On 05/15/13 at 4:05 pm, observation revealed on the Third floor in Room 3239B, that a sprinkler was located too low to provide adequate water coverage to the ceiling area. Sprinklers can be a maximum of 12" below an unobstructed ceiling. This observed situation is not compliant with NFPA 13 (1999 ed.), 5-6.4.1.1.

7. On 05/15/13 at 4:07 pm, observation revealed on the Third floor in the all the third floor patient bathrooms in Smoke Compartment 3G, that the rooms were not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The patient bathrooms were missing adequate sprinkler coverage that would reach the shower area. This observed situation is not compliant with NFPA 101 (2000 ed.).

8. On 05/15/13 at 4:36 pm, observation revealed on the Fourth floor in the all the fourth floor patient bathrooms in Smoke Compartment 4G, that the rooms were not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The patient bathrooms were missing adequate sprinkler coverage that would reach the shower area. This observed situation is not compliant with NFPA 101 (2000 ed.).

9. On 05/15/13 at 4:39 pm, observation revealed on the Fourth floor in Room 4239A, that a sprinkler was located too low to provide adequate water coverage to the ceiling. Sprinklers can be a maximum of 12" below an unobstructed ceiling. This observed situation is not compliant with NFPA 13 (1999 ed.), 5-6.4.1.1.

10. On 05/15/13 at 4:49 pm, observation revealed on the Fifth floor in the all the fifth floor patient bathrooms in Smoke Compartment 5E, that the rooms were not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The patient bathrooms were missing adequate sprinkler coverage that would reach the shower area. This observed situation is not compliant with NFPA 101 (2000 ed.).

11. On 05/15/13 at 4:59 pm, observation revealed on the Fifth floor in the Room 5239A, that a sprinkler was located too low to provide sprinkler coverage to the ceiling area. Sprinklers can be a maximum of 12" below an unobstructed ceiling. This observed situation is not compliant with NFPA 13 (1999 ed.), 5-6.4.1.1.

12. On 05/15/13 at 1:00 pm, observation revealed on the Second Third, Fourth , Fifth and Sixth floor in the patients rooms - second floor rooms: 2321,2323,2332,2300 & 2243; third floor rooms: 3327,3329,3331,3333 & 3330; fourth floor rooms: 4322,4237,4234,4233 & 4232; fifth floor rooms: 5047,5043,5044,5050 & 5049; sixth floor rooms: 6253,6251,6249,6315 & 6317; that the sprinkler was placed farther than 22" below the ceiling. The metal pan ceiling allows heat to pass through the holes when there is no insulation on the metal pans. The condition was observed throughout the above mentioned floors. This situation would delay release of water and does not satisfy listing requirements. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-5.4.1.

13. On 05/15/13 at 5:12 pm, observation revealed on the Fifth floor in the Stair #1, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. There was no sprinkler coverage at the top of Stair #1. This observed situation was not compliant with NFPA 101 (2000 ed.).

14. On 05/15/13 at 5:34 pm, observation revealed on the Sixth floor in the all the sixth floor patient bathrooms I , that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The patient bathrooms were missing adequate sprinkler coverage that would reach the shower area . This observed situation was not compliant with NFPA 101 (2000 ed.).

15. On 05/16/13 at 8:11 am, observation revealed on the Second floor in the ICU Room 2402, Smoke Compartment 2Q, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included a Medical Gas Column. This condition was found throughout the patient rooms in the ICU. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

16. On 05/16/13 at 8:49 am, observation revealed on the Second floor in the 2445A-B data closets, Smoke Compartment 2R, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The data closet was not sprinkler protected. This observed situation was not compliant with NFPA 101 (2000 ed.).

17. On 05/16/13 at 9:12 am, observation revealed on the Second floor in the Stair 6, that sprinkler protection was not provided at Skylight in Canopy overhang outside Stair 6. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-13.8.1.

18. On 05/16/13 at 9:33 am, observation revealed on the Third floor in the 3207A&B Utility Closets, that a sprinkler was located too low to provide adequate sprinkler protection to the ceiling area. Sprinklers can be a maximum of 12" below an unobstructed ceiling. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.4.1.1.

19. On 05/16/13 at 10:10 am, observation revealed on the Third floor in the Room 3080, Male Physician's Locker Room, Smoke Compartment 3B, that the sprinkler support system was used to support nonsystem components. Sprinkler heads were dusty and dirty. This observed situation was not compliant with NFPA 13 (1999 ed.), 6-1.1.5.

20. On 05/16/13 at 10:10 am, observation revealed on the Third floor in the Room 3080 & Room 3071 Room, Smoke Compartment 3B, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. It was noted that sprinkler coverage in the shower areas was missing. This observed situation was not compliant with NFPA 101 (2000 ed.).

21. On 05/16/13 at 10:20 am, observation revealed on the Third floor in the Room 3070 , that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. There is no sprinkler coverage provided to the shower. This observed situation was not compliant with NFPA 101 (2000 ed.).

22. On 05/16/13 at 1:35 pm, observation revealed on the Fourth floor in the Corridor 4830B, Smoke Compartment 4F, that the sprinkler support system was used to support nonsystem components. Sprinkler heads were noted to be dusty throughout the corridor. This observed situation was not compliant with NFPA 13 (1999 ed.), 6-1.1.5.

23. On 05/16/13 at 12:15 pm, observation revealed on the Fifth floor in the Room 5606A, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. Big pipe chase not sprinkler protected in men's toilet room. This observed situation was not compliant with NFPA 101 (2000 ed.).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
______________________________________

Based on observation and interview, the facility failed to install the sprinkler system in accordance with the requirements of NFPA 101 - 2000 edition, Sections 19.3.5, 19.3.5.1 and 9.7: NFPA 13 - 1999 edition, Section 5-1.1. This deficient practice could affect all patients, staff, and visitors in 29 of the 29 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/2013 at 2:45 pm, observation revealed that the Powerhouse upper level had a main fire pump water supply line valve that was not supervised by the fire alarm system. No visible wiring or supervisor tamper switch was observed in the overhead area around this elevated valve. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M4 (Director of Facilities - Elmbrook) and Staff M17 (Lead Boiler).

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, and sprinklers free of lint. This deficiency occurred in 2 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 12:35 pm, observation revealed on the 1st floor in the outpatient pharmacy in south tower, that the escutcheon ring on the sprinkler was missing This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

2. On 5/15/2013 at 4:00 pm, observation revealed on the 1st floor in the Concession area, room 1200A, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. In addition, a Pepsi machine blocks full sprinkler coverage. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).



27230

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. This deficient practice could affect all patients, staff, and visitors in 25 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 9:36 am, observation revealed on the First floor in the Fire Command Center #1418, Smoke Compartment 1M, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. Two sprinkler heads were noted to be dusty. This observed situation is not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

2. On 05/15/13 at 9:44 am, observation revealed on the first floor in the Housekeeping Closet #1428, that a sprinkler had paint on the head. The sprinkler deflector was bent also changing the sprinkler flow pattern. This observed situation is not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

3. On 05/15/13 at 9:46 am, observation revealed on the first floor in the Room 1431, Room 1433, Room1427, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. Sprinkler heads were dusty throughout rooms in Smoke Compartment 1M. This observed situation is not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

4. On 05/15/13 at 9:52 am, observation revealed on the First floor in the ER17 in Smoke Compartment 1M, that the escutcheon ring on the sprinkler was missing. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation is not compliant with NFPA 25 (1998 ed.), 1-11.1 .

5. On 05/15/13 at 3:35 pm, observation revealed on the Second floor in the Room 2225A, that the escutcheon ring on the sprinkler was missing from the closet sprinkler. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation is not compliant with NFPA 25 (1998 ed.), 1-11.1.

6. On 05/15/13 at 4:02 pm, observation revealed on the Third floor in the Room 3230, that the escutcheon ring on the sprinkler was not tight to the ceiling. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation is not compliant with NFPA 25 (1998 ed.), 1-11.1.

7. On 05/16/13 at 8:54 am, observation revealed on the Second floor in the Corridor 239C, that the escutcheon ring on the sprinkler was missing on the sprinkler outside the double doors. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation is not compliant with NFPA 25 (1998 ed.), 1-11.1.

8. On 05/16/13 at 2:08 pm, observation revealed near Elevator F, in Room 4830A, that sprinkler heads were not maintained properly. Paint was observed on the sprinkler bulbs above the nurse's station and in front of Elevator F. This observed situation is not compliant withNFPA 25 (1998 ed.), 2-2.1.1.

9. On 05/16/13 at 10:21 am, observation revealed in Room 3119, Employee Lounge, that the escutcheon ring on the sprinkler was not tight to the ceiling. This gap may reduce the response time of the sprinkler in the room and does not duplicate the tight conditions that are used in the sprinkler escutcheon listed testing agency certification test. This observed situation is not compliant with NFPA 25 (1998 ed.), 1-11.1.

10. On 05/16/13 at 8:55 am, observation revealed on Stair 13 stairwell, Smoke Compartment 2R, that sprinkler heads throughout the stairwell were not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. Sprinkler heads were dusty throughout the stairwell. This observed situation is not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

11. On 05/16/13 at 9:52 am, observation revealed in OR1, OR2, and OR3, Smoke Compartment 3B, that sprinkler heads in all three operating rooms were dusty and not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation is not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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Based on record review and staff interview, the facility did not provide portable extinguishers in compliance with NFPA 101- Section: 19.3.5.6 and 9.7.4.1 as evidenced by the following finding. This deficient practice could affect all patients, staff, and visitors in 10 of the 29 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/2013 at 10:32 am, record review revealed that the facility had five (5) portable halon fire extinguishers in the facility. Portable halon extinguishing agents have been deemed detrimental to healthcare occupants. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M16 (Safety Coordinator) and Staff M20 (EUA).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, access to fire dampers, and compliant fire dampers. This deficiency occurred in 4 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/14/2013 at 10:10 am, observation revealed on the 2nd floor in the Cath lab office, , that airflow between the corridor and this room was not neutral. There was supply into the room, but no return. Air was being returned in the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.), 2-3.11.1.

2. On 5/16/2013 at 11:00 am, observation revealed on the basement floor in the room 0023, storage, that airflow between the corridor and this room was not neutral. The room was positive pressure to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.), 2-3.11.1.

3. On 5/16/2013 at 1:50 pm, observation revealed on the basement floor in the Electrical Vault from WL 09 to WL10, that a service opening of sufficient size was not provided adjacent to the fire damper to permit maintenance and resetting the device. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 and NFPA 90A, (1999 ed.) 2-3.4.1.

4. On 5/16/2013 at 2:30 pm, observation revealed on the basement floor in the Electrical Transfer Vault near WL 09 & WL 10, that a duct with a fire damper that penetrated the rated ceiling did not have retaining angles and could not be confirmed it was installed according to its listing instructions. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 and NFPA 90A (1999 ed.), 3-3.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not maintain a kitchen hood system as required by NFPA 96. This deficient practice could affect all patients, staff, and visitors in 15 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 5:49 pm, observation revealed on the Second floor in Room E267, Smoke Compartment 2N, that the kitchen hood suppression system was not compliant. There were four abandoned grease ducts in the shaft that are no longer being used. Staff could not verify any fire termination system at the end of the grease ducts. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.2.6 and 9.2.3 and NFPA 96.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).

Based on observation and interview, the facility did not maintain an egress path that was free of obstructions that obstruct egress. This deficiency occurred in 2 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 12:45 pm, observation revealed on the 1st floor in the patient registration office, room 1806A, that items were stored in the exit access pathway, including chair blocking the door swing The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use and relocation during a fire emergency. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 (exception 6), and 19.7.5.5.

2. On 5/14/2013 at 9:52 am, observation revealed on the 2nd floor in the OR corridor, that items were stored in the exit access pathway, including 3 carts of storage The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 and 19.7.5.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
______________________________________

Based on interview, and a review of facility flame spread documents, the facility did not provide hanging drapes or curtains that met code requirements, such as flammability or sprinkler obstruction with cubical curtains that permit the designed distribution of sprinkler water, and verification of rated hanging materials. This deficiency occurred in 5 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/14/2013 at 12:30 pm, observation revealed on the 7th floor in the curtains in the Hospice area, that loosely hanging fabric was installed that did not have a manufactures flame spread label and the facility was unable to verify that it met the appropriate listing. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.1 and 10.3.1.

2. On 5/14/2013 at 4:30 pm, observation revealed on the 3rd floor in the tub rooms of south west area of OBYGN, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water at the solid plastic strip of curtain above the holes of the tub curtain. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.5 and NFPA 13 (1999 ed.) 5-6.5.2.3.

3. On 5/15/2013 at 10:45 am, observation revealed on the 1st floor in room 1151, that loosely hanging fabric was installed that did not have a manufactures flame spread label and the facility was unable to verify that it met the appropriate listing. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.1 and 10.3.1.

4. On 5/16/2013 at 8:50 am, observation revealed on the basement floor in the PT living skills area, that loosely hanging fabric was installed that did not have a manufactures flame spread label and the facility was unable to verify that it met the appropriate listing. PT living skills has a canvas awning in the car room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.1 and 10.3.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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27230

Based on observation and interview, the facility did not provide cubical curtains that permit the designed distribution of sprinkler water. This deficient practice could affect all patients, staff, and visitors in 1 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/16/13 at 1:55 pm, observation revealed on the Fifth floor in Room 5856, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to water due to the lack of clearance. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.5.5 and NFPA 13 (1999 ed.) 5-6.5.2.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
______________________________________

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with and properly sized storage containers for soiled/trash. This deficiency occurred in 3 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/16/2013 at 10:10 am, observation revealed on the Basement floor, in the corridor outside of the sterile processing room, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. A 2 foot by 4 foot by 3 foot container full of cardboard was stored in the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

2. On 5/16/2013 at 11:55 am, observation revealed on the Basement floor in the corridor by lab, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. Two trash container were greater than 32 gallons in the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

3. On 5/16/2013 at 1:20 pm, observation revealed on the Basement floor in Room 0040, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. Three 32 gallon trash contains were next to each other. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with properly labeld gas monitors and cylinders restrained from falling. This deficient practice could affect all patients, staff, and visitors in 2 of the 29 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/2013 at 10:50 am, observation revealed on the 5th floor in the ICU Nurse Station (562), that patient medical gas monitor was not labeled to identify the rooms or spaces it served. This observed situation is not compliant with NFPA 101 (2000 ed.) section 19.3.2.4 and NFPA 99 (1999 ed.) section 4-3 Level 1 Piped Systems.

2. On 05/15/2013 at 2:15 pm, observation revealed on the 1st floor in Room 133B, that four (4) carbon dioxide size H cylinders were not restrained. These cylinders were not secured are were subject to being, damaged, dislocated, knocked over or falling.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff M4 (Director of Facilities - Elmbrook) and Staff M7 (EUA).

Based on observation and interview with staff, the facility did not provide smoke removal system for anesthetizing locations. This deficient practice could affect all patients, staff, and visitors in 1 of the 92 smoke compartments.
FINDINGS INCLUDE:

1. On 05/14/13 at 8:45 am, observation revealed in Operation Room (OR) area, Cysto-1, that an automatic smoke removal system was not installed for this anesthetizing location. This observed situation was not compliant with NFPA 99 (1999 edition), 5-4.1.3.

The above observed condition was confirmed with concurrent observation and interview with Staff M3 (HVAC tradesman), Staff M9 (Mechanic), Staff M13 (Risk Analyst), and Staff M7 (Architect EUA).

Item #1
Based on observation and interview, the facility did not ensure that corridors did not have excessively long dead-ends as permitted by the code. This deficient practice could affect all patients, staff, and visitors in 3 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 1:52 pm, observation revealed on the 2nd floor in the corridor 2829 (labeled passage) near elevator F, that a dead end corridor of 34 feet was observed. The surveyor observed that it would be practical and feasible to alter the layout to provide a corridor without a dead end. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.10.

2. On 5/14/2013 at 3:40 pm, observation revealed on the 3rd floor in the corridor by elevator FF on the 3rd floor, that a dead end corridor of 46 feet is created by locking of across corridor doors. In addition, the dead end corridor creates a smoke barrier area that does not have a pathway out. The surveyor observed that it would be practical and feasible to alter the layout to provide a corridor without a dead end. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.10.

3. On 5/16/2013 at 12:08 pm, observation revealed on the Basement floor in the Entrance (south entrance) to Main Lab, that a dead end corridor of 40 feet was observed. The surveyor observed that it would be practical and feasible to alter the layout to provide a corridor without a dead end. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.10.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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ITEM #2

Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies, and suite travel distance under the required limits. This deficient practice could affect all patients, staff, and visitors in 5 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/14/2013 at 8:50 am, observation revealed on the 2nd floor in the OR staff lounge, that the travel distance through two intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. The travel distance through 2 intervening rooms of the suite is 66 feet. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.8.

2. On 5/14/2013 at 3:50 pm, observation revealed that stair 10 doors, which serves 8 stories, did not allow re-entry from the stair enclosure to the interior of the building per NFPA 101, 7.2.1.5.2.

3. On 5/15/2013 at 2:40 pm, observation revealed on the 1st floor in the stair 16, that stair 16 doors, which serves 8 stories, did not allow re-entry from the stair enclosure to the interior of the building per NFPA 101, 7.2.1.5.2 for at least the first 3 floors.

4. On 5/16/2013 at 8:45 am, observation revealed on the basement floor in room 0012L, that the travel distance through two intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. The travel distance through 2 intervening rooms of the suite is 72 feet. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.8.

5. On 5/16/2013 at 9:20 am, observation revealed on the basement floor in the pool room of PT/OT area, that the travel distance through two intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. The travel distance is 115 feet. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.8.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).

______________________________________

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with electrical panels with complete directories, fixed wiring rather than extension cords, non-compliance, and working clearances at electrical panels. This deficiency occurred in 7 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 1:15 pm, observation revealed on the 1st floor in the rooms 1819, and 1829, that electrical panel breaker(s) were not labeled to identify the loads they fed. The spare breakers were not labeled. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

2. On 5/13/2013 at 4:25 pm, observation revealed on the 2nd floor in the various machines in the operating room were connected to a strip plug extension cord (temporary power tap (also called 'the power ball') ) that was used as a substitute for fixed wiring. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

3. On 5/15/2013 at 2:20 pm, observation revealed on the 1st floor in the elevator room near room 1022A, that access to electrical panel was less than 3'-0" clearance. Carts, ladders and light bulbs blocked the access to the electrical panels. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

4. On 5/16/2013 at 10:25 am, observation revealed on the basement floor in the housekeeping room near sterile processing (room 0027), that access to electrical panel was less than 3'-0" clearance. Carts were in front of electrical panel This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

5. On 5/16/2013 at 2:00 pm, observation revealed on the basement floor in the Electrical Vault near door WL 09 and WL10, that the electrical code was not followed. There was storage of ventilation filters in the dedicated electrical vault. This observed situation was not compliant with NFPA 70 (1999 ed.).

6. On 5/16/2013 at 2:20 pm, observation revealed on the basement floor in the Labor/ Delivery Triage area, by reception desk, that access to electrical panel was less than 3'-0" clearance. A refrigerator obstructed the electrical panel. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

7. On 05/13/13 at 12:15 pm, observation by surveyor #22198 revealed in the Neonatal ICU, room #3812 that 2 electrical boxes (one large above and one smaller directly below it) were open. The smaller electrical box was open and the cover hanging below it, exposing wires that were covered with electrical tape. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

These conditions were confirmed with concurrent observation and interview with Staff M3 (HVAC tradesman), Staff M9 (Mechanic), Staff M13 (Risk Analyst), and Staff M7 (Architect EUA).
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27230

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords, electrical panels with complete directories, closed electrical raceways, fixed wiring rather than extension cords, and working clearances at electrical panels. This deficient practice could affect all patients, staff, and visitors in 12 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/13 at 3:34 pm, observation revealed on the Second floor in Room 2226, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to an electrical power strip being used to power a microwave, toaster and coffee pot. This observed situation is not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

2. On 05/15/13 at 3:58 pm, observation revealed on the Third floor in Corridor 308C, that electrical panel breaker(s) were not labeled to identify the loads they fed. Breakers #10 and #18 were in the "on position" but were noted as spares on the panel labeled Emergency 3/XE. Breaker #28, in Panel 3-F located next to Panel 3/XE, was in the "on position" but labeled as a spare. This observed situation is not compliant with NFPA 70 (1999 ed.), Section 110-22.

3. On 05/15/13 at 5:42 pm, observation revealed on the Second floor in Room E267, Smoke Compartment 2N, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel P/25 indicated breaker #7 was in the "on position" but was not identified. This observed situation is not compliant with NFPA 70 (1999 ed.), Section 110-22.

4. On 05/15/13 at 5:42 pm, observation revealed on the Second floor in Room E267, Smoke Compartment 2N, that a electrical box did not have a cover so the raceway system was not enclosed. This observed situation is not compliant with NFPA 70 (1999 ed.), 517-12.

5. On 05/16/13 at 8:19 am, observation revealed on the Second floor in Room 2440K, Soiled Utility Room, Smoke Compartment 2Q, that access to the electrical panel was less than 3'-0" clearance. A 100 gallon dumpster was parked in front of the electrical panel blocking access to the panel. This observed situation is not compliant with NFPA 70 (1999 ed.), 110-26.

6. On 05/16/13 at 8:20 am, observation revealed on the Second floor in Room 2440F, that access to the electrical panel was less than 3'-0" clearance. Three electrical panels were blocked by two 24" x 60" carts. This observed situation is not compliant with NFPA 70 (1999 ed.), 110-26.

7. On 05/16/13 at 8:33 am, observation revealed on the Second floor in Room 2440H, Smoke Compartment 2Q, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to charge the Respiratory Care Vent Machine Batteries. This observed situation is not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

8. On 05/16/13 at 8:53 am, observation revealed on the Second floor in the N2303 Storage Room, Smoke Compartment 2R ,that access to the electrical panel was less than 3'-0" clearance. Electric panel 2NC/A was blocked by stacked chairs and a paper box. This observed situation is not compliant with NFPA 70 (1999 ed.), Section 110-26.

9. On 05/16/13 at 10:17 am, observation revealed on the Third floor in Room W335, Electrical Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Electric Panel 3/C was missing the identification card for all breakers. Panel MDP-12-W did not have breaker #4 identified but it was in the "on position". Panel EC3C had breakers #31 and #33 labeled as spares but both breakers were in the "on position". This observed situation is not compliant with NFPA 70 (1999 ed.), Section 110-22.

10. On 05/16/13 at 10:22 am, observation revealed on the Third floor in Corridor 3030C outside room 3078, Smoke Compartment 3A, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel L31 had breakers #8 &-#18 labeled as spares but the breakers were in the "on position". This observed situation is not compliant with NFPA 70 (1999 ed.), Section 110-22.

11. On 05/16/13 at 12:56 pm, observation revealed on the Fifth floor in Stair 15, level 5, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panels 5/B had breakers #8,#12 & #17 in the "on position" but not identified. This observed situation is not compliant with NFPA 70 (1999 ed.), Section 110-22.

12. On 05/16/13 at 1:48 pm, observation revealed on the Fifth floor in the Room 5818, that access to electrical panel was less than 3'-0" clearance. Panel 5S/CD had items blocking access to Electrical Panel. This observed situation is not compliant with NFPA 70 (1999 ed.), 110-26.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
______________________________________

Based on record review and interview, the facility did not provide and use a program to respond to outages of the sprinkler system with a complete procedure for responding to outages. This deficient practice could affect all patients, staff, and visitors in 92 of the 92 smoke compartments.

FINDINGS INCLUDE:

On 5/13/2013 at 2:25 pm, review of facility documents revealed that the facility did not have an appropriate response to outages of the sprinkler system that occur for more than 4 hours in a 24 hour period. The Wheaton Franciscan Policy and Procedures Manual contained a Fire Watch policy for sprinkler outages that was incorrect in its response when a fire watch participant observes an actual fire situation. When an actual fire is observed no unique activity was identified in how to notify the occupants of the facility. The Safety Coordinator (M12) explained that it was the facility's intent to reference other facility policies. The written procedure lacked any specific detail different from when the sprinkler system was out of service or their corresponding sprinkler system was out of service, each has a different means to notify emergency forces and facility staff. Written procedures are required to ensure effective communication under varying conditions to local emergency responders and all staff to facilitate in-service training and improve effective performance during an actual system outage.

This observed situation is not compliant with NFPA 101 (2000 edition), 9.7.6.1. The condition was confirmed at the time of discovery by a record review and interview with the Safety Coordinator (M12) and V.P. Construction Facilities (M1).

Based on record review and interview, the facility did not provide and use a program to respond to outages of the fire alarm system with a complete procedure for responding to outages. This deficient practice could affect all patients, staff, and visitors in 92 of the 92 smoke compartments.

FINDINGS INCLUDE:

On 5/13/2013 at 2:30 pm, review of facility documents revealed that the facility did not have an appropriate response to outages of the fire alarm system that occur for more than 4 hours in a 24 hour period. The Wheaton Franciscan Policy and Procedures Manual contained a Fire Watch policy for fire alarm outages that was incorrect in its response when a fire watch participant observes an actual fire situation. When an actual fire is observed no unique activity was identified in how to notify the occupants of the facility, given that the fire alarm system was rendered inoperable. The Safety Coordinator (M12 explained that it was the facility's intent to reference other facility policies. The written procedure lacked any specific detail different from when the fire alarm system was out of service or their corresponding sprinkler system was out of service, each has a different means to notify emergency forces and facility staff. Written procedures are required to ensure effective communication under varying conditions to local emergency responders and all staff to facilitate in-service training and improve effective performance during an actual system outage.

This observed situation is not compliant with NFPA 101 (2000 edition), 9.6.1.8. The condition was confirmed at the time of discovery by a record review and interview with the Safety Coordinator (M12) and V.P. Construction Facilities (M1).