HospitalInspections.org

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 corridor (223C) going into the Parking Garage, from the employee bridge, that the 'door' in the 2-hour fire-rated separation wall could not be verified of having at least a 90 minute fire-rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4 and 8.2.3.2.3.
Approved POC stated 10/4/2013.

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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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:
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.
Approved POC stated 10/4/2013.

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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27230

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 1 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.
POC states completion January 4, 2014.

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 1 of the 92 smoke compartments.

FINDINGS INCLUDE:

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 (0049 Work Area+ Rm. 408C+ Rm. 4016), 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.
Accepted POC stated July 4, 2014.

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 (S16-00) 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.
Accepted POC stated July 4, 2014.

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 doors with positive-latching hardware, and rated wall construction. This deficient practice could affect all patients, staff, and visitors in 8 of the 92 smoke compartments.

FINDINGS INCLUDE:
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.
Approved POC extention to 7/4/2013.

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.
Approved POC extention to 7/4/2013.

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 8 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.
Approved POC stated 1/4/2014.

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 (Outside Room 2219 in Corridor 211C), 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.
Approved POC stated 10/4/2013.

2. On 5/14/2013 at 0:11 am, observation revealed on the 2nd Floor in the OR Suite, that the fire barrier door at (Room 2052, Clean Storage) was magnetically held open and did not have an adjacent smoke detector that was inter-connected 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.
Approved POC stated 10/4/2013.

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 (Outside of Room 2219 in Corridor 211C), that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was inter-connected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.
Approved POC stated 10/4/2013.

2. On 5/14/2013 at 0:11 am, observation revealed on the 2nd floor in the OR Suite (Door at Room 2052 Clean Storage) , that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was inter-connected 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.
Approved POC stated 10/4/2013.

4. On 5/15/2013 at 3:50 pm, observation revealed on the 1st floor at the door FC1200W (at Cafeteria Dining), that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was inter-connected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.
Approved POC stated 7/4/2014.

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.
Approved POC stated 7/4/2014.

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 smoke compartments of the appropriate layout or egress configuration. This deficient practice could affect all patients, staff, and visitors in 2 of the 92 smoke compartments.

FINDINGS INCLUDE:

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.
Approved POC extended to 7/4/2014.

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 2 of the 92 smoke compartments.

FINDINGS INCLUDE:

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.
Approved POC extention to 7/4/2014.

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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Outstanding items remaining after V.V. on 8/27/2013:
(Sandy - please go in and make all the nessary corrections, and if all elements are completed, please show the entire tag as corrected.)

Based on observation and staff interview, the facility did not provide smoke barrier doors that were self-closing or installed with proper astragals as required in NFPA 101-Section 19.3.7 as evidenced by the following findings. This deficient practice could affect all patients, staff, and visitors in 1 of the 29 smoke compartments.

FINDINGS INCLUDE:

1. On 05/15/2013 at 11:53 am, observation revealed on the 2nd Floor that the north door of the paired opening in this smoke barrier near QC room #R232 was not equipped with a door closer. 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 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 2 of the 92 smoke compartments.

FINDINGS INCLUDE:
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.
Approved POC stated 10/4/2013.

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.
Approved POC stated 1/4/2014.

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 rated doors and rated wall construction. This deficient practice could affect all patients, staff, and visitors in 5 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 1:38 pm, observation revealed on the 1st floor in the conference Room 1825 and Room 1835, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The door also did not have a required door closer. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.
Approved POC stated 1/4/2014.

2. On 5/14/2013 at 12:45 pm, observation revealed on the 8th Floor in the Storage Room of the Pharmacy (8074 & 8076), going into the Pharmacy Drug Clean Rooms, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute fire rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.
Approved POC stated 1/4/2014.

3. On 5/15/2013 at 9:50 am, observation revealed on the 2nd floor in Room 2011E, Medical Staff Office, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was not installed above the lay in ceiling. The door also was not fire rated and did not have a required door closer. Movable files were stored in this room. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.
Approved POC extended to 10/4/2013.

4. On 5/15/2013 at 11:00 am, observation revealed on the 1st floor in the Room 1155, New Storage Room, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The door also did not have a required door closer. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.
Approved POC stated 1/4/2014.

5. On 5/15/2013 at 1:15 pm, observation revealed on the 1st floor in the Radiology Film Room (1041F), that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had shutter that was not installed in a one hour rated wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.
Approved POC stated 10/4/2013.

These conditions were 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 and maintain at least 2 approved and remote Eits 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 Compartment, rather than into a corridor system. The other EXIT goes into the treatment area and 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:

1.1. On 5/15/2013 at 3:40 pm, observation revealed on the 1st floor in the Exit Passageway, containing a Linen Chute Room 1096A, Housekeeping Room next to 1096A and a Service Elevator 'H' all opening onto the Exit Passageway. These spaces are considered unoccupied and not allowed to open onto an Exit Passageway. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).
Approved POC stated 7/4/2014.

1.2. On 5/16/2013 at 2:10 pm, observation revealed on the Basement floor in Stair 17-00, that an opening in an exit enclosure was from an unoccupied space. The unoccupied space is from the Basement Air Handler Room. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).
Approved POC stated April 4, 2014.

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, 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:
1.1. On 5/13/2013 at 12:00 pm, observation revealed on the 1st floor in Stair 23-01, 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.
Approved POC stated 7/4/2014.

1.2. On 5/13/2013 at 1:00 pm, observation revealed on the 1st floor in the Lobby South Tower, 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.
Approved POC stated 7/4/2014.

1.4. On 5/14/2013 at 8:10 am, observation revealed on the 2nd floor in the Recovery Room, that the egress path was not compliant. The double doors out of the Recovery Suite and into the Surgery Corridor could not be opened manually (currently automatic only). The doors did not latch to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.2.7 and 7.7.
Approved POC stated 7/4/2014.

1.5. On 5/14/2013 at 8:20 am, observation revealed on the 2nd floor in Room 284, the doors in the path of egress opened when a force of 31 pounds was applied. This 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.
Approved POC stated 7/4/2014.

1.11. On 5/15/2013 at 8:10 am, observation revealed on the 2nd floor in the 4 Exits to 51st Street at the Open Parking Garage, that the door threshold on one side of the door was 7 inches to the 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.
Approved POC stated 7/4/2014.

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 2 of the 92 smoke compartments.

FINDINGS INCLUDE:

2.1. On 05/16/13 at 8:55 am, observation revealed on the Second floor in the Stair 13-01, 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.
Approved POC stated 7/4/2014.

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 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 (at entrance), that the clear and unobstructed width of the corridor was 7'-6" because a CR machine stuck out into the 8 feet wide corridor. On 8/27/2013 observed four linen and supply carts in the corridor without being attended to. The equipment storage is still an issue within the Surgery Department. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3.
Approved POC extention to 7/4/2014.
(Until a proper storage room is created within Surgery Department.)

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 Hospital Entrance 1000/119C, 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.
Approved POC stated 1/4/2014.

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 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:

1.1. On 5/14/2013 at 8:11 am, observation revealed on the 2nd floor at the Recovery Room 2025, double doors, that the door(s) in the exits/corridor were 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.
Approved POC stated 7/4/2014.

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 2 of the 92 smoke compartments.

FINDINGS INCLUDE:

2.2. On 05/16/13 at 12:42 pm, observation revealed on the 5th Floor in Rooms 5056 & 5052, that the doors 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.
Approved POC stated 7/4/2014 with letter extension.

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 doors with the required clear width. This deficient practice could affect all patients, staff, and visitors in 2 of the 92 smoke compartments.

FINDINGS INCLUDE:

1. On 5/13/2013 at 12:13 pm, observation revealed on the 1st Floor in the Main Lobby (1800), the side doors to the revolving doors of the New South Tower, that the door(s) in the exits/corridors used by patients, was narrower than the required 41.5" minimum clear width. Door(s) 36 inches wide were located 12 to 13 feet to the side of the revolving door. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5.
Approved POC stated 7/4/2014.

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 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 1 of the 92 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1.9. On 5/15/2013 at 9:10 am, observation revealed on the 1st floor under 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.).
Approved POC stated 1/4/2014.

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:
2.5. On 05/15/13 at 3:46 pm, observation revealed on the 3rd Floor at Old Chapel, Smoke Compartment 3.19 on the smoke compartment plans, that the room was not sprinkler protected at pipe organ closets made of wood. These areas were on two sides of back room, although the entire facility was required to be sprinkled. 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 Old Chapel was found not to be full-sprinkler protected. This observed situation is not compliant with NFPA 101 (2000 ed.), 19.3.5.1 (exception).
Approved POC with extension to 7/4/2014.

2.7. On 05/15/13 at 4:07 pm, observation revealed on the 3rd Floor Toilet Room 3009A, and in other 3rd 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.).
Approved POC stated 1/4/2014.

2.8. On 05/15/13 at 4:36 pm, observation revealed on the 4th Floor Toilet Rooms, the 4th 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.).
Approved POC stated 7/4/2014.

2.10. On 05/15/13 at 4:49 pm, observation revealed on the 5th Floor Toilet Rooms (example; 5000), the 5th 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.).
Approved POC stated 7/4/2014.

2.12. On 05/15/13 at 1:00 pm, observation revealed on the 2nd, 3rd, 4th, 5th & 6th Floor Patient Rooms, that the sprinkler was placed farther than 22 inches below the floor/ceiling deck. The ceiling were using perforated metal pan and it was observed that some insulation was missing at some tiles creating the >22 inch distance. The following rooms were observed with insulation missing at the top of the perforated pan ceilings: 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 the sprinkler system listing requirements. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-5.4.1.
Approved POC stated 7/4/2014.

2.14. On 05/15/13 at 5:34 pm, observation revealed on the 6th Floor in all the 6th Floor Patient Bathrooms, that the rooms were not fully-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.).
Approved POC stated 1/4/2014.

2.15. On 05/16/13 at 8:11 am, observation revealed on the 2nd 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.
Approved POC stated 1/4/2014.

2.20. On 05/16/13 at 10:10 am, observation revealed on the 3rd Floor in the Room 3080 & Room 3071, both within the Smoke Compartment 3B, 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. It was noted that sprinkler coverage in the shower areas was missing. This observed situation was not compliant with NFPA 101 (2000 ed.).
Approved POC stated 7/4/2014.

2.21. On 05/16/13 at 10:20 am, observation revealed on the 3rd 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.).
Approved POC stated 7/4/2014.

2.22. On 05/16/13 at around 10:30 am, observation revealed on the 4th Floor in the Room 4830A, 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.).
Approved POC stated 7/4/2014.

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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Outstanding items remaining after V.V. on 8/27/2013:
(Sandy - please go in and make all the nessary corrections, and if all elements are completed, please show the entire tag as corrected.)

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers at required exterior locations, sprinklers mounted flush with ceilings, proper ceiling enclosures, and valves with proper supervision. This deficient practice could affect all patients, staff, and visitors in 10 of the 29 smoke compartments.

FINDINGS INCLUDE:

3. On 05/15/2013 at 12:25 pm observation revealed that the 1st floor Entrance W5 had an exterior overhang that was not sprinkler protected. The building is fully-sprinkler protected and the connected over-hang was approximately twenty-five (25) feet by forty (40) feet in surface area. Over-hangs or canopies greater than four (4) feet are required to be sprinkle protected. This observed situation is not compliant with NFPA 13 (1999 edition) section 5-13.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M4 (Director of Facilities - Elmbrook) and Staff M7 (EUA).

4. On 05/15/2013 at 12:40 pm observation revealed that the Entrance E4 had an exterior overhang that was not sprinkler protected. The connected building is fully-sprinkler protected. Over-hangs or canopies greater than 4' are required to be sprinkle protected. This observed situation is not compliant with NFPA 13 (1999 edition) section 5-13.8.1. This condition was 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 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:

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.
Approved POC stated 1/4/2014.

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.
Approved POC stated 1/4/2014.

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 2nd 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. These ducts were abandoned at the time of the Kitchen Renovation several years ago. These ducts travel from 1st Floor (Kitchen) to the 7th Floor (Penthouse) straddling between the 1928 & 1929 Buildings. 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.
Approved POC stated 1/4/2014.

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 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 continues to occur in 1 of the 92 smoke compartments, and has the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1.2. On 5/14/2013 at 4:30 pm, observation revealed on the 3rd Floor in the Tub Rooms of the Southwest Inpatient area of OB/GYN, that cubical curtains were 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.
Approved POC stated 10/4/2013.

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:

2.1. On 05/16/13 at 1:55 pm, observation revealed on the 5th 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 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.
Approved POC stated 10/4/2013.

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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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:

1.1. On 5/13/2013 at 1:52 pm, observation revealed on the 2nd Floor in the Corridor 2829 (labeled Passage C-240) 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.
Approved POC stated 7/4/2014.

1.2. On 5/14/2013 at 3:40 pm, observation revealed on the 3rd Floor in the Corridor by Elevator FF, 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.
Approved POC stated 7/4/2014.

1.3. On 5/16/2013 at 12:08 pm, observation revealed on the Basement Floor in the Entrance (South Entrance) to the Main Clinical 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.
Approved POC stated 7/4/2014.

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).

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:

2.2. 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.
Approved POC stated 9/19/2013.

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/levels.
Approved POC stated 9/19/2013.

2.4. On 5/16/2013 at 8:45 am, observation revealed on the Basement Floor in Office (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.
Approved POC stated 7/4/2014.

2.5. On 5/16/2013 at 9:20 am, observation revealed on the Basement Floor in the Therapy Pool Room (0009C) of PT/OT Suite, 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.
Approved POC stated 7/4/2014.

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).
______________________________________

ITEM #1
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 per NFPA 101 (2000 ed.) section 40.3.2. This deficient practice could affect all patients, staff, and visitors in 2 of the 92 smoke compartments.

FINDINGS INCLUDE:
Item K130-1-3: On 05/13/13 at 2:12 pm, observation revealed that Door FS014N fire-rated at 45 minutes, did not support the 2 hour fire-rated wall the door assembly was located within. This observed situation is not compliant with NFPA 101 (2000 ed.), 40.3.2 and 8.4.1.
Approved POC stated 10/4/2013.

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