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Based on observation and interview, the facility did not provide a common separation wall with rated wall construction. This deficiency could affect 50 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/10/2012 at 2:20 pm surveyor #12187 & #29942 observed on the Level -1P floor in the Corridor 1806B, that the separation wall was not present at this location. There was no 2 hour separation between Pavilion and Specialty Clinics buildings. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

Based on observation and interview, the facility did not provide and maintain the required building construction type with sealed floor penetrations, and a compliant type of construction. This deficiency could affect 50 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/09/2012 at 2:21 PM surveyor #12187 & #29942 observed on the Basement floor in the Shaft inside the Mechanical room number SB001, that the building's construction type was not compliant because 2 x 4 wood studs were used in Type I(443) construction. This observed situation was not compliant with NFPA 101 (2000 edition), Table 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/11/2012 at 1:50 PM surveyor #12187 & #29942 observed on the Level-4P floor in the Electric room 435P, that there were penetrations through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included two floor penetrations that were not fire stopped. At the floor penetrations steel mesh was exposed through the plaster and may negate the 2 hour fire rating. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 07/12/2012 at 8:45 am surveyor #12187 observed on the Penthouse E floor in the top of Stair 36, that the building's construction type was not compliant because fire proofing was missing on the structural beams both on the beam and at clamps on the beams. This observed situation was not compliant with NFPA 101 (2000 edition), Table 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of corridor wall separation or smoke detector in two spaces that have sliding glass windows in accordance with NFPA 101 19.3.6.1, 19.3.6.3.2. This deficient practice affected 1 of 59 smoke compartments in Building 02.

Findings include

(i) During a tour of the facility with Staff M1 (safety and emergency preparedness director), Staff M3 (project manager) and M8 (senior mechanic), Surveyor 12316 observed on 7/11/12 at 11:40 am that the Reception Room 2516 in Rehab Services on the 2nd Floor had sliding glass windows in the corridor wall. The reception room with sliding windows is considered open to corridor, and did not have a smoke detector, nor was the room separated from corridor with smoke tight walls.

(ii) During a tour of the facility with Staff M1 (safety and emergency preparedness director), Staff M3 (project manager) and M8 (senior mechanic), Surveyor 12316 observed on 7/11/12 at 2:37 pm that the Phlebotomy Reception Room 2513 on the 2nd Floor West Hospital had sliding glass windows. The reception room with sliding windows is considered open to corridor, and did not have a smoke detector, nor was the room separated from corridor with smoke tight walls.

The above deficiency was acknowledged by the project manager and senior mechanic at the time of discovery, and confirmed with Staff M2 (director of plant operations) at the daily exit conference on 7/11/2012 at 4:30 pm.



29942

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with rooms open to the corridor with the required safe-guards, no combustible material storage, and a smoke-tight corridor ceiling (in a sprinkled smoke zone). This deficiency could affect 50 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/11/2012 at 11:40 am surveyor #12187 & #29942 observed on the 3rd floor in the room 3933, 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. There was no wall above the ceiling on the north wall of the corridor. This observed situation was not compliant with NFPA 101 (2000 edition) 19.3.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/12/2012 at 9:36 am surveyor #12187 observed on the 2nd floor in the corridor 2473, that the corridor space was used for storage, and was not separated by a wall from the corridor. Storage included scrub ex machine (which contains both clean and dirty scrubs) and a full linen cart. This quantity of materials was deemed hazardous for storage in a corridor. This observed situation was not compliant with NFPA 101 (2000 edition) 19.3.6.1, and 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 07/12/2012 at 3:27 PM surveyor #12187 observed on the 3rd floor in the room 3505B, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes occured in the corridor wall above the ceiling. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

4. On 07/12/2012 at 9:55 am surveyor #12187 observed on the 2nd floor in the corriodor 2473, that penetration(s) were not sealed according to an approved listed testing agency design. The deficiency included a 2 x 4 hole in the wall above the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to a wide gap at the meeting edge of corridor doors. The observed situation was not compliant with NFPA 101 18.3.6.3.1. This deficient practice affected 1 of 59 smoke compartments in the North and West Hospital.

Findings include

During a tour of the facility with Staff M1 (safety and emergency preparedness director), Staff M3 (project manager) and M8 (senior mechanic), Surveyor 12316 observed on 7/09/12 at 2:28 pm that the double corridor doors of the Patient Room 9N102 had a ¼ " gap at the meeting edge, and did not prevent smoke transfer from the patient room to corridor in the event of fire in the room.

The above deficiency was acknowledged by the project manager and senior mechanic at the time of discovery, and confirmed with Staff M2 (director of plant operations) at the daily exit conference on 7/09/2012 at 4:30 pm.

Based on observation and interview, the facility did not provide reliable enclosure opening protectives for multi-floor vertical openings. This deficient practice could affect all patients of the Mother-Baby Unit and an undeterminable number of staff and visitors within the 1 of 4 smoke compartments on the seventh floor.

FINDINGS INCLUDE:
At 1:45 PM, on July 12, 2012, surveyor 13960 observed that the elevator lobby double door assembly meeting edges was attempting to be sealed by a non-compliant astragal. The elevator lobby is a 1 hour fire rated enclosure as documented by the Froedtert Health 7th floor life safety code plan. The double door assembly is also fire rated yet the plastic brush seals are not an astragal. Astragals are required per NFPA 80 for meeting edges of double door assemblies that exceed 0.125 inch, and the measured gap between the actual doors was approximately 0.25 inch. Plastic brush seals at most can provide a seal against smoke movement yet are not listed astragals for fire rated door assemblies. Plastic brushes would never pass the elevated temperatures that are required for astragals on a fire rated door assembly.

This observed situation was not compliant with NFPA 80 (1999 edition) section 2-3.1.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with the Staff M15 (Facility Planning & Development Director) and Staff M16 (Maintenance Coordinator).
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Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included smoke doors held-open with the required safe guards. This deficiency could affect 25 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/09/2012 at 3:35 PM surveyor #12187 & #29942 observed on the Lower level floor in the Door between Stair (number 33) exit passageway and corridor number 100B, that the fire barrier door was magnetically held open and did not have smoke detector within 5 feet. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).
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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 with exit signs when the egress path is not readily apparent, and "no-exit" signs at doors that may be confused as exits. This deficiency could affect 25 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/09/2012 at 2:30 PM surveyor #12187 & #29942 observed on the Lower level floor in the Pavilion Building Entrance, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. Big Turn stile door was not a legal exit door and "No exit" was not provided. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/09/2012 at 2:31 PM surveyor #12187 & #29942 observed on the Lower level floor in the Pavilion Building Entrance, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near Corridor L700D and inside Corridor L700E. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 07/09/2012 at 2:45 PM surveyor #12187 & #29942 observed on the Lower level floor in the Corridor L-22 near pavilion entrance, 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 edition), 7.10.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).
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Based on observation and interview, the facility failed to ensure safety to patients, visitors and Staff of the facility due to one set of smoke doors not fully closing. This observed situation was not compliant with NFPA 101 18.3.7.1. This deficient practice affected 2 of 59 smoke compartments in Building 02.

Findings include

During a tour of the facility with Staff M3 (project manager) and M8 (senior mechanic), Surveyor 12316 observed on 7/09/2012 at 2:50 pm that the 8th Floor double smoke doors south of Stair 15 Exit and adjacent to Room N8213 did not fully close, and left a gap of 3 inch at the meeting edge. Such a gap is more than required for necessary operation of doors, and does not prevent smoke from transferring from one smoke compartment into another. Smoke compartmentation is required in the 8th floor due to health care occupancy on the floor above.

The above deficiency was acknowledged by the project manager and senior mechanic at the time of discovery, and confirmed with Staff M2 (director of plant operations) at the daily exit conference on 7/09/2012 at 4:30 pm.
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Based on observation and interview, the facility failed to ensure safety to patients, visitors and Staff of the facility due to (i) exposed wall cavity on corridor side of one smoke/fire barrier, and (ii) unsealed penetration of smoke barrier. The barrier was not maintained/installed in accordance with NFPA 101 19.3.7.3 and 8.2.3.1. This deficient practice affected 1 of 59 smoke compartments in Building 02.

Findings include

During a tour of the facility with Staff M3 (project manager) and M8 (senior mechanic), Surveyor 12316 observed that (i) on 7/10/2012 at 9:32 am that the 2-hr fire-rated smoke/fire barrier (labeled 2S on the facility life safety plan) had one approximately 4 inch x 5 inch hole on the corridor side of wall exposing the wall cavity located to the north of fire-rated double doors to the 5th Floor NW unit; (ii) on 7/12/12 at 11:46 am, one electrical conduit penetration through the 2-hr smoke/fire barrier above smoke doors in Corridor 2300 adjacent to the GI Lab area was not fire-stopped around the conduit.

The above deficiency was acknowledged by the project manager and senior mechanic at the time of discovery, and confirmed with Staff M2 (director of plant operations) at the daily exit conference on 7/10/2012 at 4:30 pm.
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29942

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 deficiency could affect 50 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/12/2012 at 9:55 am surveyor #12187 observed on the 2nd floor in the corridor 2473, that penetration was not sealed according to approved listed testing agency designs. The deficiency included a 2 X 4 hole in the wall above the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/12/2012 at 1:00 PM surveyor #12187 observed on the 3rd floor in the room 3153, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the smoke barrier wall at the top by the outside wall was not extended to the deck above to provide vertical continuity. This observed situation was not compliant with NFPA 101 (2000 edition) 19.3.7.3, 8.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 07/12/2012 at 2:45 PM surveyor #12187 observed on the 3rd floor in the room N3109, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because there were (26) 2" by 4" electrical or medical gas boxes with a total area of 208 square inches in a 100 square feet of a rated smoke barrier wall. A maximum of 100 square inches in 100 square feet is allowed. The same smoke barrier in the room N3110 could have similar condition, which was not surveyed for due to a patient in the room 3110 at the time of survey. This observed situation was not compliant with NFPA 101 (2000 edition) 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

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Based on observation and interview, the facility did not provide space in adjacent smoke compartments to accommodate the number of persons needing to be evacuated with adequate refuge space. This deficiency could affect 5 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/10/2012 at 9:00 am surveyor #12187 & #29942 observed on the Lower level floor in the Corridor L700A, that the available refuge space was not adequate for the occupants from the smoke compartment located east-side of the smoke barrier based on 30 square feet per patient and 6 square feet per non-patient. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

Based on observation and staff interview, the facility did not provide astragals at the meeting edges of paired doors in smoke barrier walls in accordance with NFPA 101 18.3.7.5, 18.3.7.8 as evidenced by the following six items. This deficient practice affected 4 of 21 smoke compartments in the Specialty Clinics.

Findings include

Item #1
While on a tour with Staff M5 (Sr. project coordinator), M7 (project coordinator), M9 (mechanic), and M17 (consultant) between July 09 and July 13, 2012, Surveyor 14105 observed on 7/9/12 at 2:52pm that the meeting edge of the paired doors between corridors L800 and L829A were not covered with an astragal to prevent the passage of smoke for this smoke compartment in the Lower Level.

Item #2
Surveyor 14105 observed at 3:02pm on Monday July 09th with Staff M5, M7, M9 and M17 that no astragal was installed at the meeting edge of two sets of smoke doors from L849A and L828 in the north-south oriented smoke wall across this corridor system in the Lower Level.

Item #3
Surveyor 14105 observed at 2:16pm on Tuesday July 10th with Staff M5, M7, M9 and M17 that the meeting edge of the east paired doors from L879B were not covered with an astragal to prevent the passage of smoke through this smoke barrier wall in the Lower Level.

Item #4
Surveyor 14105 observed at 2:21pm on Tuesday July 10th with Staff M5, M7, M9 and M17 the meeting edge of the paired doors from L901A were not covered with an astragal to prevent the passage of smoke through this smoke barrier wall in the Lower Level.

Item #5
Surveyor 14105 observed at 8:11am on Wednesday July 11th with Staff M5, M7, M9 and M17 that the meeting edge of the paired smoke doors from Room 1885 into Suite #4 (Children ' s ED) were not covered with an astragal to prevent the passage of smoke through this smoke compartment wall on the 1st Floor.

Item #6
Surveyor 14105 observed at 8:14am on Wednesday July 11th with Staff M5, M7, M9 and M17 that the meeting edge of the paired doors from Corridor 1900A into Suite #4 (Children ' s ED) were not covered with an astragal to prevent the passage of smoke through this smoke compartment wall on the 1st Floor

Item #7
Surveyor 14105 observed at 9:23am on Wednesday July 11th with Staff M5, M7, M9 and M17 that the meeting edge of the paired cross-corridor doors at the west end of Corridor 1815A were not covered with an astragal to prevent the passage of smoke through this smoke barrier wall on the 1st Floor.

The above condition at seven locations was confirmed at the time of discovery by a concurrent observation and interview with the senior project coordinator, project coordinator, mechanic and consultant.

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Based on observation and interview, the facility did not provide fire barriers protecting hazardous areas that were constructed to minimum standards for these walls in accordance with NFPA 101 18.3.2.1. This deficient practice affected 3 of 21 smoke compartments in the Specialty Clinics.
Findings include
Item #1: While on a tour with Staff M5 (Sr. project coordinator), M7 (project coordinator), M9 (mechanic), and M17 (consultant), Surveyor 14105 observed at 2:35pm on Tuesday July 10th that the perimeter walls of L901 Storage room did not have all of the tape fully embedded in joint compound and the screw heads were not covered with joint compound to a one-hour standard.
Item #2: Surveyor 14105 observed at 9:04am on 7/11/12 with Staff M5, M7, M9 and M17 that the perimeter walls of Clean Utility 1840 on the 1st Floor had a ¾ " hole in the west wall that was not fire caulked to a one-hour standard.
Item #3: Surveyor 14105 observed at 9:37am on 7/11/12 with Staff M5, M7, M9 and M17 that the door into Storage #1924 on the 1st Floor was not 45-minute rated.

Item #4: While on a tour with Staff M5 (Sr. project coordinator), M7 (project coordinator), M9 (mechanic), and M17 (consultant), Surveyor 14105 observed at 1:00pm on Wednesday July 11th that a 24" round duct on the 2nd Floor was not fire caulked at the penetration of this fire barrier.

Item #5: Surveyor 14105 observed at 2:44pm on Wednesday July 11th with Staff M5, M7, M9 and M17 that the perimeter walls of #2818 Soiled Utility and #2884 Storage on the 2nd Floor did not have all of the tape fully embedded in joint compound and the screw heads were not covered with joint compound to provide a one-hour standard.

Item #6: Surveyor 14105 observed at 3:05pm on Wednesday July 11th with Staff M5, M7, M9 and M17 that each set of doors into #2852 Mechanical Room did not have the doors labeled at 45-minutes into this one-hour room.
The above condition at six locations was confirmed at the time of discovery by a concurrent observation and interview with the senior project coordinator, project coordinator, mechanic and consultant.

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Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to (i) one non-latching stairwell exit door, and (ii) exit doors out of Stairwell #4 not easily operable from the egress side. This observed situation was not compliant with NFPA 101 8.2.3.2.1, 7.2.1.5.1. This deficient practice affected 2 of 17 stairwells in patient sleeping/treatment floors of the West and North Hospital (Building 02).

Findings include

(i) During a tour of the facility with Staff M1 (director of safety and emergency preparedness), Staff M3 (project manager) and M8 (senior mechanic), Surveyor 12316 observed on 7/10/12 at 10:54 am that the exit door of Stair #2 on the 2nd Floor SE did not latch.

(ii) Surveyor 12316 accompanied by Staff M3 and Staff M8 also observed on 7/11/12 at 1:35 pm that the right leaf of double exit doors out of the Stair #4 would not open when a force of greater than 50 pounds was applied. It was revealed that the door threshold was rusty with the door binding to it. NFPA 101 7.2.1.4.5 does not allow more than 50 lbf for existing doors to set a means of egress door in motion.

The above deficiency was acknowledged by the project manager and senior mechanic at the time of discovery, and confirmed with Staff M2 (director of plant operations) at the daily exit conference on 7/10 and 7/11/2012 at 4:30 pm.

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Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to normally unoccupied spaces open in 2 of 17 stairwell enclosures. This observed situation was not compliant with NFPA 101 19.3.1.1 7.1.3.2.1(d). This deficient practice affected 2 of 17 stairwells in patient sleeping/treatment floors of the West and North Hospital (Building 02).

Findings include

During a tour of the facility with Staff M3 (project manager) and M8 (senior mechanic), Surveyor 12316 observed on 7/11/12 between 12:05 pm and 1:16 pm that there were openings to Stairs 3 and 4 from normally unoccupied Mechanical Rooms 2124 and 2168. The access to enclosure is not allowed from normally unoccupied spaces.

The above deficiency was acknowledged by the project manager and senior mechanic at the time of discovery, and confirmed with Staff M2 (director of plant operations) at the daily exit conference on 7/10 and 7/11/2012 at 4:30 pm.

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29942

Based on observation and interview, the facility did not provide exit stairwells without openings to unoccupied rooms. This deficiency could affect 25 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/12/2012 at 10:40 am surveyor #12187 observed on the 3rd floor in the stair 1 on third floor, that an opening in an exit enclosure was from an unoccupied space-the Mechanical Room 3321. This observed situation was not compliant with NFPA 101 (2000 edition) 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/12/2012 at 11:00 am surveyor #12187 observed on the 1st floor in the room 1408B (medical gas ante room), that an opening in an exit enclosure was from the unoccupied space 1408B. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 07/12/2012 at 11:00 am surveyor #12187 observed on the 1st floor in the room 1468, that an opening in an exit enclosure was from an unoccupied space-the Mechanical Room 1468. This observed situation was not compliant with NFPA 101 (2000 edition) 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

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Based on observation and interview, the facility did not ensure that corridors did not have excessively long dead-ends as permitted by the code with too long of dead end corridors. This deficiency could affect 20 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/12/2012 at 3:30 pm surveyor #12187 observed on the 3rd floor in the Corridor C3501, that a dead end corridor of 40 feet is created when the across corridor doors are locked at night. The doors are located adjacent to Room 3731A. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.5.10. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

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Based on observation and interview, the facility did not provide egress paths at all times with doors that opened with a force less than or equal to 50 pounds, compliant egress path, egress without passing through intervening hazardous rooms. This deficiency could affect 60 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/11/2012 at 11:15 am surveyor #12187 & #29942 observed on the 3rd floor in the door to room 3802, that the door in the path of egress would not open when a force of greater than 50 pounds was applied, which exceeded the maximum 50 pounds needed to open an existing exit door. This observed situation was not compliant with NFPA 101 (2000 edition) 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/12/2012 at 10:05 am surveyor #12187 observed on the 3rd floor in the main entrance to SICU, that the egress path was not compliant. The magnetic lock out of the Day Surgery did not have both a manual release device located within 5 feet of the door and a sensor to open the door when a person approaches the door per NFPA 101, 7.2.1.6.2. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 07/12/2012 at 10:20 am surveyor #12187 observed between 10:20 am and 10:25 am on the 3rd floor in the SICU patient room doors, that the egress path was not compliant. The patient room doors are breakaway doors that a) were prevented from swinging because of the glove box holder obstructed the swing; b) there was not a sign indicating that one can push the door to break it open and c) there was no handle to pull the door open from the common area of the SCIU. This observed situation was not compliant with NFPA 101 (2000 edition) 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

4. On 07/12/2012 at 9:55 am surveyor #12187 observed on the 3rd floor in the door number 3200B, that the egress path was not compliant. A 15 second delayed egress sign posted in the egress doors that were not actually equipped with a magnetic delayed egress locking system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

7. On 07/12/2012 at 1:45 PM surveyor #12187 observed on the 3rd floor in the clean utility room by room 3162, that the egress path was not compliant. The full door swing was blocked by equipment racks inside of the room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

8. On 07/12/2012 at 11:10 am surveyor #12187 observed on the 1st floor in the loading dock area, that an intervening room in the means of egress was hazardous. The exit discharge from stairs 2, 7 and 13 enters the loading dock area which is enclosed on 3 walls, a floor and ceiling. Two large trash compactors are in this room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

9. On 07/12/2012 at 11:15 am surveyor #12187 observed on the 1st floor in the the exit discharge from stair 2 and 13, that an intervening room in the means of egress was hazardous. There is a storage bins 5 feet tall, 6 feet wide and 2.5 feet wide full of trash in the corridor / exit passageway. This creates a hazardous area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

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Based on observation and interview, the facility did not provide a clear and unobstructed width of the egress corridors three locations. This deficient practice could affect patients, staff and visitors in 3 of 21 smoke compartments in the Specialty Clinics.

Findings include:

Item #1: While on a tour with Staff M5 (Sr. project coordinator), M7 (project coordinator), M9 (mechanic), and M17 (consultant) on 7/10/12, Surveyor 14105 observed at 1:35pm that the Corridor L900H was not clear and unobstructed in its width, since gurneys were being stored along the north wall of this corridor in the Lower Level.

Item #2: Surveyor 14105 observed at 2:19pm on Tuesday July 10th with Staff M5, M7, M9 and M17 that the Corridor L884A was not clear and unobstructed in its width, since gurneys were being stored along the north sides of this corridor in the Lower Level.

Item #3: Surveyor 14105 observed at 2:40pm on Tuesday July 10th with Staff M5, M7, M9 and M17 that Corridor L940D was not clear and unobstructed in its width, since gurneys were being stored along the side of this corridor in the Lower Level.
The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the senior project coordinator, project coordinator, mechanic and consultant.
____________________________




29942

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 could affect 20 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/09/2012 at 2:50 pm surveyor #12187 & #29942 observed on the Lower level floor in the Corridor L700F, that the clear and unobstructed width of the corridor was 5' -10". The width of the corridor was 11 feet 8 inches with 1' x1 ' column located in the middle of the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide.. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

______________________________________

Based on observation and interview, the facility did not provide and maintain horizontal exits to meet code requirements with compliant construction. This deficiency could affect 15 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/12/2012 at 3:40 pm surveyor #12187 observed on the 3rd floor in between the West Clinics and Connector, that horizontal exit did not have 1 hour rated walls in a 90 degree corner for 10 feet in each direction. There were non rated windows in corner offices 3691 and 3690. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.5 and 7.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

______________________________________

Based on record review and staff interview, the facility did not test the battery-powered emergency lighting units for at least 90 minutes annually. This deficiency affects patients who receive care in at least 16 surgery rooms (anesthetizing locations). The facility has a licensed bed capacity of 596.

FINDINGS INCLUDE:

During a review of facility maintenance records on 07/16/2012 at between 2:00 pm and 4:45 pm, Surveyor #12316 & #29942 determined that (i) the testing of emergency battery-powered lighting units in surgery rooms were performed for 30 seconds each month, but the monthly test record was not kept; and (ii) the annual testing of the lighting units were not performed in accordance with NFPA 101 7.9.3. The condition was confirmed at the time of discovery by a concurrent record review and interview with Staff M4 (project manager) and Staff M17 (consultant), and Staff M2 (director of plant operations).
_________________________

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 deficiency could affect 20 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/12/2012 at 10:10 am surveyor #12187 observed on the 3rd floor in the main entrance to SICU, that the exit sign was not continuously illuminated and was not served by the emergency lighting system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.8 and 7.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

______________________________________

Based on observation and interview, the facility did not provide a Fire Alarm system that was installed to minimum standards of NFPA 72 in accordance with NFPA 9.6.1.4, 9.6.3.2. This affected 1 of 6 floors in the Specialty Clinics.

Findings include:

Item #1: While on a tour with Staff M5 (Sr. project coordinator), M7 (project coordinator), M9 (mechanic), and M17 (consultant) on 7/10/12, Surveyor 14105 observed at 3:09pm that Rooms L923, L925, L927C, L929 were permanently occupied by two or more occupants and no visible notification appliances were installed in these rooms for occupant notification in the Lower Level.

Item #2: Surveyor 14105 observed at 9:49am on Wednesday July 11th with Staff M5, M7, M9 and M17 that Room #1915 was permanently occupied by two or more occupants and no visible notification appliance was found within this room in the 1st Floor.

Item #3: Surveyor 14105 observed at 10:43am on Wednesday July 11th with Staff M5, M7, M9 and M17 that Room #1985 was permanently occupied by two or more occupants and no visible notification appliance was found within this room in the 1st Floor.

Item #4: Surveyor 14105 observed at 11:12am on Wednesday July 11th with Staff M5, M7, M9 and M17 that Room #1997K and the room south of #1997H (no number on plan) were permanently occupied by two or more occupants and no visible notification appliance was found within either room in the 1st Floor.

The above condition was confirmed at the time of discovery by a concurrent observation and interview with the senior project coordinator, project coordinator, mechanic and consultant.



29942

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with smoke detectors at required locations. This deficiency could affect 5 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/10/2012 at 8:19 am surveyor #12187 & #29942 observed on the Lower level floor in the Corridor L761, that the smoke detector was not located in accordance with NFPA 72 requirements. The nearest smoke detector was located more than 15 feet away from exit. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 2-2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

______________________________________

Based on interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with required testing. This deficiency could affect 200 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/16/2012 at 11:50 am surveyor #12316 & #29942 observed that during a review of facility documents, reports were not available to verify that code-required tests of the fire alarm system were conducted. Staff M18 stated that batteries were not tested by disconnecting from the charger for a discharge test. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.7 and NFPA 72 (1999 edition) Chapter 7-2.2 & 7-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (Project Manager), staff M17 (Consultant) and staff M18 (Johnson Controls Employee).
_______________________

Based on observation and interview this facility did not provide a sprinkler system that was installed to minimum standards of NFPA 13 as evidenced by the following items. This affected 2 of 6 floors in the Specialty Clinics.

Findings include

Item #1: While on a tour with Staff M5 (Sr. project coordinator), M7 (project coordinator), M9 (mechanic), and M17 (consultant) on 7/09/12, Surveyor 14105 observed at 2:15 pm that sprinkler heads were not installed within L899 in the Lower Level.

Item #2: Surveyor 14105 observed at 3:18pm on Monday July 09th with Staff M5, M7, M9 and M17 no sprinklers were installed within the upper portions of the skylights along Corridor L9400 in the Lower Level.

Item #3: Surveyor 14105 observed at 1:56pm on Tuesday July 10th with Staff M5, M7, M9 and M17 two high temperature quick response heads mixed with two fusible link heads within L887 in the Lower Level.

Item #4: Surveyor 14105 observed at 2:13pm on Tuesday July 10th with Staff M5, M7, M9 and M17 that the sprinkler heads above the sterilizer room off of L879 were open to the ceiling space above. There appeared no way to capture the heat to activate these heads at the proper temperature in the Lower Level.

Item #5: Surveyor 14105 observed at 2:35pm on Tuesday July 10th with Staff M5, M7, M9 and M17 that the sprinkler head in L903 was not provided with an escutcheon plate within this room in the Lower Level.

Item #6: Surveyor 14105 observed at 3:09pm on Tuesday July 10th with Staff M5, M7, M9 and M17 that the sprinkler heads in L930 and L943 were not provided with escutcheons within these rooms in the Lower Level.

Item #7: Surveyor 14105 observed at 3:21pm on Tuesday July 10th with Staff M5, M7, M9 and M17 that the sprinkler head in Closet L918 was obstructed by a 12" round duct. The walls of this space did not extend up to the exposed deck above this space. There was no way to effectively capture the heat to activate these heads at the proper temperature in the Lower Level.

Item #8: Surveyor 14105 observed at 3:24pm on Tuesday July 10th with Staff M5, M7, M9 and M17 no sprinklers were installed within the upper portions of the skylights along L962 in the Lower Level.

Item #9: Surveyor 14105 observed at 3:24pm on Tuesday July 10th with Staff M5, M7, M9 and M17, that the sprinkler head in the closet in the southwest corner of L962 was obstructed by storage in the Lower Level.

Item #10: Surveyor 14105 observed at 9:08am on Wednesday July 11th with Staff M5, M7, M9 and M17 that a sprinkler head in #1826 had only 13" of clearance above the wall cabinet on the 1st Floor.

Item #11: Surveyor 14105 observed at 9:19am on Wednesday July 11th with Staff M5, M7, M9 and M17 that no sprinklers were installed in the north end of Mechanical room #1820 on the 1st Floor; the south end was protected by sprinklers.

The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the senior project coordinator, project coordinator, mechanic and consultant.



29942

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The Wisconsin Department of Health Services and Centers for Medicare and Medicaid Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable sprinkler system to defend in place. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a sprinkler system with unobstructed water distribution, all rooms sprinklered when the code required full sprinkler protection, water flow free of wall obstructions, sprinklers located the appropriate distance apart, and sprinkler coverage throughout the building. This deficiency could affect 20 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/10/2012 at 11:45 am surveyor #12187 & #29942 observed on the Lower level floor in the Room number L701, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of obstructing item . The obstruction included 1 feet drop furred continuous down less than 4 feet away from sprinkler head. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/10/2012 at 11:10 am surveyor #12187 & #29942 observed on the Lower level floor in the MRI Machine room cooling shaft, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side obstructing item . The obstruction included a fluorescent light fixture one foot away. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 07/10/2012 at 8:10 am surveyor #12187 & #29942 observed on the Lower level floor in the Corridor number L763, that a sprinkler was located 5-8". 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 edition), 5-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

4. On 07/10/2012 at 8:16 am surveyor #12187 & #29942 observed on the Lower level floor in the Electrical Closet L754, that the room was not sprinkler protected, although the entire facility was required to be sprinkler protected. The facility did not meet all the requirements of the code to avoid installing sprinklers in the space. The room was enclosed with 2-hour rated construction. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.1 (exception). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

5. On 07/10/2012 at 8:23 am surveyor #12187 & #29942 observed on the Lower level floor in the Satir number 34, that the room was not sprinkled. All areas of new healthcare must be protected with sprinklers. Bottom of the Stair enclosure did not have sprinkler protection. This observed situation was not compliant with NFPA 101 (2000 edition) 18.3.5.1, NFPA 13(1999) 5-13.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

6. On 07/10/2012 at 8:30 am surveyor #12187 & #29942 observed on the Lower level floor in the Room Number L760B and L760, that the rooms were not sprinkled. All areas of new healthcare must be protected with sprinklers. This observed situation was not compliant with NFPA 101 (2000 edition) 18.3.5.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

______________________________________

Based on observation and interview, the facility failed to ensure safety to patients, visitors, and staff of the facility due to lack of proper maintenance on automatic supervised sprinkler system in accordance with NFPA 101 9.7.5, NFPA 25(1998) 2-2.1.1, 1-11.1. This deficient practice affected 4 of 59 smoke compartments in the North and West Hospital Building 02.

Findings include

(i) During a tour of the facility with Staff M3 and M8, Surveyor 12316 observed on 7/10/12 at 3:50 pm that one sprinkler head above the 4th Floor SW Nurse Station across from the Patient Room 4SW17 was dirty.

(ii) During a tour of the facility with Staff M3 and M8, Surveyor 12316 observed on 7/11/12 between 8:15 and 9:30 am that the escutcheon plate of one sprinkler head in the 3rd Floor Sterile Storage in the Operation Room Suite was not seated properly. The sprinkler head was slightly protruding from ceiling into the space below.

(iii) During a tour of the facility with Staff M3 and M8 on 7/11/12, Surveyor 12316 observed between 11:40 am and 1:30 pm that one sprinkler head in the Rehab Services Reception on the 2nd Floor, and one sprinkler in the Equipment Storage Room 2274 in the Case Management area were dirty; and the escutcheon plates of one sprinkler head in the EEG Technologies Room 2241 and one sprinkler above the West Hospital entrance vestibule on the 2nd Floor were missing creating a gap around the sprinklers. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test.

The above deficiency was acknowledged by the project manager and senior mechanic at the time of discovery, and confirmed with Staff M2 (director of plant operations) at the daily exit conference on 7/10 and 7/11/2012 at 4:30 pm.
__________________________________




29942

Based on observation, interview and a review of documents, the facility did not maintain the automatic supervised sprinkler, and standpipe system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have verification of all monthly inspection, and a complete five year inspection. This deficiency could affect 400 of 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors. The facility had a census of 465 inpatients in the hospital campus on 7/17/12.

FINDINGS INCLUDE

1. On 07/16/2012 at 11:20 am surveyor #12316 瓶 observed that during a review of documents a monthly sprinkler inspection was not conducted. This observed situation was not compliant with NFPA 25 (1998 edition) 2-2. 4.1 and 9-6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (Project Manager) and staff M17 (Consultant).

2. On 07/16/2012 at 11:45 am surveyor #12316 瓶 observed during a review of facility documents that the five year inspection of all check valves and gauges were due in 2010. Staff M17 stated that the inspection process is ongoing, and check valves and gauges of some sprinkler systems (out of five total) have already been completed, even though the facility was lacking on keeping an up to date record of which valves and systems were inspected recently for five-year inspection items. This observed situation was not compliant with NFPA 25 (1998 edition) 2-3.2, 9-2.8.2, 9-4.2.1, 9-4.4.1.5, 9-4.3.1.3 and Tables 2-1 and 9-1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (Project Manager) and staff M17 (Consultant).

3. On 07/16/2012 at 2:30 PM surveyor #12316 瓶 observed during a review of facility documents that the five year calibration or replacement of pressure gauges of the standpipe and hose system was not conducted. This observed situation was not compliant with NFPA 25 (1998 edition), 3-3.1.4 and 2-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (Project Manager) and staff M17 (Consultant), and on 7/17/2012 at 8:30 am with staff M19 (mechanic) and staff M1 (director of plant operations).

4. On 07/12/2012 at 11:15 am surveyor #12187 observed on the 3rd floor in the N.W. Nurse Station in the West Hospital, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition) 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

5. On 07/12/2012 at 10:18 am surveyor #12187 observed on the 3rd floor in the Room 3804, that there was one or more unsealed holes near the ceiling. The hole included a missing escutcheon ring. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition) 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

6. On 07/12/2012 at 11:31 am surveyor #12187 observed on the 3rd floor in the Room 3424C, that there was one or more unsealed holes near the ceiling. The hole included a missing escutcheon ring. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition) 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

7. On 07/12/2012 at 2:20 PM surveyor #12187 observed on the 3rd floor in the rooms N3208A and N3211, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition) 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

8. On 07/12/2012 at 2:55 PM surveyor #12187 observed on the 3rd floor in the room N3121, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition) 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

9. On 07/12/2012 at 3:15 pm and 3:35 pm surveyor #12187 observed on the 3rd floor in the rooms 3507, 3632 and 3730 that the escutcheon ring on the sprinklers were missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition) 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

10. On 07/12/2012 at 11:15 am surveyor #12187 observed on the 3rd floor in the N.W. Nurse Station in the West Hospital, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition) 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

______________________________________

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A. The Life Safety Code, section 9.2.1 permits existing ventilation systems to remain in service only when specifically approved by the authority having jurisdiction (AHJ). The Wisconsin Department of Health Services and Centers for Medicare and Medicad Services directs inspectors to use NFPA 90A when evaluating the ventilation system in both new and existing facilities. Thus, the Life Safety Code supercedes NFPA 90A (1999 edition) 1-3.3, which notes that the code is not normally intended to be applied retroactively. The NFPA 90A standards require plenum mechanical rooms free of storage, corridor not used as a plenum, and neutral airflow between the corridor and rooms to not use corridor as a supply or return air plenum. This deficiency could affect 50 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/12/2012 at 10:45 am surveyor #12187 observed on the 3rd floor in the NE Mechanical pod of 3rd floor, that the mechanical room was used as a plenum for air returning to the air handling unit and was used to store plywood for mounting of electrical equipment, and IT wiring that is not rated for plenum use. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 , 9.2 and NFPA 90A, 2-3.10.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/12/2012 at 10:55 am surveyor #12187 observed on the 3rd floor in the rooms 3230 and 3231, that the ventilation system used the corridor as a plenum for air returning to the air handling unit. There is no supply in room 3230 and no return in 3231 and the corridor is being used as the supply/return system. This observed situation was not compliant with NFPA 101 (2000 edition) 19.5.2.1, 9.2 and NFPA 90A 2-3.11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 07/12/2012 at 11:40 am surveyor #12187 observed on the 3rd floor in the NW Mechanical pod of 3rd floor, that the mechanical room was used as a plenum for air returning to the air handling unit and was used to store cardboard boxes, 4 plastic pails, plywood backing of panels, and towels. This observed situation was not compliant with NFPA 101 (2000 edition) 19.5.2.1, 9.2 and NFPA 90A 2-3.10.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

4. On 07/12/2012 at 2:00 PM surveyor #12187 observed on the 3rd floor in the SW Mechanical pod of 3rd floor , that the mechanical room was used as a plenum for air returning to the air handling unit and was used to store 10 plastic pails. This observed situation was not compliant with NFPA 101 (2000 edition) 19.5.2.1, 9.2 and NFPA 90A 2-3.10.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

5. On 07/12/2012 at 2:30 PM surveyor #12187 observed on the 3rd floor in the data room N3213, that airflow between the corridor and this room was not neutral. There is a supply air in the room but no return or exhaust. This observed situation - use of corridor as a supply air plenum - was not compliant with NFPA 101 (2000 edition) 19.5.2.1, section 9.2, and NFPA 90A (1999 edition) 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

6. On 07/12/2012 at 3:10 PM surveyor #12187 observed on the 3rd floor in the room 3805, that airflow between the corridor and this room was not neutral. There is a supply air in the room but no return or exhaust. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

______________________________________

Based on observation and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96. This deficiency could affect 10 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/16/2012 at 2:45 PM surveyors 12316 & 29942 observed that during a review of documents it was discovered that the range hood wet chemical suppression system was not inspected semi-annually, as required for systems serving moderate-volume cooking operations. Inspection record indicated that the Kitchen range hood wet chemical suppression systems were last inspected on December 12, 2011. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6; 9.2.3; and NFPA 96 (1998 edition), 8-2.1 & 8-2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (Project Manager) and staff M17 (Consultant).

______________________________________

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This deficiency could affect 50 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/11/2012 at 4:10 pm surveyor #12187 & #29942 observed on the Level-4P floor in the West end of the corridor at the EVS, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. One 40 gallon unit was stored at this corridor location. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

______________________________________

Based on observation, the facility failed to (i) separate empty oxygen cylinders from full, and (ii) mark empty cylinders as required by NFPA 99 4-3.5.2.2(b). This affected 2 smoke compartments in the patient sleeping areas out of total 59 compartments in the North and West Hospital.

Findings include

During a tour of the facility with Staff (project manager) and M8 (senior mechanic), Surveyor 12316 observed between 7/09/12-7/17/12, Surveyor 12316 observed empty oxygen cylinders not separated from full in the following two locations.

1. 5th Floor North Tower NW: On 7/10/12 at 9:53 am, one empty "E" size oxygen cylinder was found not tagged or marked as empty.

2. 5th Floor NE: On 7/10/12 at 1:46 pm, Nine empty "E" size oxygen cylinders were found stored in the same cart with 3 other part-full oxygen cylinders; and two empty "E" size oxygen cylinders were found stored in the second cart with 3 other full cylinders in the O2 and Helium Storage with large O2 and Helium cylinders. It was also observed that the empty oxygen cylinders were not tagged or marked empty.

The above deficiency was acknowledged by the project manager and senior mechanic at the time of discovery, and confirmed with Staff M2 (director of plant operations) at the daily exit conference on 7/10 and 7/11/2012 at 4:30 pm.

Based on observation and interview, the facility did not provide a Medical Gas system that was installed to minimum standards of NFPA 99 as evidenced by the following items. This deficient practice affected 1 of 33 operation rooms in the hospital campus.

Findings include

While on a tour with Staff M5 (Sr. project coordinator), M7 (project coordinator), M9 (mechanic), and M17 (consultant) on 7/10/12, Surveyor 14105 observed at 1:30pm that the zone valve box for the medical gases that served OR 29 was labeled as serving OR 36 4-3.1.2.3(m), 4-3.5.4.2 in the Lower Level.

The above deficiency was confirmed at the time of discovery by a concurrent observation and interview with the senior project coordinator, project coordinator, mechanic and consultant.
___________________________




29942

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping. This deficiency could affect 10 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/10/2012 at 8:40 am surveyor #12187 & #29942 observed on the Lower level floor in the Corridor L700B, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included vacuum shut off valve labeling was covered and was not visible. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.4 and NFPA 99 (1999 edition) 4-3.1.2.3(m), 4-3.5.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

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Based on observation and interview, the facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials with non-combustible wall materials. This deficiency could affect 15 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/12/2012 at 3:15 PM surveyor #12187 observed on the 3rd floor in the room 3805, that a wall was made with combustible materials, which is not permitted in non-combustible types of building construction. The wall was constructed with a permanent wood shutter that did not move. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

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Based on observation and interview, the facility Eye Institute failed to ensure safety to patients, visitors, and staff of the facility due to one hazardous area not compliant with NFPA 101 21.3.2, 39.3.2. This deficiency practice had a potential of affecting all patients on the 6th Floor i.e. 1 of 6 floors used by the facility.

Findings include

Item #1
NFPA 101 21.3.2 Protection from Hazards. (See 39.3.2.)
39.3.2.1
"Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4. "

8.2.4.3.1
"Doors in smoke partitions shall comply with 8.2.4.3.2 through 8.2.4.3.5. "

8.2.4.3.5
" Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8. "

During a tour of the facility with Staff M3 (project manager) and Staff M8 (senior mechanic) on 7/16/12, Surveyor 12316 observed at 9:25 am that (i) the corridor door of the Patient Recovery Room 9, currently used as storage, did not have a self-closing device, and (ii) one wheel chair blocked the door from closing.
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Based on observation and interview, the facility failed to ensure safety to patients, visitors, and staff of the facility due to two corridor doors of one room not maintained readily operated under all lighting conditions, and not operable with not more than one releasing operation in accordance with NFPA 101 7.2.1.5.4. This deficiency practice affected 1 of 6 floors used by the facility.

Findings include

Item #2
NFPA 101 7.2.1.5.4
"A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation. "

On 7/13/12 at 10 am, Surveyor 12316 accompanied by Staff M3 and Staff M8 observed that the 3rd Floor office/medical supply Room 323A had both corridor doors propped open with a foot-kick stop. One of the two doors (west door) of Room 323A did not latch due to binding at top of the door frame.
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Based on observation and interview, the facility failed to ensure safety to patients, visitors, and staff of the facility due to one penetration in fire-rated floor was not fire-stopped in accordance with NFPA 101 8.2.3.2.4. This deficiency practice affected 1 of 6 floors used by the facility.

Findings include

Item #3
NFPA 101 8.2.3.2.4.2
"Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose ... .."

While on a tour with Staff M3 and Staff M8 on 7/16/12, Surveyor 12316 observed at 10:12 am that one cable penetration of the 3-hr fire resistance rated concrete floor was not in a sleeve or a conduit, and the penetration was not fire-stopped. The cable penetration was located in the Electrical Closet on the 2nd Floor.
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Based on observation and interview, the facility failed to install a ramp to overcome an abrupt change in elevation in the exit discharge from Stair 17 in accordance with NFPA 101 7.1.7.2. This deficiency practice affected all 6 of 6 floors used by the facility.

Findings include

Item #4
NFPA 101 7.1.7.2
"Changes in level in means of egress not in excess of 21 in. (53.3 cm) shall be achieved either by a ramp or by a stair complying with the requirements of 7.2.2. The presence and location of ramped portions of walkways shall be readily apparent. The tread depth of such stair shall be not less than 13 in. (33 cm), and the presence and location of each step shall be readily apparent."

While on a tour with Staff M3 and Staff M8 on 7/16/12, Surveyor 12316 observed at 10:20 am that the landing from the exit door out of Stairwell 17 was 5 inches lower than level inside the stairwell. There was no ramp to overcome the abrupt change in elevation (drop of 5 in.) in the east exit discharge from Stairwell 17.
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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler and standpipe system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have verification of all monthly inspection, and a complete five year inspection. This deficiency could affect all outpatients, staff and undetermined number of visitors.

FINDINGS INCLUDE:

Item #5

(i). On 07/16/2012 at 11:20 am surveyor #12316 瓶 observed that during a review of documents a monthly sprinkler inspection was not conducted. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2. 4.1 and 9-6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (Project Manager) and staff M17 (Consultant).

(ii). On 07/16/2012 at 11:45 am surveyor #12316 瓶 observed during a review of facility documents that the five yearly inspection of all check valves and gauges were due in 2010. Staff M17 stated that the inspection process is ongoing, and check valves and gauges of some sprinkler systems (out of five total) have already been completed, even though the facility was lacking on keeping an up to date record of which valves and systems were inspected recently for five-yearly inspection items. This observed situation was not compliant with NFPA 25 (1998 edition), 2-3.2, 9-2.8.2, 9-4.2.1, 9-4.4.1.5, 9-4.3.1.3 and Tables 2-1 and 9-1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (Project Manager) and staff M17 (Consultant).

(iii). On 07/16/2012 at 2:30 PM surveyor #12316 瓶 observed during a review of facility documents that the five yearly calibration or replacement of pressure gauges of the standpipe and hose system was not conducted. This observed situation was not compliant with NFPA 25 (1998 edition), 3-3.1.4 and 2-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (Project Manager) and staff M17 (Consultant), and on 7/17/2012 at 8:30 am with Staff M2 (director of plant operations).
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Based on interview and a review of documents, the facility did not have an essential electrical system in accordance with NFPA 99 and NFPA 110 due to a generator without a remote stop, inappropriate batteries for Level 1 installations, and derangement signals were not located at a continuously monitored location. This deficiency could affect all outpatients in the Froedtert Eye Institute as well as an undetermined number of staff and visitors.

Finding Include

Item#6
1. On 07/16/2012 at 10:00 am surveyor #12187 & #29942 observed on the Generator located outside the Eye Institute, that the generator starting battery was located at an exterior enclosure with a louvered opening that did not have a warmer. This observed situation was not compliant with NFPA 110 (1999 edition), 3-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/16/2012 at 10:05 am surveyor #12187 & #29942 observed on the Generator located outside the Eye Institute floor that the audible and visual derangement signals were not located in a continuously monitored location. The generator anunciator panel was located in the computer room and was not supervised 24 hours a day. The anunciator panel had a paging system that was not power by the generator batteries. This observed situation was not compliant with NFPA 99 (1999 edition), 3-4.1.1.15(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 07/16/2012 at 10:10 am surveyor #12187 & #29942 observed on the Generator located outside the Eye Institute, that the emergency generator was not provided with a remote stop switch. This similar condition occurred in the generators located in the separate East Generator Building. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

Based on interview and a review of documents, the facility did not have an essential electrical system in accordance with NFPA 99 and NFPA 110, due to a generator without a remote stop, inappropriate batteries for Level 1 installations, and derangement signals were not located at a continuously monitored location. This deficiency could affect 300 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/16/2012 at 9:30 am surveyor #12187 & #29942 observed on the Sub-Basement floor of the Lab building in the Generator room, that the emergency generator cooling system was not powered from the tap of the EPS terminal. The generator radiators exterior hot air discharge damper is controlled by a separate circuit from the Johnson Control system. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/16/2012 at 9:31 am surveyor #12187 & #29942 observed on the Sub-Basement floor of the Lab building in the Generator room, that audible and visual derangement signals were not located in a continuously monitored location. The generator serves the Pavilion and Lab buildings. The generator anunciator panel was located in the computer room that was not supervised 24 hours a day. The anunciator panel had a paging system that was not power by the generator batteries. This observed situation was not compliant with NFPA 99 (1999 edition), 3-4.1.1.15(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 07/16/2012 at 10:30 am surveyor #12187 & #29942 observed on the East generator Building that the emergency generator was not provided with a remote stop switch. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

4. On 07/16/2012 at 10:35 am surveyor #12187 & #29942 observed on the East generator Building the audible and visual derangement signals were not located in continuously monitored location. the generator anunciator panel was located in a computer room that was not supervised 24 hours a day. the anunciator panel had a paging system that was not power by the generator batteries. This observed situation was not compliant with NFPA 99 (1999 edition), 3-4.1.1.15(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

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Based on observation and Staff interview, the facility failed to identify the critical branch electrical outlets of the essential electrical power system in all 10 CVICU patient rooms in accordance with NFPA 99 3-3.2.1.2(a)1, NFPA 70 517-19(a). This deficiency practice affected 10 patients out of 596 licensed beds in the facility.

Findings include

During a tour of the facility with Staff NN1 (nurse manager), Staff M3 (project manager) and M8 (senior mechanic), Surveyor 12316 observed on 7/11/12 between 9:25 am and 9:35 am that the red-colored, critical branch electrical wall outlets in 10 CVICU patient rooms located on 4th Floor West Hospital were not identified as to which electrical panel and branch circuit the power is supplied from.

The above deficiency was acknowledged by the nurse manager, project manager and senior mechanic at the time of discovery, and confirmed with Staff M2 (director of plant operations) at the daily exit conference on 7/09/2012 and 7/11/12 at 4:30 pm.


NFPA 70 517-19(a).
" Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal
system shall be from a single panelboard. Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. "



29942

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, working clearances at electrical panels. This deficiency could affect 25 of the 596 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/11/2012 at 8:10 am surveyor #12187 & #29942 observed on the 3rd floor in the OR 1, 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 various pieces of equipment. The strip plug was on a cart with a set of wheels. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/11/2012 at 8:20 am surveyor #12187 & #29942 observed on the 3rd floor in the sterile storage, rooms 3407/3497, that access to electrical panel was less than 3'-0" clearance. There were 3 panels blocked by equipment parked in front of the panels. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 07/11/2012 at 9:56 am surveyor #12187 & #29942 observed on the 3rd floor in the corridor by door 3420, that access to electrical panel was less than 3'-0" clearance. Trays and 6 boxes are in front of electrical panel A1E6N1-2. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

4. On 07/11/2012 at 10:20 am surveyor #12187 & #29942 observed on the 3rd floor in the room 3702 (between OR 15 & 16), that access to electrical panel was less than 3'-0" clearance. Each side of the room had and electrical isolation panel and each electrical panel was blocked by a cart. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

5. On 07/12/2012 at 8:30 am surveyor #12187 observed on the 3rd floor in the OR number 3, 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 medical equipments. Two extension cords carts on a set of wheels each with six outlets. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

6. On 07/12/2012 at 9:00 am surveyor #12187 observed on the 3rd floor in the front of OR 4, that access to electrical panel was less than 3'-0" clearance. Couple of beds that were stored in front of the Electrical Panel blocked the access to both Electrical panels and emergency medical gas shut off valves. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

7. On 07/12/2012 at 9:01 am surveyor #12187 observed on the 3rd floor in the front of Room number 3412, that access to electrical panel was less than 3'-0" clearance. Couple of beds that were stored in front of the Electrical Panel blocked the access to electrical panels. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

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