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Based on observation, document review and interview, the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for construction type and supporting construction for health care and/or other building occupancies. A 2-hour separation was not provided in accordance with section 8.2.1.3 in 9 of 10 fire walls inspected.

Finding include:

Observation(s), Interview(s), and review of construction documents during a facility tour on 11/13/19 between 8 am and 1:30 PM with the Facilities Supervisor the following was found:

1. The 2 hr. wall located in the basement near the teleconference room had a 4"hole/penetration, 1/4"gap where the wall and ceiling meet and the fire stopping material used (fire bricks) were not installed per manufacturers recommendations (required putty as part of the assembly). The penetrations were not protected by a fire-stop system or device in accordance with NFPA 221 (2012 edition), Standard for High Challenge Fire, section 4.9.2 Fire-stop Systems and Devices Required - Penetrations for cables, cable trays, conduit, pipes, tubes, combustible vents and exhaust vents, wires and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire stop system or device. This deficient practice could affect, patients, visitors, and members of facility staff in this location(s).

2. Basement classroom above the ceiling (area of the projector screen) had missing fire proofing on the structural beams.

3. Basement speech room/Erica's office had missing fire proofing on structural beams located above the ceiling.

4. Above the double 90 min. fire doors (2 hr. wall assembly) located near central sterile (basement) had a 2" conduit w/ data cables and two flexible electrical conduits that penetrated the rated wall assembly and had no fire stopping material present. There were several other pipe penetrations that had drywall compound applied up to the pipes with no fire stopping material present.

5. The 2 hr. wall assembly located in the "purchasing hall" (above store room) had a 2" pipe penetration with no fire stopping material present and polyurethane spray foam was used to seal several other penetrations.

6. Above the 90 min rated doors in the purchasing hall 2 hr wall assembly had flexible and rigid conduit no fire stopping, urethane spray foam sealing penetrations and duct penetrations with no fire dampers present.

7. Purchasing hall exit stairwell had penetrations in rated wall above door (stairwell side). There were 2 pipes in which half the 2 hr. rated wall assembly, and a a 8"x 8" piece of plywood being used to cover a hole/penetration.

8. Above the 90 min. rated doors in the 2 hr. wall assembly located in the emergency department there was a 10" penetration w/ 20 (or so) flexible electrical conduits and no fire stopping material was present.

9. The 2 hr. wall assembly located in the emergency department back hall (across from CT) had duct penetrations with no fire damper present, four flexible conduit, a 4" rigid conduit w/ data cables, and a 3" rigid conduit with data cables with no fire stopping material present. There was also a surface mounted patch (aprox. 12" x 12") and no documentation could be provided to indicate the UL/listed repair that was used to maintain the 2 hr. rating.

10. Above the 90 min. rated doors in the 2 hr. wall assembly located in lab hall had a 6"x6" square penetration w/ wires and two 2" rigid conduits with no fire stopping material present. There was also a large surface mounted patch with no fire stopping and no documentation could be provided to indicate the UL/listed repair that was used to maintain the 2 hr. rating.

11. Above the 90 min. rated doors in the 2 hr. wall assembly located in swing bed hall had urethane spray foam used to seal penetrations.

This finding was verified by the Facilities Supervisor at the time of observations and document review on 12/10/19.

Based on observation and interview, the hospital failed to meet the requirements of NFPA 101, Life Safety Code, 2012 Edition, section 19.2.3.4 (4) to ensure the means of egress were free from all obstructions in 2 of 3 patient care floors.

Findings:

Observations and interview during a facility tour on December 10, 2019 between 10:00am and 3:00pm with the Maintenance Supervisor:

1. Three wheeled vital machines found plugged in and stored in the corridor outside Patient Room 219 on the 2nd Floor.
2. Four wheeled vital machines found plugged in and stored in the corridor outside Patient Room 207 on the 2nd Floor.
3. Two patient room swing bed chairs found stored in the corridor outside Care Coordination/Discharge Planning Office on the 2nd Floor.
4. Two shelving units for linens and medical supplies found stored in the corridor outside the Stockroom on the Ground Floor.

These findings were verified by the Maintenance Supervisor at the times of the observation and interview.

Based on observation and interview, the hospital failed to meet the requirements of NFPA 101, Life Safety Code, 2012 Edition, section 19.3.2.1.5. (7), section 19.3.2.1.2. and section 19.3.2.1.3 to ensure the hazardous areas have been equipped with self-closing hardware in 8 of 34 hazardous areas.

Findings:

Observations and interview during a facility tour on December 10, 2019 between 10:00am and 3:00pm with the Maintenance Supervisor:

1. MSU Oxygen Storage Room found not equipped with self-closing hardware on the 2nd Floor. Doors shall be self-closing per NFPA 101, Life Safety Code, section 19.3.2.1.3.
2. North Storage Room corridor doors found not equipped with self-closing hardware on the 2nd Floor. This room exceeds 50 sq. ft and is used to store combustible supplies. Hazardous areas shall have doors that are self-closing per NFPA 101, Life Safety Code, section 19.3.2.1.5 (7) and 19.3.2.1.3.
3. North Storage Room left corridor door has a 3/4" gap at the top. Corridor walls and doors shall resist the passage of smoke per NFPA 101, Life Safety Code, section 19.3.2.1.2.
4. ICU Supply and Respiratory Storage Room found not equipped with self-closing hardware on the 2nd Floor. This room exceeds 50 sq. ft and is used to store combustible supplies. Hazardous areas shall have doors that are self-closing per NFPA 101, Life Safety Code, section 19.3.2.1.5 (7) and 19.3.2.1.3.
5. ER Electrical closet has a wire penetration and large pieces of sheetrock missing over the door to the corridor on the Ground Floor. Corridor walls and doors shall resist the passage of smoke per NFPA 101, Life Safety Code, section 19.3.2.1.2.
6. Telcom has missing sheetrock and holes over the door to the corridor on the Ground Floor. Corridor walls and doors shall resist the passage of smoke per NFPA 101, Life Safety Code, section 19.3.2.1.2.
7. Laundry corridor door found equipped with an unapproved kickstop. Doors shall be self-closing per NFPA 101, Life Safety Code, section 19.3.2.1.3.
8. Stockroom ceiling has multiple holes and pipe penetrations throughout the ceiling on the Ground Floor. Corridor walls and doors shall resist the passage of smoke per NFPA 101, Life Safety Code, section 19.3.2.1.2.
9. Stockroom wall ceiling assembly to the Back Room is sealed with plastic and duct tape on the Ground Floor. Corridor walls and doors shall resist the passage of smoke per NFPA 101, Life Safety Code, section 19.3.2.1.2.

These findings were verified by the Maintenance Supervisor at the times of the observation and interview.

Based on observation and interview, the hospital failed to meet the requirements of NFPA 101, Life Safety Code, 2012 Edition, section 19.3.5.3 to ensure the building is sprinklered in all areas and NFPA 25, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, section 5.2.1.1.2 to ensure that all sprinkler heads remain unobstructed in 2 of 3 patient care floors.

Findings:

Observations and interview during a facility tour on December 10, 2019 between 10:00am and 3:00pm with the Maintenance Supervisor:

1. IT Closet in Air Handler space is not equipped with fire sprinkler protection on 3rd Floor. All areas shall be protected with sprinkler coverage per NFPA 101, Life Safety Code, 19.3.5.3.
2. Laundry Biohazard Room has fire sprinkler head that has been obstructed with plastic on the Ground Floor. Sprinkler heads shall be inspected so ensure they are not obstructed per NFPA 25, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 5.2.1.1.2. A piece of a plastic bag was found stuck around the deflector.

These findings were verified by the Maintenance Supervisor at the times of the observation and interview.

35163

Based on observation, document review and interview, the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition andn in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives for 1 door in 1 of 12 smoke compartments.


Finding include:

1. The exit stairwell door located near the basement teleconference room had two 3/4" holes/penetrations on the corridor side (not all the way through door) which compromises the integrity of the door assembly.

2. The exit stairwell door located near the basement teleconference room had a rating label that was not legible.

3. Purchasing hall exit staiwell door rating label was painted and not legible

4. 90 minute fire rated doors in the Purchasing hallway did not latch properly, attempted to close and latch the doors 4 times.

5. Fire rated corridor doors located in the Swingbed Corridor have gap in the center of the pair of doors that is 1/2" wide, and a 3/4" overlap at the center base of the door gap.

6.On 12-10-19 at 1000am to 400pm during records review, Interview(s) with Facilites Director. Facility failed to have a Maintenance, Inspection & Testing- Door program for inspection and tested annually.


Observation(s), Interview(s), and review of facility life safety plans during a facility tour on 12/10/19 between 10 am and 4:00 PM with the Facilities Supervisor the following was found:





39983

Based on document review from the Director of Facilities and Maintance Director Medical Gas Testing and evaluation, testing completed October 16, 2019, From W.G. Frank Medical Gas Testing & Consulting, LLC . Facility failed to meet the requirments of NFPA 99 Chapter 5.

Finding Include:

Reviewof the Medical Gas Report this surveyor found 26 deficiencies listed in the summary of compliance deficiencies.; to include WAGD intel leaks, vacuum inlet leaks, oxygen outlet damaged faceplate, zone valve box location issue, area alarm panel labeled appropriately, oxygen zone valve no pressure indicator, vacuum zone valve has no vacuum indicator, nitrous oxide manifold, nitrous oxide manifold indoor central supply manifold location does not have walls and floors with an hour fire resistance rating, bulk oxygen system outdoor needs minimum of two entry/exits, EOSC needs to be secured to prevent unauthorized tampering.

Copy of the report is attached to this survey. And copy of the summary of compliance deficiencies dated 11-21-19 by W.G. Frank. 4 areas with 6 deficiencies in compliance; Surgical Serices, Cardio- Pulmonary/ Cardiac Rehab/ Master Alarm Panels,

Areas not in comliance;
1. Surgical Service, zone valve box location.

2. ACA, area alarm panel does not have separate visual indicators.

3. Emergency Department,
a area alarm panel needs to be labeled.
b zone valve needs to be labeled.

4. Radiology,
a. valves need to be labeled.

5. Medical Surgical,
a. Master alarm panel labeled appropriately.
b. oxygen zone valve no pressure indicator on the station outlet side.
c. vacuum zone valve no vacuum indicator on the station inlet side.
d. oxygen zone valve does not permit in-line serviceablity.
e. no pressure indicator on the station outlet side.

6. Sources;
Nitrous Oxide Manifold. ,
a. indoor central supply location does not have an hour fire resistance rating.
b. manifold room needs to be secured.
c. mechanical exhaust inlets shall be unobstructed.
d. multiple tanks are not secured from falling.

Bulk Oxygen System;
a. outdoor systems needs to be provided with a minimun of two entry/ exits.
b. currently not a minimum of three feet of workspace.
c. there is no pressure indicator adjacent to the alarm-initiating device for source.

7. EOSC needs to be secured to prevent unauthorized tampering.

Based on observation and interview, the hospital failed to meet the requirements of NFPA 101, Life Safety Code, 2012 Edition, section 9.1.2 and NFPA 70, National Electrical Code, 2011 Edition, section 210.21 (B) (2) to ensure the electrical wiring and equipment has been installed in accordance with the Code in 1 of 3 patient care floors.

Finding:

Observations and interview during a facility tour on December 10, 2019 between 10:00am and 3:00pm with the Maintenance Supervisor:

1. ICU has a Christmas tree that has been decorated with 3 strands of lights. These 3 cords are being powered by the same outlet, as they are plugged into one another.

This finding was verified by the Maintenance Supervisor at the time of the observation and interview.

Based on observation and interview, the hospital failed to meet the requirements of NFPA 70, National Electrical Code, 2011 Edition section 422.11 to ensure household appliances are plugged directly into an outlet and section to ensure extension cords are used for temporary use only in 1 of 3 patient care floors.

Findings:

Observations and interview during a facility tour on December 10, 2019 between 10:00am and 3:00pm with the Maintenance Supervisor:

1. Switchboard Desk refrigerator found plugged into a relocatable power tap on the Ground Floor.
2. ER Staff Lounge air fryer and toaster found plugged into a relocatable power tap on the Ground Floor.
3. OR Staff Lounge Christmas tree lights found powered by an extension cord on the Ground Floor.
4. Purchasing Office refrigerator and microwave found plugged into a relocatable power tap on the Ground Floor.

These findings were verified by the Maintenance Supervisor at the times of the observation and interview.

Based on observation and interview, the hospital failed to meet the requirements of NFPA 101, Life Safety Code, 2012 Edition, section 11.3.2.1 and section 11.3.4.1 to ensure the cylinder storage of portable oxygen tanks are labeled and secure from unauthorized entry in 2 of 3 patient care floors.

Findings:

Observations and interview during a facility tour on December 10, 2019 between 10:00am and 3:00pm with the Maintenance Supervisor:

1. MSU Oxygen Room shall be equipped with a door that can be secured against unauthorized entry per NFPA 99, 2011 Edition, section 11.3.2.1 on the 2nd Floor.
2. WICU Clean Utility Room shall be labeled with an approved sign indicating that it is being used for oxygen storage per NFPA 99, 2011 Edition, section 11.3.4.1. on the Ground Floor.

These findings were verified by the Maintenance Supervisor at the times of the observation and interview.