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19.3.6.5 Openings. In other than smoke compartments containing patient bedrooms, miscellaneous openings such as mail slots, pharmacy pass-through windows, and cashier pass-through windows shall be permitted in vision panels or doors without special protections, provided that the aggregate area of the openings per room does not exceed 20 square inches, and the openings are installed at or below half the distance from the floor to the room ceiling.
Exception: For rooms protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the aggregate area openings per room shall not exceed 80 square inches.


Based on observation and measurement, the facility failed to ensure that corridor walls with pass through were properly constructed.

Findings include:

The Pharmacy had a pass through window with an opening in its corridor wall. This opening measured 20 inches by 11 inches for a total of 220 square inches (greater than 80 square inches).

The corridor wall where the pass through opening was installed measured 106 inches in height. The base of the pass through opening measured at 45 inches above the finished floor and its top at 57 inches above the finished floor. The lower half of the corridor wall would be at 53 inches, making the pass through not part of the lower half of the wall.

Note #1: The smoke compartment was fully fire sprinklered.
Note #2: A roll down door for both the window above the pass through and the pass through itself was present. However, the roll down door was not connected to the fire alarm.

Based on observation, the facility failed to ensure that all corridor doors could resist the passage of smoke, could latch close, and were free from impediments to closure.

Findings include:

The below listed corridor doors had the following problems:

1) The electrical room's (near the Fire Command Room) corridor door could not latch close, due to a tape being applied over the door's striker plate.

2) The corridor door for the mammography room (#14023) had a tie-back holding the door in the open position.

3) The atrium men's and women's bathroom corridor doors could not latch close.

4) Patient room #106's corridor door had a gap greater than 1/4 inch between the top of the door and the door frame.

5) Patient room #107's corridor door had a gap greater than 1/4 inch between the top of the door and the door frame.

6) Patient room #118's corridor door was held open with a trash container.

7) Patient room #121's corridor door was held open with a trash container.

8) Patient room #209's four foot and two foot corridor doors had a gap greater than 1/4 inch between them.

9) Patient room #210's corridor door failed to latch close.

10) Patient room #211's corridor door failed to latch close.

11) Unit 2 East's housekeeping room's corridor door was blocked open with the cleaning cart.

12) Patient room #245's corridor door failed to latch close.

13) Operating room #3's corridor door failed to latch and had a gap at the top of the door.

14) Employee health's corridor door was held open with a chair.

15) Patient room #373's corridor door was impeded from closure by rubbing against the floor.

16) Patient room #355's corridor door had a gap greater than 1/4 inch between the top of the door and the door frame.

17) Corridor door #32053 was unable to close due to a tie-back.

18) Patient room #352's corridor door had a gap greater than 1/4 inch between the top of the door and the door frame.

19) Patient room #334's corridor door failed to latch close.

20) Patient room #454's corridor door was impeded within its frame.

21) Patient room #422's corridor door was difficult to open.

22) Patient room #475's corridor door was broke and could not latch close.

23) Patient room #478's corridor door was impeded within its frame.

24) Gift shop corridor and atrium doors were held open with merchandise impeding the ability for closure.

Based on observation, the facility failed to ensure that egress markings were installed in all areas that would require an exit or directional sign, were positioned for proper egress guidance, or had their chevron signs properly orientated for egress guidance.

Findings include:

The below listed location for egress markings had the following problems:

1) On 12/16/15, the egress marking in the ante-area, before the chiller room and electrical room, did not have its directional chevron pointing in the proper direction of egress.


2) On 12/16/15, the two corridor junctions near material management did not have proper egress markings:
(a) The elbow corridor near sterile processing was missing directional signs; and
(b) The T-intersection for the corridor from the floor scrubber/battery recharging room (near the Facility Plant Operations office), and the east-west corridor that connects to the elbow turn in the corridor (described in above (a)) and the exterior exit near material management did not have directional signs.


3) On 12/15/15, the T-intersection located west of the emergency department (ED) overflow suite, north of the new patient (west of ED) elevators, and the east-west corridor servicing the Facility Plant Operations offices, had an cross-corridor egress door restriction resulting in egress marking and evacuation problems. The north-south corridor, that serves the ED overflow suite's west exit, is a main egress corridor. Just south of the west ED overflow exit, the corridor had cross-corridor doors. On the morning of 12/15/15, the facility was installing a special locking device that would restrict exiting the cross-corridor doors in the south bound direction and was missing the required exit sign.


4) In the afternoon of 12/16/15, the imaging suite's north-south corridor that leads to and T's at the north, east-west emergency department corridor, both corridors had missing egress markings:
(a) The north, east-west emergency department corridor was missing a directional sign at the T intersection;
(b) The imaging suite's north-south corridor had a series of three cross-corridor doors, wherein the middle set of cross-corridor doors was missing its egress exit sign.


5) Throughout survey and throughout the Adrian Tower, the facility had confused exit egress with signs that stated:
"Stop"
"Authorized personnel Only"

Typical locations were at:
- the exit stairs' doors;
- smoke barrier doors leading to patient housing areas; and
- exit corridors that connect with procedure rooms.


6) On 12/17/15, the connector corridor between 2-East and the Cath lab, there were missing two directional signs at each end of the bend in the corridor's path.


7) On 12/17/15, at the T-intersection and suite exit for the east, north-south corridor connecting the new operating suite with the existing operating suite had chevron problems with three of the egress markings/signs:
- one egress marking needed both chevrons to be removed;
- one egress marking needed to add a chevron; and
- one egress marking needed to remove one chevron.


8) In the morning of 12/18/15, in the Cath lab corridor, an exit sign was without a directional chevron.

Based on observation and interview, the facility failed to ensure that smoke barrier doors could resist the passage of smoke.

Findings include:

1) On the morning of 12/17/15, the west leaf of the cross-corridor, smoke barrier doors between smoke compartment #11 (1 West) and the atrium failed to close to limit the transfer of smoke.

2) At 11:34 AM on 12/18/15, the atrium and 3-East smoke compartment's cross-corridor doors were held open, unable to resist the passage of smoke. The Facility Director indicated that the atrium smoke control system was keeping the doors in the open position.

Based on observation, the facility failed to ensure that all hazardous areas were equipped with 3/4-hour fire-rated doors.

Findings include:

In the morning of 12/18/15, the soiled workroom for the same day surgery only had a 20-minute fire-rated door.

Based on observation, the facility failed to ensure that egress access was available at all times.

Findings include:

1) On 12/15/15, near the plant operations and environmental office was a room that housed the large floor scrubbers and their battery rechargers. The corridor door to this room was a roll down garage door. The Facility Director and the contractor representative indicated that the corridor door to this room was connected to the fire alarm and that this door would roll down (forced) closed when the fire alarm was activated. Once the door was closed, there was no way for a person to exit from the room.

2) The exterior, exit door for the chapel was difficult to open. Require much force to release the door from it latch and frame.

3) The T-intersection located west of the emergency department (ED) overflow suite, north of the new patient (west of ED) elevators, and the east-west corridor servicing the Facility Plant Operations offices, had an cross-corridor egress door restriction. The north-south corridor, that serves as the ED overflow suite's west exit, was a main egress corridor. Just south of the west ED overflow exit, the corridor had cross-corridor doors. On the morning of 12/15/15, the facility was installing a special locking device that would restrict exiting the cross-corridor doors in the south bound direction.

4) On the afternoon of 12/16/15, within the two level egress stairs (that joins the first and second levels) had zip sticks (plastic barrier supports), visqueen (plastic barrier material), a cart, and 10-foot ladder stored within it.

2000 4.6.7 Modernization or Renovations. Any alteration or any installation of new equipment shall meet, as nearly as practicable, the requirements for new construction. Only altered, renovated, or modernized portions of an existing building, system, or individual component shall be required to meet the provisions of this Code that are applicable to new construction. If the alteration, renovation, or modernization adversely impacts required life safety features, additional upgrading shall be required. Existing life safety features that do not meet the requirements for new buildings, but that exceed the requirements for existing buildings, shall not be further diminished. In no case shall the resulting life safety features be less than those required for existing buildings.

NFPA 101 (2000 ed.) 7.1.10 Means of Egress Reliability. 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.


Based on observation and staff interview, the facility failed to ensure that equipment was not stored in a corridor used for egress.

Findings include:

On 12/18/15 at 4:05 PM, a crash cart was observed in the corridor in 4-West Peds, near room 423. The Ward Nurse was interviewed if the cart was always in the hallway. The Ward Nurse indicated that the crash cart was usually in the corridor, at that location, plugged into an emergency electrical outlet. The crash cart reduced the clear width of the corridor from 8-feet to 6-feet. The facility must maintain the pre-existing 8-foot corridor fire safety feature.

Based on observation, the facility failed to properly maintain the the fire alarm system components.

Findings include:

The below listed locations had the following fire alarm component problems:

1) In the morning of 12/16/15, in the west electrical room (off of the boiler room) there was a smoke detector with plastic cover over it.
2) In the morning of 12/16/15, in the east electrical room (off of the boiler room) there was a broken strobe light.
3) In the morning of 12/16/15, in the EVS (housekeeping) room, before the emergency department overflow, the smoke detector was taped over. (Also in this room was missing an ceiling access).
4) Morning of 12/18/15, in patient room #384, the smoke detector was missing.
5) Morning of 12/18/15, in patient room #352, the smoke detector was missing.

Based on observation, the facility create a entry space of greater that four feet in depth without fire sprinkler coverage protection.

Findings include:

In the afternoon of 12/16/15, in the imaging area near the clean room and the medical gas zone valve shut offs, the facility was doing construction. The access to the construction zone's and future room's entry had ceiling depth from the corridor of greater than 4 feet and there was no fire sprinkler head coverage for this area.

NFPA 25 ('98) 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged,loaded, or in the improper orientation.

Based on observation, the facility failed to ensure that all sprinkler heads were free of foreign materials, had their associated escutcheon rings and maintain their original installation positions.

Findings include:

During the survey for the Adrian Building, the below listed automatic fire sprinkler system had the following problems:

1) The sprinkler head in the Blood Gas Room (Room 41143), on 4 West Pediatrics, was covered with dust.


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2) In the old, abandoned rehabilitation suite's (1 West) hydro room, one of the rooms's fire sprinkler heads was missing its escutcheon ring.
3) In the housekeeping room near the dock, the fire sprinkler head was obstructed by the overhead pipes within the room.
4) The data room (near housekeeping room #14092) had two missing escutcheon rings for their respective fire sprinkler heads.
5) The Volunteer Office was missing one of its escutcheon rings for its respective fire sprinkler head.
6) The atrium's women's bathroom was missing an escutcheon ring.
7) Patient room #114 bathroom fire sprinkler head had foreign matter on it.
8) The 1 West Nurse Manager's office fire sprinkler head had foreign matter on it (filth).
9) Patient room #259 bathroom fire sprinkler head had foreign matter on it.
10) Staff Lounge on 1 West had a fire sprinkler head with foreign matter.
11) Laboratory pathology office had a fire sprinkler head that was dropped from it former position (possible hanger detachment) was also missing its escutcheon ring.
12) The micro area of the laboratory had two fire sprinkler heads that were missing their respective escutcheon rings.
13) At the surgical control station were two fire sprinkler heads with excess foreign matter on them.
14) The pre-op hold station #1's fire sprinkler head had excess foreign matter on it.
15) The women's locker room for the surgical suite had three fire sprinkler heads with foreign matter on them.
16) The Cath lab #3 fire sprinkler head was missing its cover.
17) Bathroom 24077 fire sprinkler was missing its escutcheon ring.
18) Third floor atrium public bathrooms (men and women) each had foreign matter on their fire sprinkler heads.
19) Patient room #386 bathroom fire sprinkler head was missing its escutcheon ring.
20) Patient room #384 bathroom fire sprinkler head had foreign matter on it.
21) Patient room #371 bathroom fire sprinkler head had rust on it.
22) Patient room #355 bathroom fire sprinkler head had a loose escutcheon ring.
23) Patient room #354 bathroom fire sprinkler head had a loose escutcheon ring.
24) Ante room fire sprinkler head had a loose escutcheon ring.
25) Patient room #353 bathroom fire sprinkler head had rust on it.
26) Patient room #352 bathroom fire sprinkler head had a loose escutcheon ring.
27) Patient room #334 bathroom fire sprinkler head had a loose escutcheon ring.
28) Patient room #332 bathroom fire sprinkler head had a loose escutcheon ring.
29) Patient room 303 had a fire sprinkler head that was dropped from it former position (possible hanger detachment) and had foreign matter on it.
30) Patient room #310 bathroom fire sprinkler head had foreign matter on it.
31) Soiled workroom in 3 West fire sprinkler head had foreign matter on it.
32) The newborn intensive care unit bathroom fire sprinkler head had foreign matter on it.
33) Patient room #437 bathroom fire sprinkler head had foreign matter on it.
34) Patient room #438 bathroom fire sprinkler head had foreign matter (string) on it.
35) Patient room #475 bathroom fire sprinkler head had a bent deflector.
36) Patient room #478 bathroom fire sprinkler head had foreign matter on it.
37) Patient room #488 bathroom fire sprinkler head had loose escutcheon ring.
38) Patient room #484 bathroom fire sprinkler head had foreign matter on it.

Based on observation, the facility failed to ensure that all portable fire extinguishers were properly maintained.

Findings include:

In the Fire Command Room, the portable fire extinguisher was found overcharged.

Based on observation, interview and document review, the facility was using portable space heaters against facility policy and without evidence that they conformed to allowable exceptions.

Findings include:

When the first portable space heater (PSH) was discovered within the Adrian Tower in the morning of 12/17/15, The Facility Director indicated that their presence was against the facility's policy and the facility would not have maintain documentation to determine and possibly allow them within the building.

The below listed locations that PSH were discovered:

1) Morning of 12/17/15, in the Human Information Management (HIM) office with the PSH was powered-on and unattended.
2) Morning of 12/17/15, in the Volunteer office.
3) Morning of 12/17/15, in Room #14005 a space heater was in a box behind the file cabinet.
4) Nurse Manager's office on 1-West.

Chapter 12-5.1.1 Utilities shall comply with the provisions of Section 7-1

Chapter 7-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction.

NFPA 70, Section 384-13 Panelboards. General.
All panelboard circuits and circuit modifications shall be legibly identified as to the purpose or use on a circuit directory located on the face or inside the panel doors.

NFPA 101 18.5.1.1 and 9.1 and NFPA 70 370-28(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use.

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure

NFPA 70, Section 305-4(h) Protection from Accidental Damage. Flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where passing through doorways or other pinch points, protections shall be provided to avoid damage.

Based on observation, the facility failed to ensure that the building was being maintained in accordance with the National Fire Protection Association (NFPA), 70, National Electrical Code.

Findings include:

The below listed location had the following electrical code problems:

1) In the morning of 12/16/15, in the material manager's office, the facility was substituting permanent wiring with connected (daisy chain) extension cord and power tap.
2) In the afternoon of 12/16/15, in the physician's lounge the facility was substituting permanent wiring with an extension cord.
3) In the morning of 12/17/15, in 1-West electrical room, the facility had placed picture/frames, wood dowels and ceiling tile in front of the electrical panels.
4) In the morning of 12/17/15, in 2-West at the end of the corridor was a six multiplex electrical adapter.
5) In the morning of 12/18/15, in the electrical room above the ceiling was an open J-box.
6) In the afternoon of 12/18/15, on 3-West the electrical room had ladder, light bulbs, and two, flood lights.
7) In the morning of 12/16/15, in the Pharmacy office area, a charting device was in the corridor and its electrical cord was run through a doorway to an electrical outlet.

Based on observation the facility failed to ensure that Alcohol Based Hand Rub (ABHRs) dispensers were installed a safe distance from ignition sources.

Findings include:

On 12/18/15, four ABHR's had been improperly installed directly over light switches in each of the following Operating Rooms: #11, #13, #14, and #16.