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This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to maintain the fire rated smoke barrier walls in accordance with the Life Safety Code. This was evidenced by:

There were unsealed wire chase penetrations in smoke barrier walls above the drop ceiling in the following locations:
a. the x-ray smoke barrier, and
b. in the Emergency department smoke barrier.

The smoke barrier wall deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the survey that the facility failed to maintain and protect the hazardous areas in accordance with the Life Safety Code. This was evidenced by:

1) The loading dock was found to have a tension hold-open device mounted on the required self-closing corridor door. In accordance with section 19.3.2.1, this door must either be self-closing or automatic closing, but may not, in either case, be held open by this type of device.
Note: this item was corrected during the survey.

2) The Emergency Department Supply room was found to be greater than seventy square feet in size and housed combustible materials; however, the facility failed to install a self-closure device on the corridor door.

3) The one-hour fire rated wall surrounding the electrical room adjacent to the Emergency Department was found to have an unsealed wire chase that was approximately three-inches in diameter.

The hazardous area deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

Documentation was not provided at the time of the survey to show the following drills had been completed:
a. One (1) during the second shift in the fourth quarter of 2011,
b. One (1) during the second shift in the second quarter of 2012, and
c. One (1) during the first shift in the second quarter of 2012.

The fire drill deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to install the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

The visual and audible annunciation provided in the Operating Room Suite was not adequate to provide the required notification throughout the suite. Upon activation of the Fire Alarm System, the audible alarms could not be heard over the average ambient noise found in the operating room. Further, the visual notification of the fire alarm system could not be seen in the operating room.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by review of documentation during the course of the survey that the smoke detection system maintenance records did not indicate that each smoke detector within the facility has had a sensitivity test completed as referenced in NFPA 72, National Fire Alarm Code (1999), or in accordance with the manufacturers specifications. This was evidenced by the following:

There were no current records provided by an independent fire alarm system contractor and available on premises that documented the required sensitivity test for each smoke detector installed within the facility.
Note: Sensitivity testing is required, per NFPA 72 section 7-3.2.1, which states in part "Detector sensitivity shall be checked within one year after installation and every alternate year thereafter."

The fire alarm system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code and NFPA 13. This was evidenced by:

The pendant sprinkler head located in the Emergency Department janitor closet was found to be approximately four feet from the ceiling, underneath a duct.
Note: In accordance with NFPA 13, section 5-8.4.1, a pendant style sprinkler head shall not be any more than twelve-inches away from the ceiling.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation and record review during the course of the survey that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1) The facility failed to provide documentation at the time of the survey to reflect that tamper switches for the automatic fire sprinkler system were tested during the first half of 2012.
Note: The tamper switches are required to be tested semi-annually in accordance with NFPA 25, 9-3.4.3; the last documented test of the facility's tamper switches was conducted on November 22, 2011.

2) The facility failed to provide documentation at the time of the survey to reflect that the required annual inspection of the fire sprinkler system had occurred during the last twelve-month period.

3) At the time of the survey it was observed that there were two water lines in the maintenance shop that were hanging off the branch line for the automatic fire sprinkler system. In accordance with NFPA 25, 2-2.2, nothing may bye attached to the sprinkler piping.
Note: This item was corrected during the survey.

The fire sprinkler system deficiency items were discussed during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to maintain the MedGas storage location in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

The electrical light switch, an electrical outlet, and the electrical thermostat box located in the MedGas storage room were found to be located lower than the allowable 5-feet above floor level.
Note: In accordance with NFPA 99, Health Care Facilities, 4-3.1.1.2(a)4, "electrical installation in storage locations...shall be installed in fixed locations not less than 152 cm (5 ft) above the floor."

The MedGas storage location deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

Through observation and staff interview during the survey it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99. This was evidenced by:

The Operating room did not contain exhaust capabilities in case of a fire in the operating room.
Note: Per NFPA 99, 1999 Edition 5-4.1.3 "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

The anesthetizing location deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation and through staff interview during the course of the survey that the facility failed to maintain the emergency backup generator that provides emergency lighting for egress in accordance with NFPA 101, Life Safety Code and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

1) The facility failed to provide a remote manual stop station for the generator, as required by NFPA 110, 2000 edition, 3-5.5.6.

2) The facility failed to provide a battery-backed up emergency light at the transfer switch location, capable of providing 90-minutes of illumination, as required.

The generator deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1; known as the Main Hospital.

Through observation during the survey, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70. This was evidenced by:

The blood draw room had two (2) surge protected electrical power strips plugged into a third surge protected electrical power strip.
Note: Per NFPA 70 1999 Edition, Chapter 4, Article 400, Paragraph 400.8, (" ... flexible cords and cables shall not be used for the following: (1) as a substitute for the fixed wiring of a structure ... ")

The electrical system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation, staff interview, and through record review during the course of the survey that the facility failed to provide an acceptable fire watch policy in the event the automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period. This was evidenced by the following:

At the time of the survey the facility provided a policy and documentation enacting the policy regarding the requirement set forth in NFPA 101, 9.7.6.1, wherein it states that when a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the building shall be evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. The documentation failed to:
a) reflect that the affected area must be inspected, at a minimum, every fifteen minutes, and
b) reflect a required procedure, wherein facility staff are to advise the Authority Having Jurisdiction (CDPHE) whenever the facility is on a fire watch, as required.
Note: In accordance with the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division's (Authority Having Jurisdiction) policy manual in regards to Life Safety Code Fire Watch Requirements (enacted in January of 2010), a full inspection of the affected areas within this facility shall take place at a minimum of every fifteen minutes.

The fire watch policy deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

Through observation during the survey, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly. This was evidenced by:

During the walk through of the facility there was a hand sanitizer installed directly above an electrical switch in the triage room in the Emergency Department.

The Alcohol Based Hand Rub (ABHR) dispenser deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to maintain the fire rated smoke barrier walls in accordance with the Life Safety Code. This was evidenced by:

There were unsealed wire chase penetrations in smoke barrier walls above the drop ceiling in the following locations:
a. the x-ray smoke barrier, and
b. in the Emergency department smoke barrier.

The smoke barrier wall deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the survey that the facility failed to maintain and protect the hazardous areas in accordance with the Life Safety Code. This was evidenced by:

1) The loading dock was found to have a tension hold-open device mounted on the required self-closing corridor door. In accordance with section 19.3.2.1, this door must either be self-closing or automatic closing, but may not, in either case, be held open by this type of device.
Note: this item was corrected during the survey.

2) The Emergency Department Supply room was found to be greater than seventy square feet in size and housed combustible materials; however, the facility failed to install a self-closure device on the corridor door.

3) The one-hour fire rated wall surrounding the electrical room adjacent to the Emergency Department was found to have an unsealed wire chase that was approximately three-inches in diameter.

The hazardous area deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

Documentation was not provided at the time of the survey to show the following drills had been completed:
a. One (1) during the second shift in the fourth quarter of 2011,
b. One (1) during the second shift in the second quarter of 2012, and
c. One (1) during the first shift in the second quarter of 2012.

The fire drill deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to install the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

The visual and audible annunciation provided in the Operating Room Suite was not adequate to provide the required notification throughout the suite. Upon activation of the Fire Alarm System, the audible alarms could not be heard over the average ambient noise found in the operating room. Further, the visual notification of the fire alarm system could not be seen in the operating room.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by review of documentation during the course of the survey that the smoke detection system maintenance records did not indicate that each smoke detector within the facility has had a sensitivity test completed as referenced in NFPA 72, National Fire Alarm Code (1999), or in accordance with the manufacturers specifications. This was evidenced by the following:

There were no current records provided by an independent fire alarm system contractor and available on premises that documented the required sensitivity test for each smoke detector installed within the facility.
Note: Sensitivity testing is required, per NFPA 72 section 7-3.2.1, which states in part "Detector sensitivity shall be checked within one year after installation and every alternate year thereafter."

The fire alarm system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code and NFPA 13. This was evidenced by:

The pendant sprinkler head located in the Emergency Department janitor closet was found to be approximately four feet from the ceiling, underneath a duct.
Note: In accordance with NFPA 13, section 5-8.4.1, a pendant style sprinkler head shall not be any more than twelve-inches away from the ceiling.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation and record review during the course of the survey that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1) The facility failed to provide documentation at the time of the survey to reflect that tamper switches for the automatic fire sprinkler system were tested during the first half of 2012.
Note: The tamper switches are required to be tested semi-annually in accordance with NFPA 25, 9-3.4.3; the last documented test of the facility's tamper switches was conducted on November 22, 2011.

2) The facility failed to provide documentation at the time of the survey to reflect that the required annual inspection of the fire sprinkler system had occurred during the last twelve-month period.

3) At the time of the survey it was observed that there were two water lines in the maintenance shop that were hanging off the branch line for the automatic fire sprinkler system. In accordance with NFPA 25, 2-2.2, nothing may bye attached to the sprinkler piping.
Note: This item was corrected during the survey.

The fire sprinkler system deficiency items were discussed during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to maintain the MedGas storage location in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

The electrical light switch, an electrical outlet, and the electrical thermostat box located in the MedGas storage room were found to be located lower than the allowable 5-feet above floor level.
Note: In accordance with NFPA 99, Health Care Facilities, 4-3.1.1.2(a)4, "electrical installation in storage locations...shall be installed in fixed locations not less than 152 cm (5 ft) above the floor."

The MedGas storage location deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

Through observation and staff interview during the survey it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99. This was evidenced by:

The Operating room did not contain exhaust capabilities in case of a fire in the operating room.
Note: Per NFPA 99, 1999 Edition 5-4.1.3 "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

The anesthetizing location deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation and through staff interview during the course of the survey that the facility failed to maintain the emergency backup generator that provides emergency lighting for egress in accordance with NFPA 101, Life Safety Code and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

1) The facility failed to provide a remote manual stop station for the generator, as required by NFPA 110, 2000 edition, 3-5.5.6.

2) The facility failed to provide a battery-backed up emergency light at the transfer switch location, capable of providing 90-minutes of illumination, as required.

The generator deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1; known as the Main Hospital.

Through observation during the survey, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70. This was evidenced by:

The blood draw room had two (2) surge protected electrical power strips plugged into a third surge protected electrical power strip.
Note: Per NFPA 70 1999 Edition, Chapter 4, Article 400, Paragraph 400.8, (" ... flexible cords and cables shall not be used for the following: (1) as a substitute for the fixed wiring of a structure ... ")

The electrical system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation, staff interview, and through record review during the course of the survey that the facility failed to provide an acceptable fire watch policy in the event the automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period. This was evidenced by the following:

At the time of the survey the facility provided a policy and documentation enacting the policy regarding the requirement set forth in NFPA 101, 9.7.6.1, wherein it states that when a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the building shall be evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. The documentation failed to:
a) reflect that the affected area must be inspected, at a minimum, every fifteen minutes, and
b) reflect a required procedure, wherein facility staff are to advise the Authority Having Jurisdiction (CDPHE) whenever the facility is on a fire watch, as required.
Note: In accordance with the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division's (Authority Having Jurisdiction) policy manual in regards to Life Safety Code Fire Watch Requirements (enacted in January of 2010), a full inspection of the affected areas within this facility shall take place at a minimum of every fifteen minutes.

The fire watch policy deficiency item was discussed during the survey and again during the exit conference.