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Based on observation and staff interview, the facility failed to maintain one doorway of hazardous room clear of obstruction in accordance with NFPA 101 section 19.3.6.3. This deficient practice affected 1 of 33 smoke compartments. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), and Staff M4 (manager of facilities operations), surveyor observed on 10/03/13 at 2:20 pm that the corridor door of the Carpenter Shop at the Lower Level was obstructed by a trash receptacle causing impediment to closing of door.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer), and Staff M3 (director of facilities operations-south market) at the exit conference on 10/03/13 at 4 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of exit signs to direct occupants to exits in four locations in accordance with NFPA 101 section 7.10.1.4. This deficient practice affected 3 of 33 smoke compartments. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations-south market), and Staff M4 (manager of facilities operations), surveyor observed between 9/30-10/03/13 that exit signs were not installed to direct occupants to exits in the following four locations:

(i) above two doors within the Medical Record Suite on the 1st Floor;
(ii) double doors on the north side of doors adjacent to the Resource Room;
(iii) double doors on the east side of doors adjacent to the Report Room 1; and
(iv) double doors on the west side of doors adjacent to Room 173.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients due to (i) one smoke barrier not extended to roof deck above in accordance with NFPA 101 section 19.3.7.3; (ii) one cable-in-sleeve penetration of a smoke barrier not properly sealed and supported; and (iii) one HVAC duct penetration of smoke barrier sealed with expandable foam that did not have a UL design, or other approved design for a ½ hr fire-resistance rating.

The above deficient practice could affect patients in 3 of 33 smoke compartments, undetermined number of visitors and staff in the facility. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3(director of facilities operations-south market), and Staff M4(manager of facilities operations), surveyor observed on 9/30/13 between 2 pm and 3 pm that the 5th Floor smoke barrier above the smoke doors adjacent to the Center building elevators was not extended to the underside of the roof deck above.

2. During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4 from 9/30 - 10/3/13, surveyor observed that one cable penetration in a sleeve through the smoke barrier above the smoke doors adjacent to the Kohler building elevator on the 3rd Floor was not properly sealed to provide at least ½ hr fire-resistance rating in accordance with NFPA 101 sections 19.3.7.3, 8.3.6.1. The cables were not bundled up and the sleeve and cables were not properly supported by the building structure.

3. During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4 from 9/30 - 10/3/13, surveyor observed that one HVAC duct penetration through the smoke barrier above the smoke doors adjacent to the center stair of the Kohler building on the 3rd Floor was not properly sealed to provide at least ½ hr fire-resistance rating in accordance with NFPA 101 sections 19.3.7.3, 8.3.6.1. Expandable foam was used to seal the gap around the duct penetration. There was no evidence available at the time of survey as to the flame spread rating, UL design, and material safety data sheet of the foam product.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to inadequate clear widths provided by each leaf of the smoke barrier doors in two locations in accordance with NFPA 101 section 19.3.7.5. This deficient practice affected 3 of 33 smoke compartments. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations), and Staff M4 (manager of facilities operations), surveyor observed between 9/30-10/03/13 that the cross-corridor smoke barrier doors adjacent to the surgery elevators, and smoke barrier doors adjacent to the Physicians Lounge both on the 5th Floor of the Kohler and Center buildings were not of 32 inch clear width in accordance with NFPA 101 section 19.3.7.5.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to inadequate clear widths provided by exit access doors in one location in accordance with NFPA 101 section 19.2.3.5. This deficient practice affected 1 of 33 smoke compartments. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations-south market), and Staff M4 (manager of facilities operations), surveyor observed between 9/30-10/03/13 that the exit access double doors within the Surgery Suite on the 5th Floor Kohler building were of 29½ in. and not of 32 inch clear width in accordance with NFPA 101 section 19.2.3.5.

This deficiency was confirmed by a phone conversation with the senior director of facilities operations on 10/07/13 between 10:15 am and 10:45 am.

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services, and the Centers for Medicare and Medicaid Services have not identified any exceptions to permit non-compliance with NFPA 72 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 fire alarm system to defend in place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 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 fire alarm system with a compliant notification or dialer communication lines. This deficiency could affect all patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings Include:

1. On 10/01/13 at 1:07 pm, surveyor observed on the 3rd floor that the fire alarm installation was not compliant. The call room for physicians had no strobe. This observed situation was not compliant with NFPA 101 (2000 edition) sections 9.6.1.4, 9.6.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M1 (senior director of system facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations-south market), and Staff M4 (manager of facilities operations).

2. On 10/01/13 between 2:45 pm and 3:15 pm, surveyor observed on the 2nd floor in the physicians sleep room across from Post-Partum Room 226 that the fire alarm installation was not compliant. The call room for physicians had no strobe. This observed situation was not compliant with NFPA 101 (2000 edition) sections 9.6.1.4, 9.6.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations.

3. On 10/02/13 between 11:15 am and 12 pm, surveyor observed on the 1st floor in the physicians call room in the emergency department that the fire alarm installation was not compliant. The call room for physicians had no strobe. This observed situation was not compliant with NFPA 101 (2000 edition) sections 9.6.1.4, 9.6.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations.

4. On 10/03/13 between 2:15 and 3 pm, surveyor observed on the ground floor in the Rehab Gymnasium for inpatients that the fire alarm installation was not compliant. The inpatient Rehab Gymnasium had no strobe. This observed situation was not compliant with NFPA 101 (2000 edition) sections 9.6.1.4, 9.6.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations.

5. On 10/3/13 between 2 and 3:15 pm, surveyor observed that the automatic dialer component of the facility fire alarm system, when placed in trouble by disconnecting the dedicated phone lines, did not communicate with the main fire alarm panel, and the remote annunciator panel located at the reception desk of the emergency department (ED) on the 1st Floor.

When interviewed on 10/03/13 at 3:15 pm, Staff M6 (electrician) stated that the automatic dialer located in the Fire Alarm Control Room in the lower level did annunciate audible and visible trouble signals at the dialer panel upon testing of phone line failure; but the remote annunciator at the 1st Floor ED reception desk, where it is likely to be heard, did not.

This observed situation was not compliant with NFPA 101 section 9.6.1.4, and NFPA 72 Chapters 5 and 7 requirements on installation and testing of automatic transmission equipment (DACT) to provide annunciation of trouble signals from phone line failure.

This deficiency was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, manager of facilities operations, and electrician, and also confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

References:
NFPA 101 section 9.6.1.4
"A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, the National Fire Alarm Code..."

NFPA 101 section 9.6.3.6
"Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided."

"NFPA 72 section 1-5.4.4
"Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated."

NFPA 72 (1999) section 1-5.4.6
"Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard."

NFPA 72 section 1-5.4.6.1
"Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:

(1) Control unit (central equipment) for protected premises fire alarm systems
(2) Building fire command center for emergency voice/alarm communications service
(3) Central station or remote station location for systems installed in compliance with Chapter 5"

Based on interview and record review, the facility failed to perform the required maintenance of the fire alarm system batteries in accordance with NFPA 72. This deficient practice could affect all patients that the facility is licensed to serve, as well as an undetermined number of visitors and staff in the facility. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. On 10/03/13, surveyor noted during a review of the maintenance record of the fire alarm system with Staff M1 (senior director of system facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations-south market), and Staff M4 (manager of facilities operations), Staff M9 (manager of system facilities operations), Staff M8 (facility operations assistant) and Staff M6 (electrician) between 8:15 am and 12:15 pm that reports were not available to verify that the load voltage test of fire alarm system batteries was performed semiannually in accordance with NFPA 72 sections 7-2.2, 7-3.2. The semiannual voltage test between the 2012 and 2013 annual fire alarm inspections was missing.

When interviewed on 10/03/13 at 10:25 am, Staff M6 stated that the load voltage test was not performed in between the annual fire alarm system inspection and tests performed by the SimplexGrinnell.

This deficiency was also confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and staff interview, the facility failed to maintain the sprinkler system due to (i) sprinkler piping supporting other materials in two locations, which is not permitted by NFPA 25 section 2-2.2; and (ii) lack of sprinkler on top of one stair shaft in accordance with NFPA 13 section 5-13.3.2. This deficient practice affected 4 of 33 smoke compartments. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations), and Staff M4 (manager of facilities operations), surveyor observed between 9/30-10/03/13 that (i) one electrical conduit, and two data cables were supported by sprinkler piping in the ceiling plenum space above the smoke doors near the elevators in the 5th Floor Center building; and (ii) one sprinkler head was missing on top of the west stair shaft in the South building.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

References:
NFPA 25 (1998) section 2-2.2* Pipe and Fittings.
" Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown. "

NFPA 13 section 5-13.3.2
"In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.

Exception: Sprinklers shall be installed beneath landings or stairways where the area beneath is used for storage."

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff due to (i) one corridor used as a return air plenum which is not permitted by NFPA 90A section 2-3.11.1; and (ii) lack of smoke isolation dampers in two air-handling units in accordance with NFPA 90A section 2-3.9.2. This deficient practice could affect patients in 6 of 33 smoke compartments, undetermined number of visitors and staff in the facility, if there was a fire in the facility. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3(director of facilities operations-south market), and Staff M4(manager of facilities operations), surveyor observed on 10/01/13 between 8:50 am and 12 pm that the 4th Floor corridor serving patient sleeping areas in the Kohler building was partially used as a return air plenum as evidenced by the airflow occurring from both the east and west stairs into the corridor through the undercut of the stairwell doors.

2. During a tour of the facility with Staff M1, Staff M2, Staff M3, Staff M4, and Staff M5 (HVAC technician) from 9/30 - 10/3/13, surveyor observed that the two air-handling units, AHU #7 and AHU #9, with a fan capacity of greater than 15000 cfm did not have smoke isolation dampers in the return and supply sides of the units to restrict the circulation of smoke.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to soiled linen/trash receptacles not stored in a room protected as a hazardous area in accordance with NFPA 101 section 19.7.5.5 in four locations. This deficient practice affected 4 of 33 smoke compartments in the facility. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of system facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations), and Staff M4 (manager of facilities operations), surveyor observed on 10/01/13 at 9:15 am that one waste and two soiled linen receptacles of a combined capacity of more than 32 gal were left unattended for greater than 30 minutes in Operation Room #4 on the 5th Floor of Kohler building, and not stored in a room protected as a hazardous area.

2. During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/01/13 between 2:45 pm and 3:15 pm that one trash receptacle of approximately 1 ½ ft wide x 3 ft x 3 ft with a combined capacity of more than 32 gal was left unattended for greater than 30 minutes in the 2nd Floor Lucas building alcove-like space in front of Elevator #6, and not stored in a room protected as a hazardous area.

3. During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, and Staff A1 (nurse manager), surveyor observed on 10/02/13 between 10:30 am and 11:30 am that one trash, one soiled linen and one biohazard waste receptacles of a combined capacity of more than 32 gal were left unattended for greater than 30 minutes in the C-Section Room #1 on the 2nd Floor of South building, and not stored in a room protected as a hazardous area.

4. During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/02/13 at 1:05 pm that one X-Ray labeled container with combustibles of a combined capacity of more than 32 gal was left unattended for greater than 30 minutes in the passage across from the Radiology Room 3 in the Radiology suite on the 1st Floor, and not stored in a room protected as a hazardous area. The container was of approximately 1¾ ft wide x 2½ ft x 2½ ft dimensions.

This deficiency was acknowledged by the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and interview, the facility failed to ensure safety to patients due to lack of medical gas and vacuum area alarm panel in three areas in accordance with NFPA 99 section 4-3.1.2.2(c). This deficient practice affected 7 of 33 smoke compartments in patient sleeping areas on 3 floors. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), M3 (director of facilities operations), and M4 (manager of facilities operations), surveyor observed between 9/30-10/03/13 that the medical surgical patient rooms in three areas of the 2nd, 3rd and 4th Floors of the hospital did not have medical gas and vacuum system area alarm panels to notify staff in the area, if the pressure/vacuum in oxygen medical gas and vacuum piping was outside of the allowable 20%± range.

This deficiency was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, manager of facilities operations, and electrician, and also confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and interview between September 30 and October 3, 2013, the facility failed to meet code requirements referenced in the following miscellaneous items in the Ambulatory Health Care occupancy. These deficiencies could affect all patients, staff and an undetermined number of visitors in the surgery center.

Findings include:

Item #1
NFPA 72 (1999) section 1-5.6* Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

While on tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations-south market), and Staff M10 (maintenance technician) on 10/2/13 between 3:15 and 4:30 pm, it was observed that there was no smoke detector installed (i) in the automatic phone dialer equipment room (generator room) on the 1st Floor and (ii) in the main fire alarm panel room on the 1st Floor in accordance with NFPA 101 sections 21.3.4.1, 9.6.2.1, NFPA 72(1999) section 1-5.6.


Item #2
NFPA 99 (1999) section 3-4.1.1.15
"A remote annunciator, storage battery powered, shall be provided to operate outside of the generator room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is to supply power to load
2. When the battery charger is malfunctioning source generator.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2] "

While on tour of the facility with Staff M1, Staff M2, and Staff M3, surveyor observed that there was no remote annunciator to annunciate a generator fault condition in accordance with NFPA 99 (1999) 3-4.1.1.15, NFPA 110 section 3-5.6.1 (1999) at a continuously monitored location. The generator is located in the 1st Floor mechanical room.


Item #3
NFPA 101 section 7.10.1.4*
"Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.

Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements."

While on tour of the facility with Staff M1, Staff M2, and Staff M3 on 10/2/13 between 3:15 pm and 4:30 pm, surveyor observed that there was no exit sign installed above doors adjacent to Room 640 in the sleep lab area to direct occupants to exit in accordance with NFPA 101 7.10.1.4.


This deficiency was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, and maintenance technician also confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and staff interview, the facility failed to maintain one doorway of hazardous room clear of obstruction in accordance with NFPA 101 section 19.3.6.3. This deficient practice affected 1 of 33 smoke compartments. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), and Staff M4 (manager of facilities operations), surveyor observed on 10/03/13 at 2:20 pm that the corridor door of the Carpenter Shop at the Lower Level was obstructed by a trash receptacle causing impediment to closing of door.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer), and Staff M3 (director of facilities operations-south market) at the exit conference on 10/03/13 at 4 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of exit signs to direct occupants to exits in four locations in accordance with NFPA 101 section 7.10.1.4. This deficient practice affected 3 of 33 smoke compartments. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations-south market), and Staff M4 (manager of facilities operations), surveyor observed between 9/30-10/03/13 that exit signs were not installed to direct occupants to exits in the following four locations:

(i) above two doors within the Medical Record Suite on the 1st Floor;
(ii) double doors on the north side of doors adjacent to the Resource Room;
(iii) double doors on the east side of doors adjacent to the Report Room 1; and
(iv) double doors on the west side of doors adjacent to Room 173.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients due to (i) one smoke barrier not extended to roof deck above in accordance with NFPA 101 section 19.3.7.3; (ii) one cable-in-sleeve penetration of a smoke barrier not properly sealed and supported; and (iii) one HVAC duct penetration of smoke barrier sealed with expandable foam that did not have a UL design, or other approved design for a ½ hr fire-resistance rating.

The above deficient practice could affect patients in 3 of 33 smoke compartments, undetermined number of visitors and staff in the facility. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3(director of facilities operations-south market), and Staff M4(manager of facilities operations), surveyor observed on 9/30/13 between 2 pm and 3 pm that the 5th Floor smoke barrier above the smoke doors adjacent to the Center building elevators was not extended to the underside of the roof deck above.

2. During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4 from 9/30 - 10/3/13, surveyor observed that one cable penetration in a sleeve through the smoke barrier above the smoke doors adjacent to the Kohler building elevator on the 3rd Floor was not properly sealed to provide at least ½ hr fire-resistance rating in accordance with NFPA 101 sections 19.3.7.3, 8.3.6.1. The cables were not bundled up and the sleeve and cables were not properly supported by the building structure.

3. During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4 from 9/30 - 10/3/13, surveyor observed that one HVAC duct penetration through the smoke barrier above the smoke doors adjacent to the center stair of the Kohler building on the 3rd Floor was not properly sealed to provide at least ½ hr fire-resistance rating in accordance with NFPA 101 sections 19.3.7.3, 8.3.6.1. Expandable foam was used to seal the gap around the duct penetration. There was no evidence available at the time of survey as to the flame spread rating, UL design, and material safety data sheet of the foam product.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to inadequate clear widths provided by each leaf of the smoke barrier doors in two locations in accordance with NFPA 101 section 19.3.7.5. This deficient practice affected 3 of 33 smoke compartments. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations), and Staff M4 (manager of facilities operations), surveyor observed between 9/30-10/03/13 that the cross-corridor smoke barrier doors adjacent to the surgery elevators, and smoke barrier doors adjacent to the Physicians Lounge both on the 5th Floor of the Kohler and Center buildings were not of 32 inch clear width in accordance with NFPA 101 section 19.3.7.5.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to inadequate clear widths provided by exit access doors in one location in accordance with NFPA 101 section 19.2.3.5. This deficient practice affected 1 of 33 smoke compartments. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations-south market), and Staff M4 (manager of facilities operations), surveyor observed between 9/30-10/03/13 that the exit access double doors within the Surgery Suite on the 5th Floor Kohler building were of 29½ in. and not of 32 inch clear width in accordance with NFPA 101 section 19.2.3.5.

This deficiency was confirmed by a phone conversation with the senior director of facilities operations on 10/07/13 between 10:15 am and 10:45 am.

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services, and the Centers for Medicare and Medicaid Services have not identified any exceptions to permit non-compliance with NFPA 72 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 fire alarm system to defend in place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 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 fire alarm system with a compliant notification or dialer communication lines. This deficiency could affect all patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings Include:

1. On 10/01/13 at 1:07 pm, surveyor observed on the 3rd floor that the fire alarm installation was not compliant. The call room for physicians had no strobe. This observed situation was not compliant with NFPA 101 (2000 edition) sections 9.6.1.4, 9.6.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M1 (senior director of system facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations-south market), and Staff M4 (manager of facilities operations).

2. On 10/01/13 between 2:45 pm and 3:15 pm, surveyor observed on the 2nd floor in the physicians sleep room across from Post-Partum Room 226 that the fire alarm installation was not compliant. The call room for physicians had no strobe. This observed situation was not compliant with NFPA 101 (2000 edition) sections 9.6.1.4, 9.6.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations.

3. On 10/02/13 between 11:15 am and 12 pm, surveyor observed on the 1st floor in the physicians call room in the emergency department that the fire alarm installation was not compliant. The call room for physicians had no strobe. This observed situation was not compliant with NFPA 101 (2000 edition) sections 9.6.1.4, 9.6.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations.

4. On 10/03/13 between 2:15 and 3 pm, surveyor observed on the ground floor in the Rehab Gymnasium for inpatients that the fire alarm installation was not compliant. The inpatient Rehab Gymnasium had no strobe. This observed situation was not compliant with NFPA 101 (2000 edition) sections 9.6.1.4, 9.6.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations.

5. On 10/3/13 between 2 and 3:15 pm, surveyor observed that the automatic dialer component of the facility fire alarm system, when placed in trouble by disconnecting the dedicated phone lines, did not communicate with the main fire alarm panel, and the remote annunciator panel located at the reception desk of the emergency department (ED) on the 1st Floor.

When interviewed on 10/03/13 at 3:15 pm, Staff M6 (electrician) stated that the automatic dialer located in the Fire Alarm Control Room in the lower level did annunciate audible and visible trouble signals at the dialer panel upon testing of phone line failure; but the remote annunciator at the 1st Floor ED reception desk, where it is likely to be heard, did not.

This observed situation was not compliant with NFPA 101 section 9.6.1.4, and NFPA 72 Chapters 5 and 7 requirements on installation and testing of automatic transmission equipment (DACT) to provide annunciation of trouble signals from phone line failure.

This deficiency was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, manager of facilities operations, and electrician, and also confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

References:
NFPA 101 section 9.6.1.4
"A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, the National Fire Alarm Code..."

NFPA 101 section 9.6.3.6
"Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided."

"NFPA 72 section 1-5.4.4
"Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated."

NFPA 72 (1999) section 1-5.4.6
"Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard."

NFPA 72 section 1-5.4.6.1
"Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:

(1) Control unit (central equipment) for protected premises fire alarm systems
(2) Building fire command center for emergency voice/alarm communications service
(3) Central station or remote station location for systems installed in compliance with Chapter 5"

Based on interview and record review, the facility failed to perform the required maintenance of the fire alarm system batteries in accordance with NFPA 72. This deficient practice could affect all patients that the facility is licensed to serve, as well as an undetermined number of visitors and staff in the facility. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. On 10/03/13, surveyor noted during a review of the maintenance record of the fire alarm system with Staff M1 (senior director of system facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations-south market), and Staff M4 (manager of facilities operations), Staff M9 (manager of system facilities operations), Staff M8 (facility operations assistant) and Staff M6 (electrician) between 8:15 am and 12:15 pm that reports were not available to verify that the load voltage test of fire alarm system batteries was performed semiannually in accordance with NFPA 72 sections 7-2.2, 7-3.2. The semiannual voltage test between the 2012 and 2013 annual fire alarm inspections was missing.

When interviewed on 10/03/13 at 10:25 am, Staff M6 stated that the load voltage test was not performed in between the annual fire alarm system inspection and tests performed by the SimplexGrinnell.

This deficiency was also confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and staff interview, the facility failed to maintain the sprinkler system due to (i) sprinkler piping supporting other materials in two locations, which is not permitted by NFPA 25 section 2-2.2; and (ii) lack of sprinkler on top of one stair shaft in accordance with NFPA 13 section 5-13.3.2. This deficient practice affected 4 of 33 smoke compartments. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations), and Staff M4 (manager of facilities operations), surveyor observed between 9/30-10/03/13 that (i) one electrical conduit, and two data cables were supported by sprinkler piping in the ceiling plenum space above the smoke doors near the elevators in the 5th Floor Center building; and (ii) one sprinkler head was missing on top of the west stair shaft in the South building.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

References:
NFPA 25 (1998) section 2-2.2* Pipe and Fittings.
" Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown. "

NFPA 13 section 5-13.3.2
"In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.

Exception: Sprinklers shall be installed beneath landings or stairways where the area beneath is used for storage."

Based on observation and staff interview, the facility failed to ensure safety to patients, visitors and staff due to (i) one corridor used as a return air plenum which is not permitted by NFPA 90A section 2-3.11.1; and (ii) lack of smoke isolation dampers in two air-handling units in accordance with NFPA 90A section 2-3.9.2. This deficient practice could affect patients in 6 of 33 smoke compartments, undetermined number of visitors and staff in the facility, if there was a fire in the facility. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3(director of facilities operations-south market), and Staff M4(manager of facilities operations), surveyor observed on 10/01/13 between 8:50 am and 12 pm that the 4th Floor corridor serving patient sleeping areas in the Kohler building was partially used as a return air plenum as evidenced by the airflow occurring from both the east and west stairs into the corridor through the undercut of the stairwell doors.

2. During a tour of the facility with Staff M1, Staff M2, Staff M3, Staff M4, and Staff M5 (HVAC technician) from 9/30 - 10/3/13, surveyor observed that the two air-handling units, AHU #7 and AHU #9, with a fan capacity of greater than 15000 cfm did not have smoke isolation dampers in the return and supply sides of the units to restrict the circulation of smoke.

This deficiency was acknowledged by the senior director of facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to soiled linen/trash receptacles not stored in a room protected as a hazardous area in accordance with NFPA 101 section 19.7.5.5 in four locations. This deficient practice affected 4 of 33 smoke compartments in the facility. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of system facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations), and Staff M4 (manager of facilities operations), surveyor observed on 10/01/13 at 9:15 am that one waste and two soiled linen receptacles of a combined capacity of more than 32 gal were left unattended for greater than 30 minutes in Operation Room #4 on the 5th Floor of Kohler building, and not stored in a room protected as a hazardous area.

2. During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/01/13 between 2:45 pm and 3:15 pm that one trash receptacle of approximately 1 ½ ft wide x 3 ft x 3 ft with a combined capacity of more than 32 gal was left unattended for greater than 30 minutes in the 2nd Floor Lucas building alcove-like space in front of Elevator #6, and not stored in a room protected as a hazardous area.

3. During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, and Staff A1 (nurse manager), surveyor observed on 10/02/13 between 10:30 am and 11:30 am that one trash, one soiled linen and one biohazard waste receptacles of a combined capacity of more than 32 gal were left unattended for greater than 30 minutes in the C-Section Room #1 on the 2nd Floor of South building, and not stored in a room protected as a hazardous area.

4. During a tour of the facility with Staff M1, Staff M2, Staff M3, and Staff M4, surveyor observed on 10/02/13 at 1:05 pm that one X-Ray labeled container with combustibles of a combined capacity of more than 32 gal was left unattended for greater than 30 minutes in the passage across from the Radiology Room 3 in the Radiology suite on the 1st Floor, and not stored in a room protected as a hazardous area. The container was of approximately 1¾ ft wide x 2½ ft x 2½ ft dimensions.

This deficiency was acknowledged by the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, and manager of facilities operations at the time of discovery, and confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and interview, the facility failed to ensure safety to patients due to lack of medical gas and vacuum area alarm panel in three areas in accordance with NFPA 99 section 4-3.1.2.2(c). This deficient practice affected 7 of 33 smoke compartments in patient sleeping areas on 3 floors. The facility had an average census of 57 in the week of survey with a licensed capacity of 185 beds.

Findings include:

1. During a tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), M3 (director of facilities operations), and M4 (manager of facilities operations), surveyor observed between 9/30-10/03/13 that the medical surgical patient rooms in three areas of the 2nd, 3rd and 4th Floors of the hospital did not have medical gas and vacuum system area alarm panels to notify staff in the area, if the pressure/vacuum in oxygen medical gas and vacuum piping was outside of the allowable 20%± range.

This deficiency was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, manager of facilities operations, and electrician, and also confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.

Based on observation and interview between September 30 and October 3, 2013, the facility failed to meet code requirements referenced in the following miscellaneous items in the Ambulatory Health Care occupancy. These deficiencies could affect all patients, staff and an undetermined number of visitors in the surgery center.

Findings include:

Item #1
NFPA 72 (1999) section 1-5.6* Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

While on tour of the facility with Staff M1 (senior director of facilities operations), Staff M2 (director of facilities operations), Staff M3 (director of facilities operations-south market), and Staff M10 (maintenance technician) on 10/2/13 between 3:15 and 4:30 pm, it was observed that there was no smoke detector installed (i) in the automatic phone dialer equipment room (generator room) on the 1st Floor and (ii) in the main fire alarm panel room on the 1st Floor in accordance with NFPA 101 sections 21.3.4.1, 9.6.2.1, NFPA 72(1999) section 1-5.6.


Item #2
NFPA 99 (1999) section 3-4.1.1.15
"A remote annunciator, storage battery powered, shall be provided to operate outside of the generator room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is to supply power to load
2. When the battery charger is malfunctioning source generator.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2] "

While on tour of the facility with Staff M1, Staff M2, and Staff M3, surveyor observed that there was no remote annunciator to annunciate a generator fault condition in accordance with NFPA 99 (1999) 3-4.1.1.15, NFPA 110 section 3-5.6.1 (1999) at a continuously monitored location. The generator is located in the 1st Floor mechanical room.


Item #3
NFPA 101 section 7.10.1.4*
"Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.

Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements."

While on tour of the facility with Staff M1, Staff M2, and Staff M3 on 10/2/13 between 3:15 pm and 4:30 pm, surveyor observed that there was no exit sign installed above doors adjacent to Room 640 in the sleep lab area to direct occupants to exit in accordance with NFPA 101 7.10.1.4.


This deficiency was confirmed at the time of discovery by a concurrent observation and interview with the senior director of system facilities operations, director of facilities operations, director of facilities operations-south market, and maintenance technician also confirmed with Staff JJ (chief nursing officer) at the exit conference on 10/03/13 at 4 pm.