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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.

As a result of a verification visit on 12/03/13, surveyor determined that the facility was making a satisfactory progress toward correcting the deficiency. When interviewed on 12/02/13 between 10:45 am and 11:30 am, Staff M3 (director of facilities operations-south market) stated that the hospital has hired the Excel Engineering - a consulting design firm - to prepare plans and specifications for correcting the deficiency, and submit plans to the Wisconsin Division of Quality Assurance (DQA) for review and approval.

The approved completion date is 6/1/2014.

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.

As a result of a verification visit on 12/03/13, surveyor determined that the facility was making a satisfactory progress toward correcting the deficiency. When interviewed on 12/02/13 between 10:30 am and 11 am, Staff M3 (director of facilities operations-south market) stated that the hospital has hired the Excel Engineering - a consulting design firm - to prepare plans for correcting the deficiency of narrow smoke doors in two smoke barriers.

The approved completion date is 4/1/2014.

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.


As a result of a verification visit on 12/03/13, surveyor determined that the facility was making a satisfactory progress toward correcting the deficiency. When interviewed on 12/02/13 between 10:45 am and 11:30 am, Staff JJ (chief nursing officer) stated that the hospital would replace the existing double doors to surgery suite with a pair of same size doors of required clear widths.

The approved completion date is 2/1/2014.

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.

As a result of a verification visit on 12/03/13, surveyor determined that the facility was making a satisfactory progress toward correcting the deficiency. When interviewed on 12/02/13 between 10:45 am and 11:30 am, Staff M3 (director of facilities operations-south market) stated that the hospital has hired the consulting firm Ring & duChateau to correct the return air plenum situation and for installation of smoke isolation dampers stated in the above two findings. Staff M3 further stated that the hospital would most likely replace the existing unit with a new air-handling unit of a larger capacity to correct the deficiency.

The approved completion date is 6/1/2014.

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.

As a result of a verification visit on 12/03/13, surveyor determined that the facility was making a satisfactory progress toward correcting the deficiency. When interviewed on 12/02/13 between 2:15 pm and 3 pm, Staff M3 (director of facilities operations-south market) stated that the hospital has hired the consulting firm Ring & duChateau to design. Staff M3 further stated that the hospital will submit the medical gas and vacuum system plans and specifications to the Wisconsin Division of Quality Assurance for review and approval.

The approved completion date is 6/1/2014.

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.


As a result of a verification visit on 12/03/13, surveyor determined that the facility corrected the Items #1 and #3 of the deficiency cited on 10/7/13, and was making a satisfactory progress toward correcting Item #2 of the deficiency.

The approved completion date of the deficiency Item #2 is 2/1/2014.