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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.
As a result of the 2nd follow-up visit on 3/21/14, the facility has made a satisfactory progress toward correcting the deficiency. Based on observation, and interview with Staff M3 (director of facilities operations-south market) on 3/21/14 between 10 am and 12 pm, the hospital has construction plans approved from the state, and has scheduled construction work during the weekend hours to minimize the impact on the routine operation of the hospital.

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.
As a result of the 2nd follow-up visit on 3/21/14, the facility has made a satisfactory progress toward correcting the deficiency. Based on observation, and interview with Staff M3 (director of facilities operations-south market) on 3/21/14 between 10 am and 12 pm, the hospital has construction plans approved from the state for installation of new code compliant doors, and has scheduled construction work during the weekend hours to minimize the impact on the routine operation of the hospital.

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.
As a result of the 2nd follow-up visit on 3/21/14, the facility has made a satisfactory progress toward correcting the deficiency. Based on observation, and interview with Staff M3 (director of facilities operations-south market) on 3/21/14 between 10 am and 12 pm, the hospital has construction plans approved from the state for installation of new code compliant doors, and has scheduled construction work during the weekend hours to minimize the impact on the routine operation of the hospital.

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.
While on a 2nd verification visit of the facility on 3/21/14, surveyor verified that the Item No. 2 deficiency above had been corrected. The facility is making a satisfactory progress toward correcting the deficiency Item No. 1 stated above.

Based on record review, and interview with Staff M3 (director of facilities operations-south market) on 3/21/14 between 10 am and 12 pm, the hospital has construction plans approved from the state for installation of a new replacement air-handling unit of a greater capacity, and related ductworks.