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Based on observation the facility failed to ensure all areas above smoke and fire rated separations had all conduits, wires, and pipes and the area around where they passed through the wall sealed properly to prevent fire and smoke from spreading to other areas. This affected two smoke/fire rated walls. Findings included:
During tour of the facility on 5/18-19/10 it was observed that two areas above the ceiling and in a rated wall had pipes and/or wires passing through the wall. The area located outside the Bordley conference room and labeled as a two hour separation, had one penetration through the wall sealed by expandable foam (the type from an aerosol can) which did not have a fire or smoke rating.
The second area was on the ninth floor and was labeled as a one hour separation. The area above the ceiling had two water pipes and one set of cables which had no fire caulk (rated sealant) around them or any other sealant to prevent the spread of smoke or fire.

Based on observation the facility failed to ensure that all patient room doors latched and remained closed for rooms in the main hospital and West Pavillion. Findings included:
During tour of the facility on 5/18-19/10 patient room doors were closed to ensure the latching mechanism would engage and keep the doors shut. Doors to Patient rooms, 510, 504, 605, 404, 405, 407, 408, 412, 905, and 812 did not latch when shut.

Based on observation the facility failed to ensure that all sprinkler heads remained positioned properly to provide protection in case of fire in two areas and that all inspection forms indicated compliance with all requirements for flow alarms. This affects all persons in a census of 239. Findings included:
1. During tour on 5/19/10 on the nursing unit of six South the clean utility room was protected by four sprinkler heads. Three of the sprinkler heads were not positioned properly below the ceiling. The diffuser (portion of the sprinkler that forms the pattern of water to extinguish fires) was not below the level of the ceiling and could not function properly. This observation was confirmed by the Associate administrator for facilities also on tour.
In the area for neurophysiology there was a treatment room with seven lights which were suspended below the ceiling. Two of the lights were positioned within four inches of the lights and the diffuser of the sprinkler heads were above the bottom of the light and would be blocked from forming a full pattern of water spray to protect this area.
2. Review of the most recent testing done on the facility sprinkler system performed by an outside contractor indicated the date the water flow alarms were tested (designated on report by WF) and indicated that each device passed.. The most recent test was performed on 1/18/2010.
The report did not contain any timed response information on how long each device took to activate an alarm. The report indicated that 50 devices had been tested in January.
During an interview on 5/17/10 at 3:40 p.m. the associated administrator for facilities stated that all water flow alarms for the ABI (Anheuser Busch Institute), West Pavilion and main hospital were done semi-annually and documented as pass only and there was no time documented on the reports.
The 2002 edition of the National Fire code Alarm (72) states under 5.10.2 that initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm initiating device when flow occurs that is equal to or greater that that from a single sprinkler.
Chapter 2-3.3 of the 1998 edition of The National Fire Protection Association code 25 states that waterflow alarm devices shall be tested quarterly.

Based on record review and interview the facility failed to insure that a comprehensive policy regarding impairment of the fire alarm/extinguishment was developed and in place for use by staff. This affects all persons in a census of 239. Findings included:
Review of the policy titled "interim life safety measures" and revised 4/10 instructed staff to notify the fire department and initiate a fire watch when a fire alarm or sprinkler system is out of service more than four hours in a 24 hour period in an occupied building. Notification and fire watch times are documented.
The policy, nor any other policy detailed what a "fire watch" was to include or the duties of the person who was conducting a fire watch was to perform.
When a system is impaired for more than four hours in a 24 hour period the facility is either to evacuate all persons from the area or implement a fire watch with specific duties for staff performing the fire watch. The facility did not detail or provide any policy or procedure for implementing the fire watch or include provisions for evacuating staff and patients.
During an interview on 5/18/10 at 1:40 p.m. the associate administrator for facilities stated that there was no policy on fire watch to include how to use or implement the fire watch and that the facility had recently begun to develop one.

Based on record review and interview the facility failed to insure that a comprehensive policy regarding impairment of the fire alarm/extinguishment was developed and in place for use by staff. This affects all persons in a census of 239. Findings included:
Review of the policy titled "interim life safety measures" and revised 4/10 instructed staff to notify the fire department and initiate a fire watch when a fire alarm or sprinkler system is out of service more than four hours in a 24 hour period in an occupied building. Notification and fire watch times are documented.
The policy, nor any other policy detailed what a "fire watch" was to include or the duties of the person who was conducting a fire watch was to perform.
When a system is impaired for more than four hours in a 24 hour period the facility is either to evacuate all persons from the area or implement a fire watch with specific duties for staff performing the fire watch. The facility did not detail or provide any policy or procedure for implementing the fire watch or include provisions for evacuating staff and patients.
During an interview on 5/18/10 at 1:40 p.m. the associate administrator for facilities stated that there was no policy on fire watch to include how to use or implement the fire watch and that the facility had recently begun to develop one.

Based on observation the facility failed to ensure all areas above smoke and fire rated separations had all conduits, wires, and pipes and the area around where they passed through the wall sealed properly to prevent fire and smoke from spreading to other areas. This affected two smoke/fire rated walls. Findings included:
During tour of the facility on 5/18-19/10 it was observed that two areas above the ceiling and in a rated wall had pipes and/or wires passing through the wall. The area located outside the Bordley conference room and labeled as a two hour separation, had one penetration through the wall sealed by expandable foam (the type from an aerosol can) which did not have a fire or smoke rating.
The second area was on the ninth floor and was labeled as a one hour separation. The area above the ceiling had two water pipes and one set of cables which had no fire caulk (rated sealant) around them or any other sealant to prevent the spread of smoke or fire.

Based on observation the facility failed to ensure that all patient room doors latched and remained closed for rooms in the main hospital and West Pavillion. Findings included:
During tour of the facility on 5/18-19/10 patient room doors were closed to ensure the latching mechanism would engage and keep the doors shut. Doors to Patient rooms, 510, 504, 605, 404, 405, 407, 408, 412, 905, and 812 did not latch when shut.

Based on observation the facility failed to ensure that all sprinkler heads remained positioned properly to provide protection in case of fire in two areas and that all inspection forms indicated compliance with all requirements for flow alarms. This affects all persons in a census of 239. Findings included:
1. During tour on 5/19/10 on the nursing unit of six South the clean utility room was protected by four sprinkler heads. Three of the sprinkler heads were not positioned properly below the ceiling. The diffuser (portion of the sprinkler that forms the pattern of water to extinguish fires) was not below the level of the ceiling and could not function properly. This observation was confirmed by the Associate administrator for facilities also on tour.
In the area for neurophysiology there was a treatment room with seven lights which were suspended below the ceiling. Two of the lights were positioned within four inches of the lights and the diffuser of the sprinkler heads were above the bottom of the light and would be blocked from forming a full pattern of water spray to protect this area.
2. Review of the most recent testing done on the facility sprinkler system performed by an outside contractor indicated the date the water flow alarms were tested (designated on report by WF) and indicated that each device passed.. The most recent test was performed on 1/18/2010.
The report did not contain any timed response information on how long each device took to activate an alarm. The report indicated that 50 devices had been tested in January.
During an interview on 5/17/10 at 3:40 p.m. the associated administrator for facilities stated that all water flow alarms for the ABI (Anheuser Busch Institute), West Pavilion and main hospital were done semi-annually and documented as pass only and there was no time documented on the reports.
The 2002 edition of the National Fire code Alarm (72) states under 5.10.2 that initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm initiating device when flow occurs that is equal to or greater that that from a single sprinkler.
Chapter 2-3.3 of the 1998 edition of The National Fire Protection Association code 25 states that waterflow alarm devices shall be tested quarterly.

Based on record review and interview the facility failed to insure that a comprehensive policy regarding impairment of the fire alarm/extinguishment was developed and in place for use by staff. This affects all persons in a census of 239. Findings included:
Review of the policy titled "interim life safety measures" and revised 4/10 instructed staff to notify the fire department and initiate a fire watch when a fire alarm or sprinkler system is out of service more than four hours in a 24 hour period in an occupied building. Notification and fire watch times are documented.
The policy, nor any other policy detailed what a "fire watch" was to include or the duties of the person who was conducting a fire watch was to perform.
When a system is impaired for more than four hours in a 24 hour period the facility is either to evacuate all persons from the area or implement a fire watch with specific duties for staff performing the fire watch. The facility did not detail or provide any policy or procedure for implementing the fire watch or include provisions for evacuating staff and patients.
During an interview on 5/18/10 at 1:40 p.m. the associate administrator for facilities stated that there was no policy on fire watch to include how to use or implement the fire watch and that the facility had recently begun to develop one.

Based on record review and interview the facility failed to insure that a comprehensive policy regarding impairment of the fire alarm/extinguishment was developed and in place for use by staff. This affects all persons in a census of 239. Findings included:
Review of the policy titled "interim life safety measures" and revised 4/10 instructed staff to notify the fire department and initiate a fire watch when a fire alarm or sprinkler system is out of service more than four hours in a 24 hour period in an occupied building. Notification and fire watch times are documented.
The policy, nor any other policy detailed what a "fire watch" was to include or the duties of the person who was conducting a fire watch was to perform.
When a system is impaired for more than four hours in a 24 hour period the facility is either to evacuate all persons from the area or implement a fire watch with specific duties for staff performing the fire watch. The facility did not detail or provide any policy or procedure for implementing the fire watch or include provisions for evacuating staff and patients.
During an interview on 5/18/10 at 1:40 p.m. the associate administrator for facilities stated that there was no policy on fire watch to include how to use or implement the fire watch and that the facility had recently begun to develop one.