HospitalInspections.org

Based on observation, and staff interview, the facility failed to ensure complete 2-hour fire separation between 3 of 3 nonconforming buildings. The findings were:

Observation on 11/3/11 at 10:37 AM showed the cancer center south exit lead into a glass wall an ceiling walk-way that connected the hospital and the intermountain internal medicine (IIM) physicians' building. Further observation showed none of the three exit doors were fire rated neither were their frames, barrier walls or hardware. At the time of observation the facility supervisor confirmed the findings and reported the glass walk-way was added several years ago for convenience during severe winter weather. He was not aware the walk-way connected the buildings and thus required 2-hour separation.

Based on observation, blue print review and staff interview, the facility failed to ensure complete 2-hour fire separation between 3 of 3 nonconforming buildings, failed to ensure interior 1-hour fire rated walls had rated doors and equipment, and failed to ensure 2 of 5 fire rated barrier walls were smoke resistant. The findings were:

1. Observation on 11/3/11 at 10:37 AM showed the hospitals north first floor exit lead into a glass wall and ceiling walk-way that connected the cancer center and the intermountain internal medicine (IIM) physicians building. Further review showed none of the three exit doors were fire rated, nor were their frames or hardware. At the time of observation the facility supervisor confirmed the findings and reported the glass walk-way was added several years ago for convenience during severe winter weather. He was not aware the walk-way connected the buildings and thus required 2-hour separation.

2. Observation of the 1-hour rated fire barrier between the admitting area and the laboratory on 11/4/11 at 9:21 AM showed a 3/8 inch gap between the meeting edge of the double doors. Review of the blue prints confirmed this was a 1-hour fire rated wall. At the time of observation the facility supervisor reported he was aware the gap could not be greater than 1/8th inch. He could not explain why the gap had not been noticed and repaired during the quarterly inspections.

3. Observation of the IIM second floor 2-hour rated fire barrier door on 11/4/11 at 9:43 AM showed the latching hardware was not fire rated. At the time of observation the facility supervisor reported he was unaware the hardware was required to be rated in accordance with fire rating of the door.

4. Observation of the 1-hour rated fire barrier between the emergency room and radiology on 11/4/11 at 10:47 AM showed the door was not equipped with a 3/4 hour rating placard. Review of the blue prints confirmed this was a 1-hour rated fire barrier wall. At the time of observation the facility supervisor confirmed he was aware all doors in rated fire barrier walls were required to have rating placards.

5. Observation of fire barrier walls above the ceiling tile on 11/7/11 between 11 AM and 12 PM showed the barrier near room #2261 and the mountain view conference room had unsealed penetrations. The largest gap measured 2 inches by 4 inches. At 11:29 AM the facility supervisor could not explain why the penetrations had not been noticed and repaired during the semi-annual inspections.

Based on observation and staff interview, the facility failed to ensure room walls and ceilings were smoke resistant on 2 of 3 floors. The findings were:

1. Periodic observation on 11/3-7/11 showed the ceiling tiles had been removed from the communication/security room, second floor telecommunication room, radiology information technology (IT) room, MRI equipment room, and the third floor IT closet. The largest gap measured 24 inches by 24 inches. On 11/3/11 at 2:32 PM the facility supervisor could not explain why the missing ceiling tiles had not been noticed and replaced during the semi-annual inspections.

2. Periodic observation on 11/3-4/11 showed the wall was incomplete in the second floor electrical room, executone room, and the ambulance garage storeroom. The largest gap measured 4 feet by 6 feet. On 11/3/11 at 3:06 PM the facility supervisor reported he was unaware the walls were required to be smoke resistance for proper operation of the smoke detector in the area.

Reference:
NFPA 101, 2000 Edition;
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Based on observation and staff interview, the facility failed to ensure corridor doors were smoke resistant on 1 of 3 floors. The findings were:

Observation of the material management corridor double door on 11/7/11 at 11:26 AM showed one of the doors was equipped with a steel astragal. When the doors were released from the magnetic hold open devices, the door with the astragal closed first preventing the doors from being smoke resistant. Further observation showed the doors were not equipped with a sequencing device. At the time of observation the facility supervisor could not explain why the closing speed of the doors had not been noticed and a sequencer installed during the semi-annual inspections.

Based on observation and staff interview, the facility failed to ensure the doors in 1 of 2 stairwells were smoke resistant. The findings were:

Observation of the south stairwell on 11/7/11 at 12:56 AM showed the second floor double doors did not latch into the door frame because the meeting edges of the doors rubbed against each other. At the time of observation the facility supervisor could not explain why the doors had not been noticed and repaired during the semi-annual inspections.

Based on observation and staff interview, the facility failed to ensure smoke barriers on 1 of 3 floors was smoke resistance. The findings were:

Observation of the second floor smoke barrier wall near the information technology closet on 11/7/11 at 11:24 AM showed a 1/2 inch gap around an unsealed conduit penetration. At the time of observation the facility supervisor could not explain why the hole had not been noticed and repaired during the semi-annual inspections.

Based on observation and staff interview, the facility failed to ensure smoke barrier doors were smoke resistant on 1 of 3 floors. The findings were:

Observation of the smoke barrier double doors near the stress lab on 11/4/11 at 10:06 AM showed there was a 1/4 inch gap between the meeting edges of the doors, more than the allowed 1/8th inch gap. At the time of observation the facility supervisor could not explain why the gap had not been noticed and repaired during the semi-annual inspections.

Reference:
NFPA 101, 2000 Edition;
3.3.20* Barrier, Smoke. A continuous membrane, or a membrane with discontinuities created by protected openings, where such membrane is designed and constructed to restrict the movement of smoke.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas on 2 of 3 floors. The findings were:

1. Observation of the microfiche storeroom on 11/3/11 at 10:55 AM showed the room measured 8 feet by 16 feet and had several shelves of microfiche and other stored items. Further review showed the corridor door was not equipped with a self-closing device. At the time of observation the facility supervisor reported he was unaware hazardous areas were required to have a self-closing device on corridor doors.

2. Observation of the laboratory information technology server room on 11/4/11 at 8:53 AM showed a halon suppression system had been installed. Further observation showed the entrance door was not equipped with a self-closing device and it could not be determined if the air-conditioning units would shut down with the activation of the system. At the time of observation the facility supervisor reported he was unaware of the aforementioned requirement. He also reported that the system was serviced semi-annually and the last testing report, 10/17/11, did not indicate all openings were required to be self-closing.

Reference:
19.3.5.1, 9.7.3.1;
NFPA 12A, 1997 Edition;
3-3.1.2 To prevent loss of agent through openings to adjacent hazards or work areas, openings shall be permanently sealed or equipped with automatic closures. Where reasonable confinement or agent is not practicable, protection shall be extended to include the adjacent connected hazards or work areas.
3-3.1.3 Forced-air ventilating systems including in-room air conditioning units shall be shut down or closed automatically where their continued operation would adversely affect the performance of the Halon 1301 system or result in propagation of the fire.

Based on observation, blue print review and staff interview, the facility failed to ensure the corridor system had adequate headroom on 1 of 3 floors and failed to ensure the exit access corridor was accessible at all times on 2 of 3 floors. The findings were:

1. Observation of the fire barrier double doors between surgery and outpatient services on 11/3/11 at 3:37 PM showed the doors were equipped with a magnetic locking system. Further review showed the bottom of the magnetic locks did not have the required 6 feet 8 inch headroom. The bottom of the magnetic locks were only 6 feet 5 inches above the floor. At the time of observation the facility supervisor reported he was unaware of the spacing requirement.

2. Interview with the outpatient charge nurse on 11/3/11 at 3:56 PM revealed the fire barrier double doors between surgery and outpatient services was locked each night to restrict access to the surgery department. Review of the blue prints showed the locked doors restricted access to the designated egress system. Further review showed the surgery department was not a suite and thus confirmed the access through the department can not be locked with the current configuration. At the time of observation and blueprint review the facility supervisor confirmed the egress access system was designed to pass through the surgery department. He could not explain why the access to the egress system had not been noticed and addressed.

3. Observation of the behavioral health services (BHS) department on 11/7/11 at 11:06 AM showed the treatment/counseling room required patients to exit into the dining room and then enter the exit corridor. Observation and blue print review showed the area was not constructed as a separate suite. At the time of observation the facility supervisor reported he was not aware treatment rooms, not in a suite of rooms, required exit access doors leading directly to an exit access corridor without passing through an adjoining room.

4. Observation of the double corridor doors between the BHS department and the intensive care unit (ICU) on 11/7/11 at 3:05 PM showed the doors were locked for the clinical needs of the BHS patients. Further observation showed all BHS staff members had a key to unlock the door. Review of the blue prints showed the second exit from the BHS department was through the corridor that ran though the ICU suite. Review of the ICU showed it was no longer a corridor as three of four patient room corridor doors had been removed since the area was converted into a suite. Interview with the ICU charge nurse confirmed not all ICU staff members carried keys to the double doors leading into the BHS department. Review of the blue prints showed it was 4575 square feet and requires two exit access doors located remotely from each other.

Reference:
NFPA 101, 2000 Edition, 19.2.1;
7.1.5* Headroom. Means of egress shall be designed and maintained to provide headroom as provided in other sections of this Code and shall be not less than 7 ft 6 in. (2.3 m) with projections from the ceiling not less than 6 ft 8 in. (2 m) nominal height above the finished floor. The minimum ceiling height shall be maintained for not less than two-thirds of the ceiling area of any room or space, provided the ceiling height of remaining ceiling area is not less than 6 ft 8 in. (2 m). Headroom on stairs shall be not less than 6 ft 8 in. (2 m) and shall be measured vertically above a plane parallel to and tangent with the most forward projection of the stair tread.

19.2.5.1 Every habitable room shall have an exit access door leading directly to an exit access corridor.
Exception No. 1: If there is an exit door opening directly to the outside from the room at ground level.
Exception No. 2: Exit access from a patient sleeping room with not more than eight patient beds shall be permitted to pass through one intervening room to reach the exit access corridor.
Exception No. 3: Exit access from a special nursing suite shall be permitted to pass through one intervening room to reach the exit access corridor where the arrangement allows for direct and constant visual supervision by nursing personnel.
Exception No. 4: Exit access from a suite of rooms, other than patient sleeping rooms, shall be permitted to pass through not more than two adjacent rooms to reach the exit access corridor where the travel distance within the suite is in accordance with 19.2.5.8.

19.2.5.9* Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
A.19.2.5.9 Every exit or exit access should be arranged, if practical and feasible, so that no corridor, passageway, or aisle has a pocket or dead end exceeding 30 ft (9.1 m). (See also Table A.7.6.1.)

19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
A.19.2.2.2.4 Exception No. 2 The intent of the provision is that a person following the natural path of the means of egress not encounter more than one delayed release device along that path of travel to an exit. Thus, each door from the multiple floors of a building that opens into an enclosed stair is permitted to have its own delayed release device, but an additional delayed release device is not permitted at the level of exit discharge on the door that discharges people from the enclosed stair to the outside.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
19.2.2.2.5 Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

19.2.5.2 Any patient sleeping room, or any suite that includes patient sleeping rooms, of more than 1000 ft2 (93 m2) shall have not less than two exit access doors remotely located from each other.

Based on policy review and staff interview, the facility failed to ensure 2 of 8 policies were complete. The findings were:

1. Review of the smoking policy showed the policy did not indicate that "No Smoking" signs would be placed at all major entrances and no secondary signs would be posted where oxygen was in use, which was the facilities practice. Periodic observation on 11/3-7/11 showed none of the patient or treatment rooms where oxygen was used were posted with "No Smoking" signs. On 11/3/11 at 8:30 AM the chief financial officer (CFO) confirmed he was unaware the aforementioned language was required in the smoking policy.

2. Review of the smoking policy showed the policy did not indicate that ashtrays and metal self-closing containers to empty the ashtrays into would be supplied at all areas were smoking was permitted. On 11/3/11 at 8:30 AM the CFO confirmed he was unaware the aforementioned language was required in the smoking policy.

3. Review of the fire response (CODE RED) plan showed the policy did not address the evacuation of the smoke compartment of fire origin or evacuation of the floor and building. On 11/3/11 at 8:30 AM the CFO confirmed he was unaware the aforementioned language was required in the fire response policy.

Reference:
NFPA 101, 2000 Edition;
19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
19.7.4* Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based on record review and staff interview, the facility failed to ensure smoke detectors were properly installed, failed to ensure the sprinkler system was fully monitored by the fire alarm system, failed to ensure pull stations were installed properly and failed to ensure the corridors had complete smoke detection coverage on 2 of 3 floors. The findings were:

1. Periodic observation of the fire alarm system on 11/3-7/11 showed the smoke detectors in the sterile processing clean room, the sterile processing dirty room, the material management mail room, the engineering copy room, the dialysis waiting room, the stress test room, and the pediatrics nurses' station were installed closer than 36 inches from ventilation diffusers. On 11/3/11 at 11:20 AM the facility supervisor reported he was unaware of the spacing requirement and assumed the fire alarm contractor would inspect for proper spacing.

2. Observation of the 547 generator sprinkler system on 11/3/11 at 11:32 AM showed two isolation valves were not supervised by the fire alarm system. At the time of observation the facility supervisor reported he was unaware the sprinkler system isolation valves were required to be supervised. Furthermore he reported the system had been installed for more than ten years, and the last annual inspection, 4/11/11, had not indicated the lack of supervision.

3. Observation of the admitting foyer on 11/4/11 at 9:50 AM showed the entrance vestibule had an outer and inner door. Further observation showed the vestibule was not monitored by a smoke detector. At the time of observation the facility supervisor reported he was aware smoke detectors were required in the corridor system. He reported the system was inspected annually by an outside contractor and the lack of the smoke detector was not indicated during their last inspection, 4/11/11.

4. Observation of the admitting foyer on 11/4/11 at 9:55 AM showed the entrance vestibule had an outer and inner door. The facility supervisor reported the inner door was locked at night when the area was not supervised. Further observation showed the manual fire alarm pull station was located inside of the inner door, more than 5 feet from the entrance. At the time of observation, the facility supervisor reported he was unaware pull stations were required to be installed a maximum of 5 feet from the exit doorway opening.

5. Observation of the behavioral health services group room on 11/7/11 at 10:24 AM showed a strobe light harness was installed above the television set, but the device had been removed. At the time of observation the facility supervisor could not explain why the device had been removed.

Reference:
NFPA 101, 2000 Edition,
19.3.4.5.1 Corridors.
An approved automatic smoke detection system shall be installed in all corridors of limited care facilities. Such system shall be in accordance with Section 9.6.
Exception No. 1: Where each patient sleeping room is protected by an approved smoke detection system, and a smoke detector is provided at smoke barriers and horizontal exits in accordance with Section 9.6, the corridor smoke detection system shall not be required on the patient sleeping room floors.
Exception No. 2: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2.
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

19.3.4.1, 9.6.1.4;
NFPA 13, 1999 Edition;
5-14.1.1.3 Valves on connections to water supplies, sectional control and isolation valves, and other valves in supply pipes to sprinklers and other fixed water-based fire suppression systems shall be supervised by one of the following:
(1) Central station...
(2) Local signaling service that will cause the sounding of an audible signal at a constantly attended point.

NFPA 72, 1999 Edition;
2-8.2.2 Manual Fire alarm boxes shall be located within 5 ft of the exit door opening at each exit on each floor.
4-4.1 there are two methods of visible signaling. These are methods in which the message of notification of an emergency condition is conveyed by direct viewing of the illuminating appliance or by means of illumination of the surrounding area. Public mode signaling shall meet the requirements of Section 4-4 using visible notification appliances.
5.7.4.1* In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.
A 5.7.4.1 Detectors should not be located in a direct airflow or closer than 1 m (3 ft) from an air supply diffuser or return air opening ...

Based on observation and staff interview, the facility failed to ensure 1 of 7 fire alarm system components was tested. The findings were:

Review of the fire alarm system testing records showed the fire alarm system control panel batteries had not been tested semi-annually. On 11/7/11 at 2:58 PM the facility supervisor reported he was unaware of the testing requirement.

Reference:
NFPA 101, 2000 Edition,19.3.4.1, 9.6.1.4;
NFPA 72, 1999 Edition;
Table 7-3.2 Testing Frequencies.
6. Batteries-Fire alarm systems
d. Sealed Lead-Acid Type
1. Charge Test,...............................annually
(Replace batteries every 4 years.),
2. Discharge Test
(30 minutes)...................................annually
3. Load Voltage Test,....................semi-annually

Based on observation and staff interview the facility failed to ensure all areas had complete sprinkler coverage and failed to ensure sprinkler heads were installed the minimum distance from walls on 2 of 2 floors. The findings were:

1. Observation of the sprinkler system on 11/7/11 between 12:30 PM and 1 PM showed a sprinkler head in chemotherapy room #2 and #3 were installed 2 inches from the wall, not the required 4 inches.

2. Observation of the second floor storeroom on 11/7/11 at 1:08 PM showed the exposed steel "I" beam along the east side of the room was 24 inches deep. Further review showed the space between the "I" beam and the wall measured 18 inches by 100 feet and did not have sprinkler heads installed in the space. At the time of observation, the facility supervisor reported the area was inspected annually by an outside contractor and the last annual inspection (4/11/11) did not indicate a lack of sprinkler coverage.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1;
NFPA 13, 1999 Edition;
5-6.4.1.2 Under obstructed construction, the sprinkler deflector shall be located within the horizontal planes of 1 in. to 6 in. below the structural members and a maximum distance of 22 in. below the ceiling/roof deck.
Exception No. 2: Where sprinklers are installed in each bay of obstructed construction, deflectors shall be permitted to be a minimum of 1 in and a maximum of 12 in. below the ceiling.

Based on observation and staff interview, the facility failed to ensure all areas had complete sprinkler coverage on 3 of 3 floors. The findings were:

1. Observation of the atrium on 11/3/11 at 8:30 AM confirmed the building was required to be fully sprinkled. Periodic observations of the sprinkler system on 11/3-7/11 showed the medical records vault, the walk-way to the intermountain internal medicine (IIM) building, the two closets in the physicians' lounges, the first floor information technology router room, the chiller pass through room to boiler, the morgue vault, the first floor storeroom skylight, second floor electrical room, patient room #2279 restroom, the behavioral health second floor stairwell landing, behavioral health services skylight above the group room, the pipe chase by the chapel office, the third floor executone closet, the admitting vestibule, the surgery department suture storage alcove, and the sterile processing shelving walkway did not have sprinkler coverage. On 11/3/11 at 10:18 AM the facility supervisor reported he was recently made aware the building was required to be fully sprinkled. Review of the sprinkler contractors last annual inspection, 4/11/11, did not indicate a lack of sprinkler coverage.

2. Observation of the penthouse sprinkler system on 11/7/11 at 10:42 AM showed sprinkler heads had not been installed within 1 foot of atrium windows. At the time of observation the facility supervisor reported he was unaware of the spacing requirement.

Reference;
NFPA 101, 2000 Edition;
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
8.2.5.6* Unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:
Exception No. 1: Any number of levels of the building shall be permitted to open directly to the atrium without enclosure based on the results of the engineering analysis required in 8.2.5.6(5).
Exception No. 2*: Glass walls and inoperable windows shall be permitted in lieu of the fire barriers where automatic sprinklers are spaced along both sides of the glass wall and the inoperable window at intervals not to exceed 6 ft (1.8 m). The automatic sprinklers shall be located at a distance from the glass not to exceed 1 ft (0.3 m) and shall be arranged so that the entire surface of the glass is wet upon operation of the sprinklers. The glass shall be tempered, wired, or laminated glass held in place by a gasket system that allows the glass framing system to deflect without breaking (loading) the glass before the sprinklers operate. Automatic sprinklers shall not be required on the atrium side of the glass wall and the inoperable windows where there is no walkway or other floor area on the atrium side above the main floor level. Doors in such walls shall be glass or other material that resists the passage of smoke. Doors shall be self-closing or automatic-closing upon detection of smoke.

Based on observation and staff interview, the facility failed to ensure sprinklers were unobstructed on 3 of 3 floors. The findings were:

Periodic observation of the sprinkler system on 11/3-7/11 showed the sprinklers in the corridor near the morgue, the dialysis chemical storeroom, the admitting foyer, the corridor near patient room #2212, patient room #3320-3321, and room #3100 were obstructed by ceiling mounted lights or exit signs. On 11/3/11 at 10:07 AM the facility supervisor reported he was aware of the spacing requirement. He further reported that the system was inspected annually by an outside contractor and they had not noted any obstructed sprinklers on their last report, 4/11/11.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1;
NFPA 13, 1999 Edition;
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (Standard Spray Upright/Standard Spray Pendent)

Maximum allowable
Distance from distance from
sprinkler to side deflector above
of obstruction bottom of obstruction
-------------------------------------------------------
Less than 1 ft ... ... ... ... ... ... ............. ....0
1 ft to less than 1 ft 6 in. ... ... ... ... ... ...2 ½
1 ft 6 in. to less than 2 ft .... ... ... ... ......3 ½
2 ft to less than 2 ft 6 in. ...... ... ... ... ...5 ½
2 ft 6 in. to less than 3 ft ... ... ... ...........7 ½
3 ft to less than 3 ft 6 in ... ... .... ... ... ...9 ½
3 ft 6 in. to less than 4 ft ... ... ... ... ... ...12
4 ft to less than 4 ft 6 in. ......................14

Based on observation and staff interview, the facility failed to ensure soiled linen receptacles were properly separated on 1 of 3 floors. The findings were:

Observation of the radiology corridor on 11/4/11 at 11:02 AM showed a double soiled linen/trash cart was being stored in the alcove near room #2241. At the time of observation the facility supervisor was unaware soiled linen and trash receptacles were required to be separated by 64 square feet.

Based on observation and staff interview, the facility failed to ensure electrical receptacles and switches were installed at minimum heights in oxygen storage locations on 1 of 3 floors. The findings were:

Observation of the cardiopulmonary oxygen storeroom on 11/7/11 at 9:52 AM showed the electrical receptacle behind the oxygen storage rack was installed 20 inches above the floor. Further review showed this was the standard height of receptacle throughout the room. Review of the light switch showed it was installed 48 inches above the floor, not the require 60 inches for all receptacles and switches. At the time of observation the facility supervisor was unaware of the height requirement in oxygen storage locations.

Reference:
NFPA 101, 2000 Edition, 19.3.2.3, NFPA 99, 1999 Edition;
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (any Quantity; In-storage, Connected, or Both)
3. Provisions shall be made for racks or fastening to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electrical wall fixtures, switches and receptacles shall be installed in fixed locations not less than 5 ft above the floor as a precaution against their physical damage.

Based on observation and staff interview, the facility failed to ensure duct work that penetrated smoke barriers was protected by a smoke damper on 1 of 3 floors. The findings were:

Observation on 11/3/11 at 11:44 AM showed a vent, from a mechanical fan, passed through the wall between the first floor electrical room #2 and the boiler room. At the time of observation the facility supervisor reported the fan exhausted hot air from the electrical room into the boiler room. He also reported he was unaware duct work penetrating smoke barrier walls was required to be provided with a smoke damper.

Reference:
NFPA 101, 2000 Edition, 19.3.7.3;
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation and staff interview, the facility failed to ensure circuit directories were accurate and failed to ensure the Essential Electrical System (EES) was divided into a Life Safety Branch and a Critical Branch on 3 of 3 floors. The findings were:

1. Observation of the Equipment Branch panel "EMC" on 11/3/11 at 11:50 AM showed the circuit directory was labeled differently than the labeling tape next to several circuits. Circuit #1 was lined out on the directory, but the labeling tape next to the circuit showed "tank monitor". Circuit #3 was lined out on the directory, but the labeling tape showed "Exhaust ATS". Circuit #5 was lined out on the directory, but the labeling tape showed "Gas Pump". Circuit #6 and #8 was a two pull circuit and was lined out on the directory, but the labeling tape showed "Panel EMC1-B". At the time of observation the facility supervisor reported he was aware of the requirement and that several panels were not labeled correctly. He also reported the facility was working on correcting the issue, but could not explain why the directories had not been updated when they were originally changed.

2. Observation of the Critical Branch electrical panel "EMV" on 11/3/11 at 12:46 PM showed the panel supplied power to Life Safety Branch equipment. Circuit #13 and #15 supplied power to "fire/smoke dampers". At the time of observation the facility supervisor reported he was unaware the "EES" panels could only supply power to specific equipment.

3. Observation of the Life Safety Branch electrical panel "EMU" on 11/3/11 at 12:48 PM showed the panel supplied power to Critical Branch equipment. Circuit #2 and #4 supplied power to "pharmacy lights". Circuit #9 supplied power to "EM storage lights". Circuit #12 supplied power to "pixis material storage".

4. Observation of the Critical Branch electrical panel "EMQ" on 11/3/11 at 2:05 PM showed the panel supplied to Life Safety Branch equipment. Circuit #6 supplied power to "PBX medical gas panel".

5. Observation of the Critical Branch electrical panel "EMAA" on 11/3/11 at 2:28 PM showed the panel supplied power to Life Safety Branch equipment. Circuit #13 supplied power to "phone board in the communication room".

6. Observation of the Life Safety Branch electrical panel "EMA" on 11/4/11 at 9:01 AM showed the panel supplied to Critical Branch equipment. Circuit #4 supplied power to "card reader and clock". Circuit #6 and #8 supplied power to the "lab reagent refrigerator". Circuit #17 supplied power to the "admitting door access card reader".

7. Observation of the Life Safety Branch panel "EMN" on 11/4/11 at 10:13 AM showed circuit #6 supplied power to the "fire alarm control panel". The circuit director and the circuit itself were not colored with red markings. At the time of observation the facility supervisor was not aware of the aforementioned requirement.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2,
NFPA 70, 1999 Edition;
384-13 ...All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.
Article 517-30 Essential Electrical Systems for Hospitals.
Article 517-31 Emergency System
Article 517-32 Life Safety Branch
Article 517-33 Critical Branch
Article 517-34 Equipment System

Based on observation and staff interview, the facility failed to ensure damaged electrical equipment was replaced, failed to provide receptacle face plates, failed to maintain adequate work space in front of electrical panels, failed to ensure temporary wiring did not replace permanent fixed wiring, and failed to ensure electrical receptacles in wet locations had ground fault circuit interruption (GFCI) protection on 3 of 3 floors. The findings were:

1. Observation of the first floor biohazard room on 11/3/11 at 11:56 AM showed an electrical receptacle port was damaged. At the time of observation the facility supervisor could not explain why the receptacle had not been noticed and replaced during the semi-annual inspection.

2. Observation of the second floor telecommunication room on 11/3/11 at 3:03 PM showed the face plate was missing from an electrical receptacle. At the time of observation the facility supervisor could not explain why the receptacle had not been noticed and replaced during the semi-annual inspection.

3. Observation of the electrical system on 11/4/11 between 8:30 AM and 12 PM showed items were stored in front of the electrical panels in the deionized water room, the MRI equipment room, and the pharmacy. At 8:40 AM the facility supervisor reported he was aware of the spacing requirement and also that staff had been instructed several times to not store items in front of electrical panels.

4. Observation of operating room #1 on 11/4/11 at 1:02 PM showed the anesthesia drug cart was plugged into an uninterrupted power supply (UPS) device which was plugged into a surge protector. At the time of observation the director of surgery services reported she was unaware equipment towers in the surgery field could not be plugged into surge protectors and must be plugged directly into a fixed permanent receptacle.

5. Observation of the obstetrics housekeeping closet on 11/7/11 at 10:37 AM showed the two electrical outlets were installed closer than 6 feet from a sink and did not have GFCI protection. At the time of observation the facility supervisor reported he was aware of the requirement and could not explain why the receptacle had not been identified and replaced during the semi-annual inspections.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2;
NFPA 70, 1999 Edition;
90-7 Examination of Equipment for Safety.
...It is the intent of this Code that factory-installed internal wiring or the construction of equipment need not be inspected at the time of installation of the equipment, except to detect alterations of damage ...
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment ...
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in table 110-26(a) ...
Table 110-26(a)
Nominal Voltage Minimum Clear Distance (ft)
To Ground
_______________________________________
0/150 3 ft.

(b) Clear Space. Working space required by this section shall not be used for storage ...
110-27. Guarding of Live Parts.
(b) Prevent physical damage. In locations where electric equipment would be exposed to physical damage, enclosure of guards shall be so arranged and of such strength so to prevent such damage.
370-28. Pull and Junction Boxes.
(3) (c) cover. All pull boxes, junction boxes and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use....
384 Switchboards and Panel boards
C Panel boards
517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption or power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

NFPA 101, 2000 Edition, 19.3.2.3;
NFPA 99, 1999 Edition;
7-5.1.2.5 Line Voltage Equipment-Anesthetizing Locations. Flexible cord for portable lamps or portable electrical appliances operating at more than 12 V between conductors, intended for use in anesthetizing locations, shall be continuous and without switches from the appliance to the attachment plug and of a type designated for extra-hard usage in accordance with Article 501-11 of NFPA 70 ...

Based on observation and staff interview, the facility failed to ensure temporary electrical wiring was not replaced by permanent fixed wiring on 1 of 2 floors. The findings were:

Observation of the therapy directors office on 11/7/11 at 12:59 PM showed a lamp was plugged into an extension cord which was plugged into a surge protector. At the time of observation, the facility supervisor could not explain why the extension cord had not been noticed and removed during the semi-annual electrical inspections.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2;
NFPA 70, 1999 Edition;
400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls ...
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Based on observation, and staff interview, the facility failed to ensure complete 2-hour fire separation between 3 of 3 nonconforming buildings. The findings were:

Observation on 11/3/11 at 10:37 AM showed the cancer center south exit lead into a glass wall an ceiling walk-way that connected the hospital and the intermountain internal medicine (IIM) physicians' building. Further observation showed none of the three exit doors were fire rated neither were their frames, barrier walls or hardware. At the time of observation the facility supervisor confirmed the findings and reported the glass walk-way was added several years ago for convenience during severe winter weather. He was not aware the walk-way connected the buildings and thus required 2-hour separation.

Based on observation, blue print review and staff interview, the facility failed to ensure complete 2-hour fire separation between 3 of 3 nonconforming buildings, failed to ensure interior 1-hour fire rated walls had rated doors and equipment, and failed to ensure 2 of 5 fire rated barrier walls were smoke resistant. The findings were:

1. Observation on 11/3/11 at 10:37 AM showed the hospitals north first floor exit lead into a glass wall and ceiling walk-way that connected the cancer center and the intermountain internal medicine (IIM) physicians building. Further review showed none of the three exit doors were fire rated, nor were their frames or hardware. At the time of observation the facility supervisor confirmed the findings and reported the glass walk-way was added several years ago for convenience during severe winter weather. He was not aware the walk-way connected the buildings and thus required 2-hour separation.

2. Observation of the 1-hour rated fire barrier between the admitting area and the laboratory on 11/4/11 at 9:21 AM showed a 3/8 inch gap between the meeting edge of the double doors. Review of the blue prints confirmed this was a 1-hour fire rated wall. At the time of observation the facility supervisor reported he was aware the gap could not be greater than 1/8th inch. He could not explain why the gap had not been noticed and repaired during the quarterly inspections.

3. Observation of the IIM second floor 2-hour rated fire barrier door on 11/4/11 at 9:43 AM showed the latching hardware was not fire rated. At the time of observation the facility supervisor reported he was unaware the hardware was required to be rated in accordance with fire rating of the door.

4. Observation of the 1-hour rated fire barrier between the emergency room and radiology on 11/4/11 at 10:47 AM showed the door was not equipped with a 3/4 hour rating placard. Review of the blue prints confirmed this was a 1-hour rated fire barrier wall. At the time of observation the facility supervisor confirmed he was aware all doors in rated fire barrier walls were required to have rating placards.

5. Observation of fire barrier walls above the ceiling tile on 11/7/11 between 11 AM and 12 PM showed the barrier near room #2261 and the mountain view conference room had unsealed penetrations. The largest gap measured 2 inches by 4 inches. At 11:29 AM the facility supervisor could not explain why the penetrations had not been noticed and repaired during the semi-annual inspections.

Based on observation and staff interview, the facility failed to ensure room walls and ceilings were smoke resistant on 2 of 3 floors. The findings were:

1. Periodic observation on 11/3-7/11 showed the ceiling tiles had been removed from the communication/security room, second floor telecommunication room, radiology information technology (IT) room, MRI equipment room, and the third floor IT closet. The largest gap measured 24 inches by 24 inches. On 11/3/11 at 2:32 PM the facility supervisor could not explain why the missing ceiling tiles had not been noticed and replaced during the semi-annual inspections.

2. Periodic observation on 11/3-4/11 showed the wall was incomplete in the second floor electrical room, executone room, and the ambulance garage storeroom. The largest gap measured 4 feet by 6 feet. On 11/3/11 at 3:06 PM the facility supervisor reported he was unaware the walls were required to be smoke resistance for proper operation of the smoke detector in the area.

Reference:
NFPA 101, 2000 Edition;
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Based on observation and staff interview, the facility failed to ensure corridor doors were smoke resistant on 1 of 3 floors. The findings were:

Observation of the material management corridor double door on 11/7/11 at 11:26 AM showed one of the doors was equipped with a steel astragal. When the doors were released from the magnetic hold open devices, the door with the astragal closed first preventing the doors from being smoke resistant. Further observation showed the doors were not equipped with a sequencing device. At the time of observation the facility supervisor could not explain why the closing speed of the doors had not been noticed and a sequencer installed during the semi-annual inspections.

Based on observation and staff interview, the facility failed to ensure the doors in 1 of 2 stairwells were smoke resistant. The findings were:

Observation of the south stairwell on 11/7/11 at 12:56 AM showed the second floor double doors did not latch into the door frame because the meeting edges of the doors rubbed against each other. At the time of observation the facility supervisor could not explain why the doors had not been noticed and repaired during the semi-annual inspections.

Based on observation and staff interview, the facility failed to ensure smoke barriers on 1 of 3 floors was smoke resistance. The findings were:

Observation of the second floor smoke barrier wall near the information technology closet on 11/7/11 at 11:24 AM showed a 1/2 inch gap around an unsealed conduit penetration. At the time of observation the facility supervisor could not explain why the hole had not been noticed and repaired during the semi-annual inspections.

Based on observation and staff interview, the facility failed to ensure smoke barrier doors were smoke resistant on 1 of 3 floors. The findings were:

Observation of the smoke barrier double doors near the stress lab on 11/4/11 at 10:06 AM showed there was a 1/4 inch gap between the meeting edges of the doors, more than the allowed 1/8th inch gap. At the time of observation the facility supervisor could not explain why the gap had not been noticed and repaired during the semi-annual inspections.

Reference:
NFPA 101, 2000 Edition;
3.3.20* Barrier, Smoke. A continuous membrane, or a membrane with discontinuities created by protected openings, where such membrane is designed and constructed to restrict the movement of smoke.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas on 2 of 3 floors. The findings were:

1. Observation of the microfiche storeroom on 11/3/11 at 10:55 AM showed the room measured 8 feet by 16 feet and had several shelves of microfiche and other stored items. Further review showed the corridor door was not equipped with a self-closing device. At the time of observation the facility supervisor reported he was unaware hazardous areas were required to have a self-closing device on corridor doors.

2. Observation of the laboratory information technology server room on 11/4/11 at 8:53 AM showed a halon suppression system had been installed. Further observation showed the entrance door was not equipped with a self-closing device and it could not be determined if the air-conditioning units would shut down with the activation of the system. At the time of observation the facility supervisor reported he was unaware of the aforementioned requirement. He also reported that the system was serviced semi-annually and the last testing report, 10/17/11, did not indicate all openings were required to be self-closing.

Reference:
19.3.5.1, 9.7.3.1;
NFPA 12A, 1997 Edition;
3-3.1.2 To prevent loss of agent through openings to adjacent hazards or work areas, openings shall be permanently sealed or equipped with automatic closures. Where reasonable confinement or agent is not practicable, protection shall be extended to include the adjacent connected hazards or work areas.
3-3.1.3 Forced-air ventilating systems including in-room air conditioning units shall be shut down or closed automatically where their continued operation would adversely affect the performance of the Halon 1301 system or result in propagation of the fire.

Based on observation, blue print review and staff interview, the facility failed to ensure the corridor system had adequate headroom on 1 of 3 floors and failed to ensure the exit access corridor was accessible at all times on 2 of 3 floors. The findings were:

1. Observation of the fire barrier double doors between surgery and outpatient services on 11/3/11 at 3:37 PM showed the doors were equipped with a magnetic locking system. Further review showed the bottom of the magnetic locks did not have the required 6 feet 8 inch headroom. The bottom of the magnetic locks were only 6 feet 5 inches above the floor. At the time of observation the facility supervisor reported he was unaware of the spacing requirement.

2. Interview with the outpatient charge nurse on 11/3/11 at 3:56 PM revealed the fire barrier double doors between surgery and outpatient services was locked each night to restrict access to the surgery department. Review of the blue prints showed the locked doors restricted access to the designated egress system. Further review showed the surgery department was not a suite and thus confirmed the access through the department can not be locked with the current configuration. At the time of observation and blueprint review the facility supervisor confirmed the egress access system was designed to pass through the surgery department. He could not explain why the access to the egress system had not been noticed and addressed.

3. Observation of the behavioral health services (BHS) department on 11/7/11 at 11:06 AM showed the treatment/counseling room required patients to exit into the dining room and then enter the exit corridor. Observation and blue print review showed the area was not constructed as a separate suite. At the time of observation the facility supervisor reported he was not aware treatment rooms, not in a suite of rooms, required exit access doors leading directly to an exit access corridor without passing through an adjoining room.

4. Observation of the double corridor doors between the BHS department and the intensive care unit (ICU) on 11/7/11 at 3:05 PM showed the doors were locked for the clinical needs of the BHS patients. Further observation showed all BHS staff members had a key to unlock the door. Review of the blue prints showed the second exit from the BHS department was through the corridor that ran though the ICU suite. Review of the ICU showed it was no longer a corridor as three of four patient room corridor doors had been removed since the area was converted into a suite. Interview with the ICU charge nurse confirmed not all ICU staff members carried keys to the double doors leading into the BHS department. Review of the blue prints showed it was 4575 square feet and requires two exit access doors located remotely from each other.

Reference:
NFPA 101, 2000 Edition, 19.2.1;
7.1.5* Headroom. Means of egress shall be designed and maintained to provide headroom as provided in other sections of this Code and shall be not less than 7 ft 6 in. (2.3 m) with projections from the ceiling not less than 6 ft 8 in. (2 m) nominal height above the finished floor. The minimum ceiling height shall be maintained for not less than two-thirds of the ceiling area of any room or space, provided the ceiling height of remaining ceiling area is not less than 6 ft 8 in. (2 m). Headroom on stairs shall be not less than 6 ft 8 in. (2 m) and shall be measured vertically above a plane parallel to and tangent with the most forward projection of the stair tread.

19.2.5.1 Every habitable room shall have an exit access door leading directly to an exit access corridor.
Exception No. 1: If there is an exit door opening directly to the outside from the room at ground level.
Exception No. 2: Exit access from a patient sleeping room with not more than eight patient beds shall be permitted to pass through one intervening room to reach the exit access corridor.
Exception No. 3: Exit access from a special nursing suite shall be permitted to pass through one intervening room to reach the exit access corridor where the arrangement allows for direct and constant visual supervision by nursing personnel.
Exception No. 4: Exit access from a suite of rooms, other than patient sleeping rooms, shall be permitted to pass through not more than two adjacent rooms to reach the exit access corridor where the travel distance within the suite is in accordance with 19.2.5.8.

19.2.5.9* Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
A.19.2.5.9 Every exit or exit access should be arranged, if practical and feasible, so that no corridor, passageway, or aisle has a pocket or dead end exceeding 30 ft (9.1 m). (See also Table A.7.6.1.)

19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
A.19.2.2.2.4 Exception No. 2 The intent of the provision is that a person following the natural path of the means of egress not encounter more than one delayed release device along that path of travel to an exit. Thus, each door from the multiple floors of a building that opens into an enclosed stair is permitted to have its own delayed release device, but an additional delayed release device is not permitted at the level of exit discharge on the door that discharges people from the enclosed stair to the outside.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
19.2.2.2.5 Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

19.2.5.2 Any patient sleeping room, or any suite that includes patient sleeping rooms, of more than 1000 ft2 (93 m2) shall have not less than two exit access doors remotely located from each other.

Based on policy review and staff interview, the facility failed to ensure 2 of 8 policies were complete. The findings were:

1. Review of the smoking policy showed the policy did not indicate that "No Smoking" signs would be placed at all major entrances and no secondary signs would be posted where oxygen was in use, which was the facilities practice. Periodic observation on 11/3-7/11 showed none of the patient or treatment rooms where oxygen was used were posted with "No Smoking" signs. On 11/3/11 at 8:30 AM the chief financial officer (CFO) confirmed he was unaware the aforementioned language was required in the smoking policy.

2. Review of the smoking policy showed the policy did not indicate that ashtrays and metal self-closing containers to empty the ashtrays into would be supplied at all areas were smoking was permitted. On 11/3/11 at 8:30 AM the CFO confirmed he was unaware the aforementioned language was required in the smoking policy.

3. Review of the fire response (CODE RED) plan showed the policy did not address the evacuation of the smoke compartment of fire origin or evacuation of the floor and building. On 11/3/11 at 8:30 AM the CFO confirmed he was unaware the aforementioned language was required in the fire response policy.

Reference:
NFPA 101, 2000 Edition;
19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
19.7.4* Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based on record review and staff interview, the facility failed to ensure smoke detectors were properly installed, failed to ensure the sprinkler system was fully monitored by the fire alarm system, failed to ensure pull stations were installed properly and failed to ensure the corridors had complete smoke detection coverage on 2 of 3 floors. The findings were:

1. Periodic observation of the fire alarm system on 11/3-7/11 showed the smoke detectors in the sterile processing clean room, the sterile processing dirty room, the material management mail room, the engineering copy room, the dialysis waiting room, the stress test room, and the pediatrics nurses' station were installed closer than 36 inches from ventilation diffusers. On 11/3/11 at 11:20 AM the facility supervisor reported he was unaware of the spacing requirement and assumed the fire alarm contractor would inspect for proper spacing.

2. Observation of the 547 generator sprinkler system on 11/3/11 at 11:32 AM showed two isolation valves were not supervised by the fire alarm system. At the time of observation the facility supervisor reported he was unaware the sprinkler system isolation valves were required to be supervised. Furthermore he reported the system had been installed for more than ten years, and the last annual inspection, 4/11/11, had not indicated the lack of supervision.

3. Observation of the admitting foyer on 11/4/11 at 9:50 AM showed the entrance vestibule had an outer and inner door. Further observation showed the vestibule was not monitored by a smoke detector. At the time of observation the facility supervisor reported he was aware smoke detectors were required in the corridor system. He reported the system was inspected annually by an outside contractor and the lack of the smoke detector was not indicated during their last inspection, 4/11/11.

4. Observation of the admitting foyer on 11/4/11 at 9:55 AM showed the entrance vestibule had an outer and inner door. The facility supervisor reported the inner door was locked at night when the area was not supervised. Further observation showed the manual fire alarm pull station was located inside of the inner door, more than 5 feet from the entrance. At the time of observation, the facility supervisor reported he was unaware pull stations were required to be installed a maximum of 5 feet from the exit doorway opening.

5. Observation of the behavioral health services group room on 11/7/11 at 10:24 AM showed a strobe light harness was installed above the television set, but the device had been removed. At the time of observation the facility supervisor could not explain why the device had been removed.

Reference:
NFPA 101, 2000 Edition,
19.3.4.5.1 Corridors.
An approved automatic smoke detection system shall be installed in all corridors of limited care facilities. Such system shall be in accordance with Section 9.6.
Exception No. 1: Where each patient sleeping room is protected by an approved smoke detection system, and a smoke detector is provided at smoke barriers and horizontal exits in accordance with Section 9.6, the corridor smoke detection system shall not be required on the patient sleeping room floors.
Exception No. 2: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2.
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

19.3.4.1, 9.6.1.4;
NFPA 13, 1999 Edition;
5-14.1.1.3 Valves on connections to water supplies, sectional control and isolation valves, and other valves in supply pipes to sprinklers and other fixed water-based fire suppression systems shall be supervised by one of the following:
(1) Central station...
(2) Local signaling service that will cause the sounding of an audible signal at a constantly attended point.

NFPA 72, 1999 Edition;
2-8.2.2 Manual Fire alarm boxes shall be located within 5 ft of the exit door opening at each exit on each floor.
4-4.1 there are two methods of visible signaling. These are methods in which the message of notification of an emergency condition is conveyed by direct viewing of the illuminating appliance or by means of illumination of the surrounding area. Public mode signaling shall meet the requirements of Section 4-4 using visible notification appliances.
5.7.4.1* In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.
A 5.7.4.1 Detectors should not be located in a direct airflow or closer than 1 m (3 ft) from an air supply diffuser or return air opening ...

Based on observation and staff interview, the facility failed to ensure 1 of 7 fire alarm system components was tested. The findings were:

Review of the fire alarm system testing records showed the fire alarm system control panel batteries had not been tested semi-annually. On 11/7/11 at 2:58 PM the facility supervisor reported he was unaware of the testing requirement.

Reference:
NFPA 101, 2000 Edition,19.3.4.1, 9.6.1.4;
NFPA 72, 1999 Edition;
Table 7-3.2 Testing Frequencies.
6. Batteries-Fire alarm systems
d. Sealed Lead-Acid Type
1. Charge Test,...............................annually
(Replace batteries every 4 years.),
2. Discharge Test
(30 minutes)...................................annually
3. Load Voltage Test,....................semi-annually

Based on observation and staff interview the facility failed to ensure all areas had complete sprinkler coverage and failed to ensure sprinkler heads were installed the minimum distance from walls on 2 of 2 floors. The findings were:

1. Observation of the sprinkler system on 11/7/11 between 12:30 PM and 1 PM showed a sprinkler head in chemotherapy room #2 and #3 were installed 2 inches from the wall, not the required 4 inches.

2. Observation of the second floor storeroom on 11/7/11 at 1:08 PM showed the exposed steel "I" beam along the east side of the room was 24 inches deep. Further review showed the space between the "I" beam and the wall measured 18 inches by 100 feet and did not have sprinkler heads installed in the space. At the time of observation, the facility supervisor reported the area was inspected annually by an outside contractor and the last annual inspection (4/11/11) did not indicate a lack of sprinkler coverage.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1;
NFPA 13, 1999 Edition;
5-6.4.1.2 Under obstructed construction, the sprinkler deflector shall be located within the horizontal planes of 1 in. to 6 in. below the structural members and a maximum distance of 22 in. below the ceiling/roof deck.
Exception No. 2: Where sprinklers are installed in each bay of obstructed construction, deflectors shall be permitted to be a minimum of 1 in and a maximum of 12 in. below the ceiling.

Based on observation and staff interview, the facility failed to ensure all areas had complete sprinkler coverage on 3 of 3 floors. The findings were:

1. Observation of the atrium on 11/3/11 at 8:30 AM confirmed the building was required to be fully sprinkled. Periodic observations of the sprinkler system on 11/3-7/11 showed the medical records vault, the walk-way to the intermountain internal medicine (IIM) building, the two closets in the physicians' lounges, the first floor information technology router room, the chiller pass through room to boiler, the morgue vault, the first floor storeroom skylight, second floor electrical room, patient room #2279 restroom, the behavioral health second floor stairwell landing, behavioral health services skylight above the group room, the pipe chase by the chapel office, the third floor executone closet, the admitting vestibule, the surgery department suture storage alcove, and the sterile processing shelving walkway did not have sprinkler coverage. On 11/3/11 at 10:18 AM the facility supervisor reported he was recently made aware the building was required to be fully sprinkled. Review of the sprinkler contractors last annual inspection, 4/11/11, did not indicate a lack of sprinkler coverage.

2. Observation of the penthouse sprinkler system on 11/7/11 at 10:42 AM showed sprinkler heads had not been installed within 1 foot of atrium windows. At the time of observation the facility supervisor reported he was unaware of the spacing requirement.

Reference;
NFPA 101, 2000 Edition;
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
8.2.5.6* Unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:
Exception No. 1: Any number of levels of the building shall be permitted to open directly to the atrium without enclosure based on the results of the engineering analysis required in 8.2.5.6(5).
Exception No. 2*: Glass walls and inoperable windows shall be permitted in lieu of the fire barriers where automatic sprinklers are spaced along both sides of the glass wall and the inoperable window at intervals not to exceed 6 ft (1.8 m). The automatic sprinklers shall be located at a distance from the glass not to exceed 1 ft (0.3 m) and shall be arranged so that the entire surface of the glass is wet upon operation of the sprinklers. The glass shall be tempered, wired, or laminated glass held in place by a gasket system that allows the glass framing system to deflect without breaking (loading) the glass before the sprinklers operate. Automatic sprinklers shall not be required on the atrium side of the glass wall and the inoperable windows where there is no walkway or other floor area on the atrium side above the main floor level. Doors in such walls shall be glass or other material that resists the passage of smoke. Doors shall be self-closing or automatic-closing upon detection of smoke.

Based on observation and staff interview, the facility failed to ensure sprinklers were unobstructed on 3 of 3 floors. The findings were:

Periodic observation of the sprinkler system on 11/3-7/11 showed the sprinklers in the corridor near the morgue, the dialysis chemical storeroom, the admitting foyer, the corridor near patient room #2212, patient room #3320-3321, and room #3100 were obstructed by ceiling mounted lights or exit signs. On 11/3/11 at 10:07 AM the facility supervisor reported he was aware of the spacing requirement. He further reported that the system was inspected annually by an outside contractor and they had not noted any obstructed sprinklers on their last report, 4/11/11.

Reference:
NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1;
NFPA 13, 1999 Edition;
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (Standard Spray Upright/Standard Spray Pendent)

Maximum allowable
Distance from distance from
sprinkler to side deflector above
of obstruction bottom of obstruction
-------------------------------------------------------
Less than 1 ft ... ... ... ... ... ... ............. ....0
1 ft to less than 1 ft 6 in. ... ... ... ... ... ...2 ½
1 ft 6 in. to less than 2 ft .... ... ... ... ......3 ½
2 ft to less than 2 ft 6 in. ...... ... ... ... ...5 ½
2 ft 6 in. to less than 3 ft ... ... ... ...........7 ½
3 ft to less than 3 ft 6 in ... ... .... ... ... ...9 ½
3 ft 6 in. to less than 4 ft ... ... ... ... ... ...12
4 ft to less than 4 ft 6 in. ......................14

Based on observation and staff interview, the facility failed to ensure soiled linen receptacles were properly separated on 1 of 3 floors. The findings were:

Observation of the radiology corridor on 11/4/11 at 11:02 AM showed a double soiled linen/trash cart was being stored in the alcove near room #2241. At the time of observation the facility supervisor was unaware soiled linen and trash receptacles were required to be separated by 64 square feet.

Based on observation and staff interview, the facility failed to ensure electrical receptacles and switches were installed at minimum heights in oxygen storage locations on 1 of 3 floors. The findings were:

Observation of the cardiopulmonary oxygen storeroom on 11/7/11 at 9:52 AM showed the electrical receptacle behind the oxygen storage rack was installed 20 inches above the floor. Further review showed this was the standard height of receptacle throughout the room. Review of the light switch showed it was installed 48 inches above the floor, not the require 60 inches for all receptacles and switches. At the time of observation the facility supervisor was unaware of the height requirement in oxygen storage locations.

Reference:
NFPA 101, 2000 Edition, 19.3.2.3, NFPA 99, 1999 Edition;
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (any Quantity; In-storage, Connected, or Both)
3. Provisions shall be made for racks or fastening to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electrical wall fixtures, switches and receptacles shall be installed in fixed locations not less than 5 ft above the floor as a precaution against their physical damage.

Based on observation and staff interview, the facility failed to ensure duct work that penetrated smoke barriers was protected by a smoke damper on 1 of 3 floors. The findings were:

Observation on 11/3/11 at 11:44 AM showed a vent, from a mechanical fan, passed through the wall between the first floor electrical room #2 and the boiler room. At the time of observation the facility supervisor reported the fan exhausted hot air from the electrical room into the boiler room. He also reported he was unaware duct work penetrating smoke barrier walls was required to be provided with a smoke damper.

Reference:
NFPA 101, 2000 Edition, 19.3.7.3;
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation and staff interview, the facility failed to ensure circuit directories were accurate and failed to ensure the Essential Electrical System (EES) was divided into a Life Safety Branch and a Critical Branch on 3 of 3 floors. The findings were:

1. Observation of the Equipment Branch panel "EMC" on 11/3/11 at 11:50 AM showed the circuit directory was labeled differently than the labeling tape next to several circuits. Circuit #1 was lined out on the directory, but the labeling tape next to the circuit showed "tank monitor". Circuit #3 was lined out on the directory, but the labeling tape showed "Exhaust ATS". Circuit #5 was lined out on the directory, but the labeling tape showed "Gas Pump". Circuit #6 and #8 was a two pull circuit and was lined out on the directory, but the labeling tape showed "Panel EMC1-B". At the time of observation the facility supervisor reported he was aware of the requirement and that several panels were not labeled correctly. He also reported the facility was working on correcting the issue, but could not explain why the directories had not been updated when they were originally changed.

2. Observation of the Critical Branch electrical panel "EMV" on 11/3/11 at 12:46 PM showed the panel supplied power to Life Safety Branch equipment. Circuit #13 and #15 supplied power to "fire/smoke dampers". At the time of observation the facility supervisor reported he was unaware the "EES" panels could only supply power to specific equipment.

3. Observation of the Life Safety Branch electrical panel "EMU" on 11/3/11 at 12:48 PM showed the panel supplied power to Critical Branch equipment. Circuit #2 and #4 supplied power to "pharmacy lights". Circuit #9 supplied power to "EM storage lights". Circuit #12 supplied power to "pixis material storage".

4. Observation of the Critical Branch electrical panel "EMQ" on 11/3/11 at 2:05 PM showed the panel supplied to Life Safety Branch equipment. Circuit #6 supplied power to "PBX medical gas panel".

5. Observation of the Critical Branch electrical panel "EMAA" on 11/3/11 at 2:28 PM showed the panel supplied power to Life Safety Branch equipment. Circuit #13 supplied power to "phone board in the communication room".

6. Observation of the Life Safety Branch electrical panel "EMA" on 11/4/11 at 9:01 AM showed the panel supplied to Critical Branch equipment. Circuit #4 supplied power to "card reader and clock". Circuit #6 and #8 supplied power to the "lab reagent refrigerator". Circuit #17 supplied power to the "admitting door access card reader".

7. Observation of the Life Safety Branch panel "EMN" on 11/4/11 at 10:13 AM showed circuit #6 supplied power to the "fire alarm control panel". The circuit director and the circuit itself were not colored with red markings. At the time of observation the facility supervisor was not aware of the aforementioned requirement.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2,
NFPA 70, 1999 Edition;
384-13 ...All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.
Article 517-30 Essential Electrical Systems for Hospitals.
Article 517-31 Emergency System
Article 517-32 Life Safety Branch
Article 517-33 Critical Branch
Article 517-34 Equipment System

Based on observation and staff interview, the facility failed to ensure damaged electrical equipment was replaced, failed to provide receptacle face plates, failed to maintain adequate work space in front of electrical panels, failed to ensure temporary wiring did not replace permanent fixed wiring, and failed to ensure electrical receptacles in wet locations had ground fault circuit interruption (GFCI) protection on 3 of 3 floors. The findings were:

1. Observation of the first floor biohazard room on 11/3/11 at 11:56 AM showed an electrical receptacle port was damaged. At the time of observation the facility supervisor could not explain why the receptacle had not been noticed and replaced during the semi-annual inspection.

2. Observation of the second floor telecommunication room on 11/3/11 at 3:03 PM showed the face plate was missing from an electrical receptacle. At the time of observation the facility supervisor could not explain why the receptacle had not been noticed and replaced during the semi-annual inspection.

3. Observation of the electrical system on 11/4/11 between 8:30 AM and 12 PM showed items were stored in front of the electrical panels in the deionized water room, the MRI equipment room, and the pharmacy. At 8:40 AM the facility supervisor reported he was aware of the spacing requirement and also that staff had been instructed several times to not store items in front of electrical panels.

4. Observation of operating room #1 on 11/4/11 at 1:02 PM showed the anesthesia drug cart was plugged into an uninterrupted power supply (UPS) device which was plugged into a surge protector. At the time of observation the director of surgery services reported she was unaware equipment towers in the surgery field could not be plugged into surge protectors and must be plugged directly into a fixed permanent receptacle.

5. Observation of the obstetrics housekeeping closet on 11/7/11 at 10:37 AM showed the two electrical outlets were installed closer than 6 feet from a sink and did not have GFCI protection. At the time of observation the facility supervisor reported he was aware of the requirement and could not explain why the receptacle had not been identified and replaced during the semi-annual inspections.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2;
NFPA 70, 1999 Edition;
90-7 Examination of Equipment for Safety.
...It is the intent of this Code that factory-installed internal wiring or the construction of equipment need not be inspected at the time of installation of the equipment, except to detect alterations of damage ...
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment ...
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in table 110-26(a) ...
Table 110-26(a)
Nominal Voltage Minimum Clear Distance (ft)
To Ground
_______________________________________
0/150 3 ft.

(b) Clear Space. Working space required by this section shall not be used for storage ...
110-27. Guarding of Live Parts.
(b) Prevent physical damage. In locations where electric equipment would be exposed to physical damage, enclosure of guards shall be so arranged and of such strength so to prevent such damage.
370-28. Pull and Junction Boxes.
(3) (c) cover. All pull boxes, junction boxes and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use....
384 Switchboards and Panel boards
C Panel boards
517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption or power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

NFPA 101, 2000 Edition, 19.3.2.3;
NFPA 99, 1999 Edition;
7-5.1.2.5 Line Voltage Equipment-Anesthetizing Locations. Flexible cord for portable lamps or portable electrical appliances operating at more than 12 V between conductors, intended for use in anesthetizing locations, shall be continuous and without switches from the appliance to the attachment plug and of a type designated for extra-hard usage in accordance with Article 501-11 of NFPA 70 ...

Based on observation and staff interview, the facility failed to ensure temporary electrical wiring was not replaced by permanent fixed wiring on 1 of 2 floors. The findings were:

Observation of the therapy directors office on 11/7/11 at 12:59 PM showed a lamp was plugged into an extension cord which was plugged into a surge protector. At the time of observation, the facility supervisor could not explain why the extension cord had not been noticed and removed during the semi-annual electrical inspections.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2;
NFPA 70, 1999 Edition;
400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls ...
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces